A disconnect between medical resources and health care delivery

Imagine what health care in the United States could look like if we devised a system that was based on sound medical practice and proven cost effectiveness.  What if we put our brains, energies and passion behind designing the smartest health care system possible?

That was the question that kept poking through my train of thought as I read a study that appeared in the most recent issue of Pediatrics, the official journal of the American Academy of Pediatrics.  The study, out of UCLA, examined the association between length of well-child visits and quality of the visits, including things like developmental screening and anticipatory guidance.  No big surprise that the longer the duration of the well child visit, the greater the likelihood that the content of the visit was aligned with recommended practice guidelines from the AAP.  The discouraging news however is that one third of visits were reported as being less than 10 minutes in duration; these occurred to a greater degree in private practice.  Longer visits of 20 minutes or more made up 20% of the encounters, and were more likely to occur in community health centers.

The big winners in the pinch for time?  Guidance on immunizations and breastfeeding were offered in 80% of even the shortest visits.  The biggest loser: developmental assessments, which don’t even achieve a mediocre occurrence of 70% until we pass the 20-minute mark for visit duration.

What’s behind all this?  A profound disconnect between our medical resources and our health care delivery. No where has modern pediatric care evolved more dramatically than in the arena of well-child care and preventive medicine. What has not evolved along with our scope of knowledge is our delivery system.  Our fee for service approach to health care dictates that procedures and tests pay well while addressing a child’s emotional problem gets a doctor little more than a backed up waiting room.   From the patient’s view, underinsured children have to rely too much on emergency rooms, while insured parents can only get basic child rearing advice from someone with a medical degree. Health insurance companies and the pharmaceutical industry shape medical practice – and our collective health – through their reimbursement policies, marketing and aggressive lobbying.  So 25% of US children are on chronic medications, while half the children in pediatric practice are not receiving basic screening and advice. The obsolete business models that the health care industries rely on are like the tyrannosaurus-rex in the room, emphasizing expensive, short term quantity rather than cost-effective long term quality, while cognitive care – a high level of skill and expertise delivered face to face in a personal manner – is what is becoming extinct. Even as the scope and challenges of our health grow more complex, and chronic conditions overtake acute threats, we keep trying to squeeze our health care delivery into a model that was appropriate when you only went to a doctor to treat your pneumonia or have a farm implement removed from your foot.

It is not surprising that community health centers are associated with longer, higher quality well-child visits. The doctors are salaried, which means they are somewhat insulated from the array of financial disincentives that currently infuse primary care, like the need for rapid patient turnover.  The centers are also more likely to utilize a more rational division of labor, so that every issue doesn’t immediately make its way to the most expensive professional in the room simply because that is the only person who will get paid for the visit.  Nurses at all levels of skill are used for a wider scope of encounters, and there are often ancillary resources – nutritional and mental health services for example – that expand the kinds of services the patient receives, approaching the ideal of a comprehensive medical home for all patients.   It is also not surprising that the practice settings that are successfully evolving into medical homes are largely publicly funded.  By their very nature, they put patients’ best interest above profit, and have a vested interest in long-term outcomes as opposed to short term productivity.

So, back to the study from UCLA.  We know what every child should receive in the way of well-child care, and we know that quality primary care saves money in the long run.  We have professionals at all levels of training and pay scales capable of delivering high quality care.  We have incredibly skilled and dedicated pediatricians who can coordinate this kind of teamwork. So why are we wasting our time arguing about how to pay for obsolete delivery models and payment systems?  Why not design a system that does what it is capable of, and saves us money in the long run.

Imagine what health care in the United States could look like if we devised a system that was based on sound medical practice and proven cost effectiveness.  What if we put our brains, energies and passion behind designing the smartest health care system possible?

Maggie Kozel is the author of The Color of Atmosphere: One Doctor’s Journey In and Out of Medicine, from Chelsea Green Publishing. This post originally appeared on Progress Notes.

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