This post is part one of a two-part guest blog series on pediatric primary care payment reform efforts in Connecticut. It was authored by Lisa Honigfeld for the Connecticut Health Foundation, an independent private foundation dedicated to achieving health equity. Visit www.cthealth.org to learn more about their work.
A couple years ago, I visited several Nordic countries to learn about their health and social services for children. While there, I told people about Connecticut’s State Innovation Model, a federally funded health reform initiative designed to reshape how health care is financed and delivered.
I told them about efforts to improve the way we manage chronic conditions such as diabetes and hypertension – things that will improve health and save money.
Nearly everyone I talked to had a similar response: Why are you focusing on managing chronic conditions in adults? If you really want to improve health and save money, you must work to prevent those conditions in the first place, not simply manage them once they’ve developed.
It’s hard to argue with that logic. In fact, I’d venture to say that everyone agrees with the premise that investing in health and well-being at an early age pays off.
Yet it remains a challenge to make this a priority.
Part of the challenge is the need to focus on addressing health care costs, which leads many health reform efforts to prioritize investments that will pay off quickly, such as those focused on high-cost conditions and populations. Children don’t fit these criteria. In fact, children represent 24 percent of the U.S. population, but less than 12 percent of the health care dollars spent. With the exception of children with very complex medical needs – fewer than 5 percent of all kids – children are inexpensive when it comes to health care costs. As a result, they present few opportunities for realizing immediate savings.
So why look to pediatrics as a key place for health reform?
It’s simple: Many conditions – including obesity and mental health challenges – often have their roots in early childhood. They can lead to lifelong health challenges that impact learning, employment, social competency, and health care costs. Racial and ethnic health disparities are set in motion early in life, also, and addressing childhood health can help decrease disparities in the future.
Put another way: Most of the adults with chronic diseases – who require extensive and costly health care services – were once healthy children. In many cases, early interventions could have changed their trajectories.
Research has shown the importance of the early years in determining lifelong outcomes, from the development of resiliency to mitigate the effects of toxic stress to moving families out of poverty. We can make enormous improvements in population health by focusing on the earliest years of life. This will also have long-term, positive consequences for children’s experiences and success in other sectors, such as education, social services, juvenile justice, and social welfare.
Where to start?
There’s one obvious place: pediatric primary care. More than 90 percent of children visit a pediatrician or other primary care provider annually, making it a natural setting for delivering health messages, supporting parenting, identifying health and developmental concerns, and connecting patients to services that can address risks long before they lead to larger problems.
The American Academy of Pediatrics and federal schedules recommend 12 preventive care visits before a child’s second birthday. These visits provide opportunities to address a variety of topics that have implications for long term health and well-being, and ultimately public health. Public and private insurance programs universally pay for these visits, and data show that adherence to the recommended visit schedule is high.
These visits present an enormous opportunity to support families in raising healthy children. Yet, the current way that pediatric care is funded works to restrict innovation that could improve outcomes.
Pediatric primary care providers are paid on a fee-for-service basis, forcing them to limit the length of each visit so they can see enough patients per day to sustain their practices. The payment structure also limits their ability to use social service and other providers whose services are not covered under traditional health insurance plans.
Instead of the series of 15- or 20-minute visits that are typical in a pediatric practice, imagine a pediatric office in which the providers:
- Have more time and resources on hand to help families to address more of their needs.
- Can connect families with concerns to community supports that can help.
- Offer group well-child visits, which bring together multiple families within the practice who could meet with a behavioral specialist or other expert to learn about specific issues relevant parenting and managing typical childhood behaviors that rattle parents.
- Have onsite lactation and nutrition services that could support more mothers with breastfeeding or other feeding issues.
- Have an onsite developmental expert who could help parents promote motor, social, and sensory growth through the several stages of child development.
As we look to redesign health care payment and delivery, we must ensure that the new models encourage these types of activities, rather than rendering them things providers must make an extra effort to squeeze in. The system should reward outcomes – Did a child with developmental delays or behavioral health concerns receive services that helped? Did a child have a healthy weight at the start of kindergarten? – rather than the number of office visits racked up.
Connecticut has a wealth of opportunities at the state and community level to address child and family risks once they are identified.
- The state’s Birth to Three program ensures that children with developmental problems receive services.
- There are preschool special education services, and home visiting programs that support families when children are very young and at critical points during childhood.
- There are also a host of community-based services that can help parents promote their children’s health and development. To find these services, visit United Way’s 211 Child Development Infoline and the Help Me Grow system of community supports.
While primary care providers are well-positioned to ensure that families are connected to these services, their ability to do so is currently limited by the existing payment model, which is visit-based and does not support all the innovations that practices can use to better promote health and development.
If we want to get ahead in ensuring population health, reducing health disparities, and integrating community services with health, so that we can avoid having to continually address the long-term consequences of conditions that could have been prevented or better managed at earlier stages, we need to make pediatrics a priority in our health reform work.
Improving this system can strengthen families, promote resilience in young children, and would go a long way toward addressing the many consequences of poverty and the many health inequities that are rooted in the earliest years of life.
To view this blog on the Connecticut Health Foundation website, click here.
Next: Part 2: What we’re doing to make this a reality
Lisa Honigfeld, PhD, is the associate director of Connecticut Children’s Office for Community Child Health and vice president for health initiatives at the Child Health and Development Institute of Connecticut.
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