Why can't the United States have a smarter health care system?
That was the frustrating question that kept poking through my train of thought as I read a study from the most recent issue of Pediatrics, the official journal of the American Academy of Pediatrics (AAP). 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 what doctors call anticipatory guidance ("Is Suzy using a car seat?"). No big surprise that the longer the duration of the well-child visit, the greater the likelihood that the visit adhered to recommended guidelines.
Unfortunately 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 percent 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 percent of even the shortest visits. The biggest loser -- developmental assessments, which don't even achieve a mediocre occurrence of 70 percent 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. Nowhere 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.
Whether we think about it or not, the notion that health insurance companies and the pharmaceutical industry shape medical practice -- and our collective health -- through their policies, marketing and aggressive lobbying is one that is embedded in our health care culture. The result is a lopsided distribution of health care that overmedicalizes the well-insured while undertreating the underinsured. Consider that a whopping 25 percent of U.S. children are on chronic medications while, according to this UCLA study, 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 productivity 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 in danger of becoming extinct. The scope and challenges of our health grow ever more complex, and chronic conditions like obesity and diabetes overtake acute threats. Yet we keep trying to squeeze our health care delivery into the model we used back when you only went to a doctor to treat your pneumonia, or to 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 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 (and the one with the prescription pad) simply because that is the only person we know how to par 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 care 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 offers what we are capable of, and saves us money in the long run.
We all know what is standing in our way: Profit. Special interest. Self-serving politics. That is why we need to keep asking the fundamental question: Why can't we have a smarter health care system?
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