PEDIATRICS Vol. 120 No. 5 November 2007, pp. 1123-1125 (doi:10.1542/peds.2007-1471)
COMMENTARY |
Continuity, the Medical Home, and Retail-Based Clinics
Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado; Pediatrics, Consulting Editor for Health Policy
Abbreviations: AAP, American Academy of Pediatrics
The emergence and rapid spread of walk-in clinics staffed with nurse clinicians in retail stores and shopping malls challenges both medical and nonmedical communities to consider the relative priorities of continuity and the medical home compared with convenience and cost. Continuity of care has 3 dimensions: time, accessibility, and setting. The time dimension refers to having the same pediatrician (or clinician team) care for a child over a considerable period of time, optimally for many years, so that the pediatrician can develop a long-lasting relationship with the child and his or her family. Having continuous care allows for deeper understanding of the past as well as present issues that impact the child's development, health, and well-being. The accessibility dimension refers to ensuring that the family will be able to contact the pediatrician or a member of the coverage team 24 hours a day, 7 days a week, and be able to get needed care promptly in an appropriate medical setting. The setting dimension refers to coordinating care across multiple settings including the hospital, physician outpatient office, school, home health care agency, and, if necessary, hospice program. Continuity of care is important for both pediatric primary and subspecialty care. In several situations a subspecialty pediatrician, such as an oncologist, may provide continuous care and assume the care-coordination responsibilities.
For more than 3 decades pediatric residency training programs have attempted to "teach continuity" through the establishment of continuity clinics in which residents care for a panel of patients. Because most residents only attend these clinics 1 or 2 half-days per week, continuity over time tends to be limited to scheduled preventive care and chronic care visits. However, even this limited amount of continuity is being eroded when a higher priority is given to inpatient rotations on ICUs, night-call coverage schedules, and limitations on resident working hours.
The erosion of the continuity experience in residency training is also mirrored in private practice because of several internal practice reasons and external health care system reasons. More pediatricians are practicing in larger groups and share patients among several partners. More pediatricians are no longer involved in caring for their patients who require hospitalization. More pediatricians use after-hours call centers and no longer take calls or see patients in their office or an emergency department after hours. Pediatricians currently have a more limited amount of time to spend with families during their visits. On average, they are spending only 18.3 minutes with families during a well-child care visit.1 These shorter, less comprehensive visits are less satisfying to the families and pediatricians and undermine the value of continuity. Health plans attempt to purchase services at the lowest price possible, which forces pediatricians to accept unreasonably low payments for services, and often reimburse pediatricians less money than it costs to purchase and administer vaccines. To remain financially solvent despite these low payments, pediatricians see increasing numbers of children for shorter visit times. As patient volume increases, the practice becomes less efficient, because pediatricians must to hire more administrative staff for billing and authorization paperwork.
There are also structural problems in health care that undermine the ability to provide continuity of care. More families are being forced to change health plans yearly when they decide to change jobs or their employers choose a less costly health plan. Changing health plans often means changing physicians. Having so many children with gaps in insurance coverage also impacts continuity of care. On the basis of data from the Medical Expenditure Panel Survey, the American Academy of Pediatrics (AAP) found that 21 million children 0 to 21 years of age were uninsured for all or part of 2004; 9 million were without coverage for the entire year, and 12 million experienced gaps in coverage sometime during the year.2
Although there is considerable support for the medical home concept by state and national policy makers and medical home language is being included in several state and national legislative proposals, there is a disconnect between what is happening in the real world of pediatric practice and the world that the AAP and other professional societies would like to see. Continuity is considered to be a core value of practicing pediatrics by the AAP and is the foundation of the academy's conceptual framework of a "medical home." What started as a concept for children with special health care needs in 1967 has been extended to all children and, more recently, to adults.3 In February 2007 the primary care societies, including the AAP, American Academy of Family Physicians, American College of Physicians, and the American Osteopathic Association, released a statement: "Joint Principles of the Patient-Centered Medical Home."4 These principles include the following: First, each patient should have an ongoing relationship with a personal physician who has been trained to provide first-contact, continuous, and comprehensive care. Second, the personal physician should lead a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients. Third, the personal physician should be responsible for providing for all the patient's health care needs or taking responsibility for appropriately arranging care with other qualified professionals, including care for all stages of life: acute care, chronic care, preventive services, and end-of-life care. Fourth, care should be coordinated and/or integrated across all elements of the complex health care system (eg, subspecialty care, hospitals, home health agencies, nursing homes) and the patient's community (eg, family, public and private community-based services). Fifth, care should be facilitated by registries, information technology, health information exchange, and other means to ensure that patients get the indicated care when and where they need and want in a culturally and linguistically appropriate manner.
In the real world, we are beginning to see retail-based clinics that serve adults and children open up in department stores, discount warehouses, pharmacies, and grocery stores throughout the country and are becoming popular with families.5 Although professional organizations and politicians embrace continuity and the medical home concepts, the emergence and expansion of these retail-based clinics demonstrate that enhancing convenience and reducing costs may have a higher priority for many families, as well as health plans, than enhancing continuity.
Supporters of these clinics say that they are a cheaper and better alternative to hospital emergency departments, especially for uninsured patients and Medicaid patients who cannot find a regular source of primary care. They also point out that it is easier for working mothers and fathers (especially single parents) to bring their children to a retail- based clinic after work where they can also do some needed shopping. One-stop shopping and health care may result in some children receiving care that they otherwise might not get. Most of the clinics say they have referral or consultative arrangements with local physicians or clinics. Detractors voice concerns about whether the consultative and referral arrangements will be adequate and that the clinics will fragment care and disrupt attempts to have a unified medical chart. Will the nurses who staff these clinics have the training to care for children with special health care needs who present with an acute illness or to correctly diagnose more severe conditions that present with common symptoms? Concerns have also been raised that nurses who staff the clinics in drug stores will be encouraged to prescribe antibiotics and other medications. Drug stores may be willing to subsidize the operation of these clinics to capture the income from the sale of pharmaceuticals.
Pediatricians must face the challenge of retail-based clinics to continuity and the medical home by enhancing continuity in pediatric training programs and pediatric practice and by demonstrating how continuity improves quality. Both training programs and practice must strive to achieve continuity and improve access to care, quality of care, practice efficiency, convenience, and patient satisfaction. The "Joint Principles of the Patient-Centered Medical Home" statement5 and the AAP statement on retail-based clinics6 both encourage physicians to enhance access with open scheduling, expanded hours (evenings and weekends), and new options for communication among patients, their personal physician, and practice staff. The emergence and expansion of well-funded retail-based clinics requires a reappraisal of how we practice and how public health programs and private health plans pay for services. Our challenge is to clearly demonstrate the value of continuity and the medical home on quality and cost. Failure to meet this challenge will allow retail-based clinics to expand and become a dominant player in the marketplace.
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FOOTNOTES |
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Address correspondence to Stephen Berman, MD, Children's Hospital, 1056 E 19th Ave, B032, Denver, CO 80218. E-mail: berman.stephen{at}tchden.org
The author has indicated he has no financial relationships relevant to this article to disclose.
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[Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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