PEDIATRICS Vol. 118 No. 3 September 2006, pp. 1254-1256 (doi:10.1542/peds.2006-1412)
COMMENTARY |
A Jacobian Future: Can Everyone Have a Medical Home?
Department of Pediatrics, University of California, Davis, Sacramento, California
Abbreviations: SES, socioeconomic status • ACP, American College of Physicians • AAP, American Academy of Pediatrics • AAFP, American Academy of Family Physicians
Abraham Jacobi and the other founders of pediatrics in the United States established pediatrics as a primary care specialty by providing well-child visits with health screenings and immunizations. This course differed from that taken in Europe where children received their primary care from general practitioners, and pediatricians were consultants. Thus, there has been an uneasy relationship between pediatrics and family medicine in which both are competitors and partners in the care of children and adolescents.
Phillips et al1 now bring a challenge to the pediatric community regarding the future of health care for children and adolescents. The growth in the number of general pediatricians will greatly exceed the growth of the pediatric population by 2020.2 This growth is likely to exceed published measures of sufficiency,3 and there are signs of decreasing demand for general pediatricians.4 In addition, pediatrics has recognized the importance of caring for families to improve child health,5 potentially leading to a collision course with family medicine.
The increasing number of general pediatricians has led to a decrease in the percentage of pediatric visits performed by family physicians since 1980.6 Family physicians, however, still provide approximately one fifth of pediatric-age office visits, with one third of rural visits and one quarter of adolescent visits. More than 5 million children and adolescents currently live in a county without a pediatrician, and many rural areas cannot support a pediatric practice. In addition, family physicians provide care for many uninsured or publicly insured children and disproportionately staff safety-net facilities such as community health centers. Thus, family physicians play a critical role in the care of children and adolescents in the United States.
From the perspective of family medicine, Phillips et al present 4 responses to the growing number of general pediatricians and family physicians relative to the child population. Family medicine could partially or wholly withdraw from the care of children and focus on the aging population, or they could compete directly with pediatrics for the primary care of children and adolescents. An alternative to these options is for family medicine and pediatrics to collaborate in providing medical homes for all children and their families. Collaboration is an important option for the future.
The growth in the pediatrician workforce7 is part of an ongoing debate about whether there is an impending oversupply8–10 or undersupply11,12 of physicians. However, the future of pediatrics depends less on whether there will be an oversupply than on whether we can reform health care to support medical homes for children. Many children have unmet health needs because they are uninsured or live in unhealthy environments. With reform, we can better align pediatricians’ work with the needs of children. Health care in our country is still rooted in the provision of acute, episodic care for infections and injuries. Physicians are primarily reimbursed by visits and procedures, and even with capitation, physicians rarely are able to truly manage their populations.
Despite leading the world in health care expenditures, Americans are less healthy that people in most other developed countries. The United States has higher infant and child mortality rates, lower immunization rates, and higher rates of adolescent at-risk behaviors than numerous other countries.13 A recent comparison of the health in the United States and in England showed that the British population was healthier even after adjusting for behavioral risk factors.14 The study also showed disparities in health by socioeconomic status (SES) in each country, but most importantly, they found that Americans at the top of the SES distribution with excellent access to health care still were less healthy than people with low SES in England. Although the etiology of these findings is not clear, it is notable that Starfield15 ranked the United Kingdom first and the United States last in primary care of 10 Western industrialized countries in 1991. Good primary care, defined as "that level of a health service system that provides entry into the system...provides person-focused care over time, provides care for all but very uncommon or unusual conditions, and coordinates or integrates care provided elsewhere or by others,"16 exerts a positive influence on health costs, appropriateness of care, and outcomes for some common medical problems. In addition, there is growing evidence that disease onset in adulthood is related to childhood illness.17 The impact of a system of primary care or a medical home during childhood is associated with better individual and population health18 and can have significant affects on both child and adult health.
Unfortunately, our country’s already-limited system of primary care is breaking down. In 2006, the American College of Physicians (ACP) issued a report on the impending collapse of primary care.19 They noted that despite an explosion in the number of people with multiple chronic conditions, there is a dramatic decline in students entering internal medicine and family medicine. Medicare payment systems undervalue evaluation and management services and usually do not reimburse work outside of a visit or procedure. In addition, primary care physicians do not receive any benefit from savings created by quality-improvement efforts. Although the ACP report addresses the care of adults, similar problems also are present for pediatric primary care: an increase in the number of children with special health care needs, underpayment by public programs such as Medicaid, lack of reimbursement for telephone calls and care coordination, and absence of financial incentives to invest in and sustain quality-improvement efforts.
Pediatrics recognized early on that the present state of primary care in our country was unable to meet the needs of our patients. The "new morbidity"20,21 called on pediatricians to address chronic and developmental conditions such as behavioral and emotional disorders, functional distress, learning disabilities, and educational needs. Now the "millennial morbidities" 22 such as violence, obesity, family distress, and poverty call on pediatricians to change the social and physical environments in which children live. Thus, to achieve the optimal physical, mental, and social health and well-being for children, pediatricians and family physicians need to do more than just deliver traditional health care services. In 1992, the American Academy of Pediatrics (AAP) adopted the concept of a medical home,23 which expanded the principles of primary care to address the challenges facing children and their families. The medical home was defined as care that is accessible, family centered, continuous, comprehensive, coordinated, compassionate, and culturally effective. The goal of creating medical homes led to AAP policies defining new roles for pediatricians with families5 and communities.24
The ACP25 and the American Academy of Family Physicians (AAFP)26 recently embraced the medical home concept. There is now an opportunity to forge a consensus among the primary care societies (AAP, AAFP, ACP, and American College of Obstetrics and Gynecology) around the medical home and the future of primary care in the United States. By working together with a consistent message, we can advocate more powerfully for a system of primary care that will provide every person in America a medical home. We then can strive to build coalitions of patients and families, other physician groups, and other health care providers to achieve a healthier future.
Our health care delivery system needs to evolve beyond the needs of a century ago, when infection and injury were the primary causes of morbidity and mortality, to current needs to manage chronic conditions and influence social and physical environments. Creating a strong system of primary care requires that delivery of all components of a medical home are recognized and reimbursed appropriately, including after-hours telephone and other electronic communication, care coordination, interpreters, home-based care, and community outreach. In addition, universal coverage is a critical component to providing comprehensive and continuous care. We are paying for our failure to build and sustain medical homes for everyone through rising health care costs and lower health status.
Phillips et al call on pediatrics and family medicine to be partners, not competitors, in creating a Jacobian future of community-oriented care and advocacy. There is still a tremendous amount of work that can be done for children to improve the health of our nation, which can more than occupy the growing numbers of pediatricians and family physicians in the next few decades. The AAP and AAFP can collaborate on advocating for changes in Medicaid, the State Children’s Health Insurance Program, and private insurance that would facilitate medical homes for children and expand health care coverage. Collaborative education in family care, community pediatrics and community-oriented primary care in residency, and continuing medical education can build appreciation of the strengths of each specialty and foster partnerships in advocacy. Our children need both pediatricians and family physicians to provide every child a medical home and create a health system that will sustain it.
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FOOTNOTES |
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Accepted May 24, 2006.
Address correspondence to Richard J. Pan, MD, MPH, Department of Pediatrics, University of California, Davis, 2516 Stockton Blvd, Sacramento, CA 95817. E-mail: richard.pan{at}ucdmc.ucdavis.edu
The author has indicated he has no financial relationships relevant to this article to disclose.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
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