A more effective strategy would be to design insurance and care around what patients need, then reward hospitals and physicians that provide that care in a high-quality, patient-centered, cost-effective manner. Patient incentives can play a supportive role by urging patients to be active partners in their care, encouraging healthy behavior, or removing financial barriers to preventive care. But it is important not to lose sight of the central objective: to provide care of scientifically proven effectiveness, delivered in the way and at the time patients want it.

One of the most exciting recent developments is "advanced access," a process by which doctors' offices and clinics redesign their practices to provide same-day appointments. In Boston, the Institute for Healthcare Improvement has brought practice teams together to learn effective techniques. In New York, the Fund provided support that enabled the Primary Care Development Corporation to create learning collaboratives that have transformed primary care clinics serving low-income patients.⁽²⁷⁾ Because patients are able to get appointments quickly when they need them, missed appointments are reduced, physician time is used more efficiently, patients are more satisfied, staff members feel less hassled, and everyone wins.

A few pediatric practices around the country are also responding to the concerns of parents, who want to know if their young children are growing and developing normally and who want help with behavioral problems, as research by the Fund has shown.⁽²⁸⁾ The Fund has supported a number of promising approaches. Healthy Steps, which adds developmental services to pediatric practices, has greatly increased parents' satisfaction with care, improved the quality and continuity of care, reduced use of severe physical discipline by parents, and fostered loyalty to the practice.⁽²⁹⁾ In another Fund-supported model, Assuring Better Child Health and Development (ABCD), coordinated by the National Academy for State Health Policy, four state Medicaid programs have helped ensure access to developmental services for low-income parents and children.⁽³⁰⁾ By incorporating child development appraisals into regular well-baby visits, ABCD has raised levels of parent satisfaction, helped pediatric clinics respond to parent concerns, and increased specialized services for children with behavioral or developmental delays. In general, however, current financing systems do not reward approaches such as these, and changes will be necessary under Medicaid, the Children's Health Insurance Program (CHIP), and private insurance if they are to spread more broadly.