A quarter of a century ago, when I completed my residency, the health maintenance organization (HMO) was the new promising model for healthcare. Primary care and preventive medicine would triumph. The all-mighty powerful primary care gatekeeper would prevent unnecessary procedures. The population would become healthier and costs would plummet. The reality of the HMO has not lived up to this promise. We have the highest medical costs ever, we are not healthier, and our infant mortality rate ranking has dropped to 51st in the world, worse than Bosnia, Malta, and Polynesia.
The HMO movement attempted to curb expenses by creating the primary care gatekeeper, yet medical costs continue to spiral out of control.
Instead of empowering the PCP, the gatekeeper role positions physicians in the crosshairs of the battle between the patient and the insurance company. We spend our days careening between fighting for necessary care for our patients and fighting against demands for unnecessary tests and referrals. Patients have become cynical, and the bond of trust between the doctor and patient has eroded.
Now we are preparing for the next novel system to contain medical costs, the accountable care organization (ACO). With the ACO, a set of health providers—primary care, specialists, and hospitals— work collaboratively and accept collective accountability for the cost and quality of care. The ACO puts the risk and incentive on providers and health systems, which can profit if population health strategies are used and the population uses fewer medical dollars. I recently was at a presentation describing how a Texas health system invested in prenatal and postnatal programs and reduced NICU occupancy by 32%. One-third fewer extremely premature infants born to either die or require medical care for years. Do we finally have a model that will truly work to prevent illness?
During the presentation, I pictured one of my patients, a former 25-week premature infant, a smiling, friendly, nonverbal boy in a wheelchair. Recently I was typing a Letter of Medical Necessity for repair of this boy’s wheelchair, one of countless letters written to obtain essential services for this patient. What would this boy’s life be if the medical system had taken better care of his mother and he could have reached his full potential? If he had the gift of speech, what would he say to an insurance company that does not want to repair his wheelchair?
One of the joys of general pediatrics is caring for newborns in the well-baby nursery. It is amazing how profoundly the parent falls in love with their tiny newborn. The air is filled with the sense of hope and endless possibility. When I tell the mother that her baby is healthy, I frequently see tears of gratitude in reply. I wish these happy tears on more parents.
Happy and healthy babies and children grow up to become healthy adults. The roots of many long-term expensive adult problems—substance abuse, depression, obesity, heart disease— are planted in childhood and adolescence. But pediatric health is a long-term investment that requires delayed gratification and patience, and humans want a quick fix.
The study in Texas concentrated on the relatively brief 9-month period of gestation in a controlled environment, the womb. The rest of life is impacted by many forces much more difficult to modify. Pollution, violence, poverty, toxic childhood stressors— the list is endless. For so long, physicians have focused on the immediate problem in the exam room and not addressed the root causes of illness and poor health. The ACO shifts the refractive lens of healthcare systems. Can we start to work on the solution from the beginning and prevent illness and not simply deal with disease and its aftermath?
Promoting healthy babies and children is the solution to ballooning medical costs. It is also the hope for our future. Let us hope the ACO will be the economic driver to finally invest in our children.