Pediatricians traditionally focus on the care given to patients as they come into the office, one after the other. There is little choice but to be there and wait for them. Before the advent of modern technology, there were not tools to manage patients as a group – for instance, those who need specific preventive measures or those afflicted by a common disease or condition (asthma, obesity).
Up to now, a predominantly fee-for-service (FFS) payment system has encouraged episodic face-to-face encounter activities with individual patients. In this environment, it has even been difficult to be paid for episodic group encounters to educate patients with the same condition. It's true that some, to their enormous credit, have taken the time and effort to advocate and care for children in different venues, but this work has been done pro bono, on one's own time and one's own dime.
Times, however, are changing. New technologies such as digitalized billing records and electronic medical records and new communications media now give capabilities to know about and to reach patients and communities as never before. The scientific knowledgebase is increasing as well, due to investigative work on prevention and the social determinants of health (especially poverty), and the development of new interventions. Even payers are starting to change, as they develop Alternative Payment Methodologies. Practices may finally be paid for services beyond individual, face-to-face encounters. It is also possible that as pediatric practices coalesce into larger groups, their greater financial and organizational strength might facilitate harnessing the new technologies, although it is certainly true that agile smaller practices can also devise innovative ways to manage groups of patients.
In sum, although it is too early to tell, it is possible that pediatrics may be entering an era where Population Health (PH) interventions are feasible. Public health and health policy experts have long looked at populations and tried to discern what interventions would create the best outcomes for the greatest number, while clinicians have cared for patients on a one-by-one basis. New technologies can enable clinicians to apply public health perspectives to practice. Perhaps the new PH mindset is best thought of as a change from passivity to proactivity of the clinician group. While the individual relationship of patient to doctor must never, ever be lost, and still comprises the essence of pediatric practice, the ability to reach out actively to groups is novel and offers powerful and exciting new possibilities.
To make this abstract concept of PH more concrete, here are some possible applications:
Within a practice from practice records
- General Surveillance
- Discover the size, general demographics, chronic disease incidence, and psychosocial factors of the practice
- Redesign practice emphasis on basis of these findings – e.g., employ mental health specialist, establish relationship with food bank
- Budget, plan, and contract on basis of these newly discovered factors
- Identify groups with particular needs
- Institute call-back program for under-immunized patients
- Institute call-back program for patients missing well visits
- Disease Monitoring:
- Create registries and flowsheets
- Asthma registry
- Identify children with asthma in the practice
- Identify those children in need of flu shots for call-backs
- Identify those children with inhaled corticosteroid delays, excessive rescue treatments
- Identify those children who could benefit from group educational and support visits
- ADHD registry
- Identify children with ADHD missing follow-up visits for call-back
- Identify children with medication anomalies for investigation
- Send surveys to schools requesting feedback on progress
- Identify children for possible group educational and support visits
- Registries of children with significant conditions but with low frequency
- Identify children with medical complexity
- Identify children with specific diagnoses – e.g., with complex seizure disorders – to educate clinicians on best practices and to document course and treatment comparative histories
- Arrange for group meetings and self-help and education
- Age-related issues
- Identify age-specific groups for mass educational emails or texts
- Survey age group for information – what issues do people want addressed at visits, etc.
- Socio-economic and ethnic groups
- Identify children at risk for poverty associated conditions – food or housing insecurity
- Ensure special services addressed at visits, or call-backs
- Identify children at risk for language problems
- Inquire about school status and progress and advocate with parents and school
- Groups with common insurance within practice
- Survey for insurance-mandated P4P issues and call-backs
- Examine managed care patients lists to reach out to those who have not visited yet
- School-based populations
- Coordinate health education services with schools
- Coordinate with schools to survey for depression, orchestrate behavioral health services in the school
- Work with other medical practices covering the population to develop common and cooperative approach
- Work with coaches for concussion services
- Work with schools on meals and nutrition
- Housing areas
- Survey for physical exercise venues and possibilities, work with public officials and organizations to improve if necessary
- Represent children in political issues with officials, organizations
- Advocate for progressive state immunization policies
- Advocate for safe playgrounds in city planning and development
Requirements for Progress
As noted above, some preliminary experiences suggest that adoption of PH in a pediatric practice can be rewarding and impactful. To enact a PH agenda, pediatricians must be willing to increase their alertness and sensitivity to community needs and resources and to espouse innovation, and payers must pay for the true costs of this work. Other institutions – public health departments, social service agencies, and educational institutions - also need to be cooperative, flexible, non-bureaucratic, and innovative themselves. Payers will have to understand as well that pediatrics is not just like adult medicine, and that pediatric practices cannot be squeezed into an inappropriate adult straight-jacket of measures and programs. Those in practice will have to understand that when seeking to be involved in new spheres of action, not everyone will initially view this as a positive.
In addition, training institutions will have to better prepare residents and fellows for these changes in practice. Clinicians imprint quality practice habits from their training programs; if residencies continue to concentrate only on individual medicine, PH will languish. Instead, the training programs need to build upon their programs for advocacy, look to the leaders in PH, many of whom are not academically based, and bring their experiences, concepts and practices into the academic clinics, where residents can be inspired and instructed.
Pediatricians have proven their idealism time and again. The pediatric profession embraces a high standard of devotion to children and families; but as everyone in practice understands, in the end it comes to this: no margin, no mission. If payers, both governmental and private, can transition their payment methods from FFS to alternative models that actually pay for the costs to implement effective PH practices, the profession will respond, and care delivery and health care outcomes will improve.
The hazards are many on the road to implementing PH, but the potential rewards of better health for patients and communities, and of significantly increased professional satisfaction for pediatricians, should justify the hard journey.