Pediatrics: not "budget dust"

As we delve into the concept of "Value" in pediatrics and scrutinize our healthcare trajectory—including a critical examination of Medicaid's effectiveness for children—it becomes imperative to reassess our approach towards healthcare spending. The discussion, sparked last week, prompts a significant reevaluation of our current strategies and their outcomes for pediatric care.

The term "budget dust," as coined by my pediatric colleagues, encapsulates the frustration within the pediatric community. It reflects a sentiment of neglect by insurers and policymakers towards investing in pediatric care, underpinning the struggle to secure better outcomes for children due to perceived insufficient spending. Yet, a closer examination of our healthcare expenditure reveals an astonishing level of investment in pediatric healthcare even Medicaid, which paradoxically, does not correlate with improved outcomes in child health and wellness. This discrepancy begs the question: Is the purported lack of funding truly at the root of our subpar pediatric healthcare performance?

The proposition to not merely increase spending but to reallocate existing funds more effectively and efficiently presents a compelling alternative. By shifting resources from hospitals, emergency rooms (ERs), and pharmacies towards primary care, we embrace a value-based care model that emphasizes preventive measures and the management of chronic conditions. This strategic reallocation promises several advantages, including enhanced preventive care, early disease detection, cost-effectiveness, improved access for underserved populations, and a holistic approach to health management.

However, the pediatric healthcare system faces intrinsic challenges that demand a fundamental shift in thinking and practice. The current fee-for-service model, with its focus on well-visits and volume over value, promotes a short-sighted approach to healthcare that may inadvertently contribute to the fragmentation of care. Over-referral to specialists, lack of continuity, and suboptimal chronic care management are symptoms of a system in need of innovation and redirection towards a model that considers the total cost of care.

Proactive Healthcare through Primary Care Enhancement

Enhancing primary care within Medicaid is not just a fiscal reallocation; it is a call for a systemic change in the philosophy of pediatric care. Prioritizing funding for primary care encourages the adoption of a proactive approach. This means shifting from the prevalent fee-for-service model to one that rewards outcomes and quality—valuing the continuous, comprehensive care that primary care physicians are uniquely positioned to provide. It calls for pediatric primary care to act differently, championing preventive measures, effective chronic disease management, and a focus on the patient's overall well-being and total spend.

Overcoming Barriers to Access

Key to this transformation is addressing the barriers to accessing primary care. Barriers to access in primary care, especially within the Medicaid population, often stem from a payment system that disincentivizes providers from accepting Medicaid patients or prioritizing commercial patients needs. Enhancing payment rates and aligning incentives with the value provided to patients can revolutionize access to care, reduce the dependency on specialist services, and promote continuity of care.

Integrating Care and Addressing Social Determinants of Health

The integration of healthcare services and addressing social determinants of health are critical to a reimagined Medicaid strategy. Pediatric primary care access is a social determinant. Pediatric primary care that priortizes the neediest based on wider health influences, such as housing, nutrition, and education, is imperative to provide a comprehensive approach to child health.

Balancing the Narrative: Challenges and Considerations

The journey toward a primary care-centric pediatric system is fraught with challenges. There is resistance from established hospital systems and specialty care providers, and the primary care workforce. Systems aligned to more care to collect more fees are simply inadequate to meet the real needs of patients and clinicians. This transition requires re-balancing the importance of specialty care, ensuring that children with complex health needs continue to receive specialized attention in a timely manner. Less referrals will mean greater access for those most in need. Payment must align with needs and not fees.

A Path Forward

The path forward involves a move towards a system where the total cost of care is a fundamental concern, and where value is delivered through preventive measures, comprehensive chronic disease management, and a focus on continuity of care. By centering primary care and preventive services within Medicaid, states can drive improvements in health outcomes for children, reduce disparities, and create a more equitable and sustainable healthcare system. The challenge for pediatrics is to think and act differently, embodying the proactive, integrated, and holistic care that our children deserve. Pediatric primary care has to lead the transformation to value. It is not more money we need, it is a new approach to ensuring our care is driving the outcomes our patients deserve.

The time is now to clean off the talk of dust.