In the Literature
Incremental reform will not solve the problems plaguing the U.S. child heath system, contend UCLA researchers in a new Commonwealth Fund–supported study. The current system—fragmented, underperforming, and fraught with inefficiencies—will require bold, long-term, transformative changes to provide children with a healthy future, they say.
In "Transforming the U.S. Child Health System" (Health Affairs, March/April 2007), Neal Halfon, M.D., and colleagues call for broad reforms to create a more comprehensive approach to optimizing children's health and health care. Specifically, they recommend: establishing a federal agency to consolidate existing funding and planning for children's health initiatives, improving early childhood services and systems, using health information technology to coordinate care among health care providers, and organizing local child health development systems to manage care delivery.
"[T]the current system cannot achieve expected performance goals because it is powered by outdated logic, outmoded organization, and inadequate and misaligned finance strategies that were designed to be responsive to the epidemiology and health goals of the early part of the twentieth century," contend Halfon and his coauthors.
A Transformation Framework
While the U.S. health system delivers some of the finest medical care in the world, the persistent and growing gaps in access to services and the quality of care are well documented. Compared with other developed nations, the U.S. maintains higher rates of infant and child mortality; higher prevalence of asthma, child obesity, and injuries; and rapidly increasing rates of mental health problems. Based on the magnitude of the problems facing the child health system, the authors propose an agenda for radical system change.
A new logic model. The authors propose replacing the current model of child health—highlighted by an episodic, biomedical, diagnose-and-treat model—with "a more comprehensive and holistic approach to optimizing health development." At its core, the model would focus on prevention, health promotion, and the development of health potential. Parameters of care would be broadened to include psychological, social, and other non-medical factors that can influence patterns of risk, treatment response, and other factors determining long-term health development.
Organizational and financing changes. The new model for U.S. child health care should, the authors contend, be organized and financed differently than the current patchwork system that rewards episodic care. As opposed to vertical integration of today's medical system around primary, secondary, and tertiary care, the researchers envision a system that will also be "horizontally" and "longitudinally" integrated through "productive partnerships across medical, public health, and civic (e.g., education and social services) sectors, as well as innovative service delivery platforms such as comprehensive school readiness centers that can serve as hubs of integrated service delivery."
Financing reform would necessitate better integration of funding streams to support integrated services, as well as fund population health initiatives. New financing instruments that transcend the limitations of insurance should be considered to invest in long-term health capital, and to fund the infrastructure needed to support population-level health optimization.
Designing a New System
The new child health system the authors envision would focus on optimizing health outcomes, which would be linked to measurable progress indicators. It would be integrated vertically, to organize services and distribute resources according to severity and need; horizontally, to address the interacting influences of family, social, economic, and environmental factors; and longitudinally, to provide continuity of developmentally appropriate care and services across a child's life.
A new federal Child Health Development Agency would consolidate and reorganize existing funding streams, and Regional Child Health Development Trusts would be created to organize and integrate system-level funding, planning, and performance. At the community level, local Child Health Development Systems would organize, integrate and manage delivery of care. An information system would integrate personal and population-based health information to support clinical decision-making and improved performance.
Halfon and colleagues recognize there are serious challenges to transforming the child health system, among them, engaging stakeholders, executing a broad policy agenda over a long time frame, and bringing child health policy issues to the forefront of the political agenda. To address these and other challenges, they also offer policy steps to bring about change. One suggestion is to develop a strategic vision to jump-start the process, as the U.K. did in 2004 when it established the National Service Framework. Another is to disseminate innovative system changes like California's First 5, a public–private partnership that uses flexible funding to fill gaps in child health services.
"The gap between how our system is organized and performing and what the child health system is capable of providing is now a performance chasm that can only be bridged by adopting a new vision and approach," the authors conclude. "Realizing major health policy reform for our nation's children not only is in their best interest but also is an important down payment on our country's future."
Access and Quality Gaps in the Child Health System, 2005
|Access to Care|
|Percent of children under age 18 with no health insurance||16|
|Percent of children with special health care needs and no health insurance||30|
|Percent of children under age 18 who do not have primary care physician or medical home||54|
|Quality of care|
|Percent of children under age 18 not seen by a health care professional in previous year||12|
|Percent of children under age 18 reported to have had both preventive medical and dental visit in previous year||59|
|Percent of EPDST-eligible children under age 18 who receive preventive dental visit||23|
|Percent of children ages 19–35 months receiving recommended series of vaccines||75|
|Percent of children ages 12–18 years receiving needed mental health services||30|
|Source: N. Halfon, H. DuPlessis, and M. Inkelas, "Transforming the U.S. Child Health System," Health Affairs, Mar./Apr. 2007 26(2)315–30.|