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Well-Child Care: Fixing a Broken System

More and more, well-child care, as practiced in the United States, is failing to meet the needs of children, families, or even providers themselves. Recent studies have shown that many children do not receive the preventive care recommended by professional guidelines, parents have unmet needs for guidance and education, and providers are struggling with time and resource limitations. We spoke with David Bergman, M.D., associate professor of pediatrics at the Lucile Packard Children's Hospital at Stanford University, about his vision for a new, flexible model of well-child care.


You argue that well-child care today is "broken." What exactly is wrong?
David Bergman: It's simply not meeting the needs of families. Well-child care in the U.S. is a one-size-fits-all model that doesn't easily allow pediatricians to tailor the frequency and content of visits to meet the needs of kids. A well baby with no problems gets the same 18 minutes as a child who comes in with a complex condition, such as asthma, or a significant behavioral or developmental problem.


It's also broken in terms of the burden placed on providers. The content of well-child care [as outlined by the American Academy of Pediatrics' Bright Futures project] for the first few years of life is daunting for providers to accomplish. Many can't even begin to comply. Not only that, they may not have the training and skills to do what's necessary. The idea that the pediatrician or the family physician is the primary provider of well-child care is just not working. We need flexible health care teams—including medical specialists, developmental specialists, mental health professionals, nurse coordinators—that are tailored to the specific needs of the child.

The third way that it's broken—and this is more profound and difficult to deal with—is the financing system. Most pediatricians are paid on a fee-for-service basis, which makes it very difficult to innovate. They may not be reimbursed by the insurance company or health plan for innovations such as e-visits. Additionally, many of the allied health care professionals who would be part of the team are also not reimbursed under most current health plans. Significant change in well-child care has to be coupled with changes in financing.

What are the consequences of our broken system for children?
Bergman: The consequences for kids are lost opportunities. We know that there is a tremendous amount of developmental and behavioral concerns raised by parents that are not addressed. There's also a lost opportunity in not paying attention to what's going on in families. For instance, we know a significant number of mothers and fathers experience depression, and there is incontrovertible evidence that it adversely affects kids, but we do nothing about it. Another lost opportunity is not empowering kids and families to take care of themselves. It's hard to talk about healthy behaviors in 18 minutes.

In a nutshell, what is your vision of an ideal system of well-child care?
Bergman: First, we have to have some sense of biopsychosocial risk. A lot of this can be determined at birth: Is the child born premature? Does the baby have a congenital defect? Is the family situation chaotic? These are all risk factors. We then have to assign the content of care according to the level of risk. High-risk kids need more visits with a different mix of health care professionals.

We also have to tailor care by collecting information before each visit and understanding parents' concerns. That way, when we get to those 18 minutes, we can address their needs. In terms of financing, we need to align incentives to more appropriately reimburse for kids with special health care needs. This can be done through tiered capitation—defining kids at a level of biopsychosocial risk and assigning a capitated rate. Leveraging new technologies is also key.

Is good well-child care more expensive to provide? Are there examples of care that is low-cost but also high-quality?
Bergman: The highest cost we have is face-to-face visit time. Savings can be accrued—and reinvested—using innovations like virtual visits and secure messaging. The challenge is convincing providers and families that the "doctor's office" doesn't have to be a physical building. Then, through cost-shifting, we can take a bit away from low-risk families, in terms of dollar cost, and offer it to high-risk families.

There may be other models of care out there. One is a bit heretical: do physicians need to be providing well-child care? We're one of the few developed countries in the Western world where board-certified pediatricians provide well-child care. Could we get more leverage from the dollar if we had other practitioners, like public health nurses, provide the care? It's certainly a model that is used elsewhere. It allows providers or physicians to focus more on the kids who present with well-child care problems and complex medical conditions.

September 2006

Editor's Note: David Bergman's new report, A High-Performing System for Well-Child Care: A Vision for the Future, was published by The Commonwealth Fund in October 2006.

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