Reshaping Pediatric Practice

When pediatrician Donald Berwick became Administrator of the Centers for Medicare and Medicaid Services, he brought with him a simple framework to reorganize that agency and through it the US health care system.¹  The “Triple Aim” sets 3 goals: (1) reducing per capita costs of health care, (2) improving the experience of care by addressing quality and satisfaction, and (3) improving the health of populations. Combined, these aims redefined the role of the Centers for Medicare and Medicaid Services from financier of health care services to public fiduciary and change agent. They also are likely to reshape the role and organization of pediatrics in the United States.

Despite its reputation as a low-cost service, child health care will be examined for overuse and inefficiencies. Preventive care will be scrutinized. Interventions will target the small group of children who account for the majority of health care expenditures,²  and there will be greater interest in modifiable social factors that ramp up the costs of care for many children. And despite their low incomes relative to other specialists, pediatricians in the United States will not be immune from payment reform and possibly reduced reimbursement.

Pediatricians will experience increasing pressure to reduce variations in the quality of care among neonates and children with chronic and complex health problems who are at heightened risk for poor outcomes.³  Recent shifts in the prevalence of a number of pediatric morbidities are placing new demands on child health care providers for which they may be unprepared by training and unsupported by community relationships and services.^4–6  Unreliable quality of ambulatory pediatric care⁷  will increase calls for clinical guidelines and greater quality monitoring. Politics and changing demographics will heighten concerns about health disparities between racial/ethnic and income groups. Family-centered care has been advocated for as a way to increase quality and satisfaction, yet even among those families at highest risk for adverse outcomes and unmet expectations, this approach to care remains far from universal.⁸ 

Unflattering comparisons of the United States with other countries highlight the divide between the public health system with its focus on population health and the medical care system with its focus on individual health care.⁹  Public agencies have defined appropriate preventive care,¹⁰  and coverage policies increasingly support the provision of preventive services not subject to copayments. On the other hand, the health care system has been less energetic in promoting health behaviors that contribute to lifelong health, preferring to encourage technological and pharmaceutical interventions after primary prevention opportunities have passed.

Achievement of the goals of the Triple Aim will require changes not only in health care organizations and the larger health care financing systems but also in the behaviors of individual health care practitioners and in their practice settings.

Many current efforts to change practice espouse adopting the attributes of a medical home,¹¹  but incentives to create and sustain medical homes have not yet proven adequate to the tasks. Fundamentally, the medical home is a coordination center that engages all the providers, medical and nonmedical, whose services are essential for achieving the best outcomes for the patient and family. Every practice should have a designated care coordinator, referral specialist, or navigator, and coordination of care should be modeled within each practice by care teams that allow individuals to function at the top of their skill level and to constantly assess and improve their collective performance.¹² 

The past decade has seen a great deal of research and improvisation in the structure and processes of medical practices intended to improve access, quality, and efficiency. Many practices have implemented advanced access appointment systems that have decreased waiting times and increased access, both of which enhance patient satisfaction. Practices have become more efficient by using non–face-to-face methods to streamline care and to collect and share clinical information. Care is being shaped by the creative use of information technologies such as vetted Web sites, e-referrals, e-mail, and telehealth. The list of possible practice redesign elements and their benefits is extensive.¹³ 

In most cases, each patient likely has his or her own “individual care system” that comprises various health care professionals who generally are unaware of the other system members or the services they provide. One solution to this piecemeal approach to care is to create an accountable care plan, a document whose content is created and agreed upon by the patient and providers. The plan addresses acute, chronic, and preventive care; promotes life-course health; and identifies not only planned content of care but also who, including the patient, is responsible for each part of the care plan.

Improving the capacity of patients and their families to make daily decisions that improve health-related behaviors and clinical outcomes can reduce costs and improve quality.^14,15  By using principles of patient-centered care, practices should emphasize problem-solving approaches and teach patients how to monitor symptoms and their health status. Practitioners need to be able to motivate patients to undertake these new responsibilities as well as to adopt healthy lifestyles. Every practice should develop the capacity to support self-management, or partner with other service providers to ensure patients have access to these supports.

Integrated health care organizations (large, multispecialty practices that can include ambulatory and inpatient care as well as a variety of other patient services) are becoming increasingly common in both the public and private sectors. Large practices and organized health care systems are able to improve quality while controlling costs^16–18  and are in a position to address population health issues, especially in partnership with local public health systems. Even networks of independent practices have been found to achieve better outcomes at lower costs, leading some payers to tie incentives to participation in networks.

Practices need not give up their autonomy to experience the benefits of organized health care systems. Practices that identify a common need, public agencies working to fill gaps in the existing services for children, or public-private partnerships can isolate some of the things a system provides and create them as shared resources. Examples include community-based systems of care coordination, mental health and quality improvement consultation services, and after-hours call centers and coverage. There is substantial and growing evidence that when practices network around shared resources practitioners, patients, and payers all benefit.¹⁹ 

There is no question that there are substantial pressures on pediatric practices to change their structure, organization, and operation. In this climate, pediatricians can take steps to retain a sense of control over their practices while improving their patients’ experience of care, reducing costs, and improving the health of children in their communities. Practice redesign, particularly focusing on elements of a family-centered medical home, is challenging but increasingly necessary. Networking with other practices, sharing resources, or joining organized care systems can improve quality while helping defray the expenses of essential and sometimes costly infrastructure. Planning care in partnership with the patient and family, defining goals, anticipating needs, assigning accountability, and supporting self-management can improve the experience of care and quality while reducing costs. It is important for child health care providers to identify and act on opportunities for pediatric practices to prepare to better function in the changing health care system.