The President’s Message
The President’s Message: Get Ready for Value-based Pediatric Care
By Gerald P. Koocher, PhD
Congratulations! You’ve made it to the future, but watch out—almost everything you know about funding of healthcare services may soon be wrong. Most psychologists in practice today are used to a fee-for-service system where compensation ties directly to the number of service units we deliver.
Managed care was supposed to tweak that model into becoming more efficient by making sure that the units of services delivered qualified as “medically necessary,” “cost effective,” and (more recently) “evidence based.” In reality, the current healthcare system simply led to cost shifting in managed care. No one had any motivation to focus on the larger picture of how to deliver quality preventive care or well-integrated comprehensive approaches to managing complex chronic illness conditions. Instead, third-party payers sought to control costs using bureaucratic mechanisms that bore little relationship to promoting patients’ wellbeing.
We will soon witness a major restructuring of the healthcare system aiming at establishing and rewarding high-value integrated care. Proponents of such change have argued that insurers should prosper only when they act in ways that improve their policy-holders’ health (Porter, 2009). Porter and his colleagues argue that we should measure outcomes over a full cycle of care for a medical condition, not separately for each intervention. The argument holds that outcomes of care require multidimensional assessment, not focusing only on survival but also addressing quality of life including: the degree of health or recovery achieved, duration of care needed for recovery, comfort, and sustainability of recovery. Using the example of a comprehensive headache clinic, Porter argues for integrated provider teams and assessment of outcomes adjusted against patients’ initial conditions and case complexity (Porter, Guth, & Dannemiller, 2007).
Pediatric psychology stands well positioned to play a critical role in pursuit of these new directions. Our assessment skills will prove essential in measurement of health outcomes across providers and conditions. Our research on enhancing quality of life, treatment adherence, symptom control, parent training, and systematic human problem solving in the hospital and out-patient clinic has significant potential to address quality improvement. We have historically worked alongside pediatricians and specialists in ways that our psychiatric colleagues—focused on psychopharmacology and lacking meaningful training in outcome assessments—simply are not prepared to address.
Two prototypical models might include asthma and obesity in children. Both conditions lend themselves to effective combinations of preventive and rehabilitative care that can significantly reduce emergency department visits (in the case of asthma) and other health complications (type 2 diabetes in the case of obesity). Scores of studies have repeatedly demonstrated the value of behavioral interventions with these populations. The time will soon arrive when pediatric pulmonary and endocrine clinics without well-integrated behavioral components will be deemed substandard and suffer under new reimbursement models.
The key to effective integration in the emerging system will involve seeking out active partnerships that demonstrate the value added by pediatric psychologists in both primary pediatric care and the management of chronic pediatric conditions. Research aimed at integrating services, collaborative care, enhancing overall quality of care, and actively measuring shifting outcomes that result from these efforts will attract attention and funding. More importantly, initiatives that can demonstrate a value-focused difference will attract considerable attention and greater reward than simple procedure counting.
You know how to do this. What are you waiting for?
Porter, M.E. (2009). A Strategy for Health Care Reform Toward a Value-Based System. New England Journal of Medicine, 361, 109-112. www.nejm.org/doi/pdf/10.1056/NEJMp0904131.
Porter, M.E , Guth, C., Dannemiller, E. (2007). The West German Headache Center: Integrated Migraine Care. Boston: Harvard Business School Publishing.