Our medical system is failing our children. The rate of chronic diseases in children is skyrocketing. Obesity has increased. Behavioral health issues are at new highs, making suicide a leading cause of death in children. During the pandemic, rates of pediatric preventive health visits, vaccinations, and screening tests have decreased, thereby losing opportunities for early intervention.
These failures were evident before COVID hit the world — the pandemic simply accelerated the trend. The traditional medical care of our society’s most precious resource — our children — is buckling under the burdens of a flawed health care system.
Children are sicker, and pediatricians have more to manage now than ever before.
And now, a recent study indicates babies born during the pandemic may be suffering from developmental delay. Without fundamental changes in pediatric health care delivery, these problems will continue to escalate, lead to a larger burden of chronic adult disease and increase societal health care costs.
When children cannot get the care they need, doctors hurt too. Our pediatricians are not OK, with nearly half suffering from burnout. It is not only because their jobs are hard. It is because of the moral injury they suffer when children are not able to receive the care they deserve.
The current delivery model necessitates that a pediatrician sees an average of 25 patients per day and manages 2,500 children annually. Pediatricians spend an average of 16 minutes on a preventive well-child visit. During that time, they must assess normal growth, development, nutrition, sleep, and behavior. They must screen for disease and social stressors, counsel on immunizations, and manage all chronic illnesses. And then answer the child’s or family’s concerns. After the visit, insurance and other regulations require extensive documentation. All of this is not possible in the allotted time, leaving both the doctor and the patient unsatisfied.
It is a sad fact that pediatricians have come to accept that doing our best and providing whole child care is just not possible. Instead, we choose which issues to address and leave others for a future encounter, similar to the triage approach in national disasters.
Do we pursue a preventive health approach, optimize chronic diseases or address the family’s concerns — all while neglecting what may be medically in the patient’s best interest?
To address these challenges, we must evolve the transactional care of current volume-based compensation and delivery models to relational care.
A solution must allow pediatricians to develop deep, trusting, meaningful relationships with their patients and families and teach parents to have similar relationships with their children. It sounds like an impossible ask. But we actually already have an innovative health care model that has success. Direct primary care has repeatedly demonstrated improved care, decreased costs, enhanced patient experience and improved physician job satisfaction.
The time is right to expand its utilization in pediatrics.
Direct primary care eliminates the fee-for-service volume-based compensation model. It encourages the development of therapeutic relationships by decreasing the number of patients a doctor manages per year by at least 80% (from 2,500 to 300-500 per year). Imagine the advantages.
Patient visits often occur the same day requested, may occur after-hours or even at the patient’s home. Visits can last an hour if necessary. Patients embrace continuity with one doctor. Imagine the days of the true family doctor who knows your family, your pets and your children’s life aspirations — and now add 21st-century evidence-based medicine and technology. The resulting deep physician-family relationships are long-term, allowing for mutual understanding, trust, and prevention of disinformation rampant in today’s culture.
These models have proven to decrease medication prescribing, specialist referrals, ER visits, and hospitalizations and improve patients’ overall well-being.
As of now, such direct primary care models do not extensively exist for children. However, adult direct primary care models are flourishing around the country. Payment is not based on the number of patient visits or services rendered, but rather is a membership model.
For a modest dues subscription, paid either from the consumer or employer, physicians manage all the patient’s primary care needs with no additional hidden fees or co-pays. In other words, the complex and costly realm of insurance does not need to play a role in primary care but can function as a safety net for non-primary care services. We need to embrace this model for children. It works.
Our children are not OK. Our pediatricians are not OK. Please, let us not further ignore and jeopardize the future health of our society. Pediatrics needs a transformational change to direct primary care and other models that transition from transactional care to relational care. Encourage your employer to embrace direct primary care for children. The future health of our children is at stake.
Andrew Hertz and Keili Mistovich are pediatricians.
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