Chaos of consumer centric care

Last week, I outlined my 30k-foot view of the current lack of continuity in our healthcare system. The gradual decline of our ability to embrace the value of a continual relationship with a trusted healthcare team or provider has been the greatest frustration of my 30 years in pediatrics. Patient-centered care has pivoted to "consumer" centered care. Sorry, I don't get it, nor do I see how it is helping us offer better care or lower healthcare costs. The investment in workarounds, fragmentation, dilution of care doesn't seem to be really helping anyone. Costs are rising, consumer frustration is rising, clinician burnout is rising, and outcomes seem to be worsening... Am I missing something?

This week, I have outlined my perspective as a parent, pediatrician, entrepreneur, and pediatric emergency physician. The diagram above highlights for me how screwed up our current "innovation" and investment in workarounds is destroying pediatric healthcare. If you can look at this diagram above and tell me it makes any sense, I would love to hear your rationale.

I am repeatedly told that patients are consumers and they need choices, convenience, and access to care. The consumers should be empowered to make their own decisions, and giving consumers access to any care is better than no care at all. Sorry, I don't believe it nor do I see it in the ER, where often the random care is making children worse not better.

Parents are overwhelmed with the demands placed on them for their children to receive care. Outside of the routine well-child examination, the demand for pediatric care is coming from too many directions. Schools, sports teams, and camps have increased their demands for kids to be tested, treated, and have notes for parents and children to return to school or work. Parents are asked to leave work and not come back until this "paperwork" is in hand. My cynical side over the past 30 years would suggest much of the "urgent" need for convenience and access has little to do with the needs of parents or patients but rather their need for a note.

Parents of "patients" actually have genuine concerns about their children and need guidance and reassurance. Parents have not changed in this regard, and sick visits are often really a need for parents to get reassurance and assurance from someone they can trust. As a matter of fact, nurse triage can handle 80-90% of these concerns and save money based on the literature.

Add to this demand on parents the ongoing and escalating crisis being inflicted on our children's mental health from social media, COVID response, etc. It's hard to imagine how parents can keep up or find the resources and reassurance they truly want and need. Mental health and behavioral health, unlike "sick care," cannot be done effectively in the manner outlined in the above diagram. Continuity and relationships are vitally important to this care. More consumption is not the answer from random providers at random times in random places. I will also tell you that the pediatric emergency department is absolutely the best place for a medically ill child but but is likely the worst place for a child with serious mental illness. Its but true, based on my experience. So while we respond to the mental health crisis by "doubling down" on this fragmented sick child model, we are not improving anything in my opinion. Urgent cares, apps, bots, virtual on-demand mental health visits, retail mental health, and the Emergency Department as the holding area for these children who fall through the cracks are fraught with problems for the consumer.

So what should we do?

We should partner with schools, daycares, etc., to help them understand the ripples of their policies and demands on families. They need to begin thinking about the downstream impact of their actions and, rather than contracting with "random providers," think about how we can better partner with local providers, especially a child's medical home. Could we do away with the need for a "doctor's" note? Could we connect a child to their doctor? Could we keep parents at work and kids at school more?

We should begin to inform families that all care is not the same and that true value comes from a continuous and longitudinal relationship. If you have a choice, choose the physician, clinician, or practice that you know and that knows you. Random care will provide you with more costs, more visits, more prescriptions, and will not address the "other things" that are impacting your overall health. If you don't have a choice, choose wisely and ask key questions to find the right care. At minimum call your child's physician or nurse line to guide you to the best care. Could we pay primary care to offer more continuity like nurse visits and triage, integrate mental health? Seems better than paying for more urgent care and ED visits?

Primary care needs to ensure they are accessible to families. My bet is that primary care offices spend more time tracking down paperwork on patients they didn't see than the time spent on a sick visit or seeing a newborn or hospitalized patient. Why not have walk-in hours for sick kids, connect virtually with schools, add all-day nurse triage, and even consider virtual rounds on your patients in the hospital? We need to show families through our actions that relationships matter. Could we stay connected with families more than just when they show up at the office?

We should demand that those disrupting relationships demonstrate better outcomes for their "consumers." It's time we ask for transparency on the total cost of care, prescriptions, etc. Quality metrics should be monitored, measured, and made transparent. Convenience is not a quality metric. No, we should begin to examine clinical outcomes. Is any care better than no care? I am not convinced this is true based on my ED experience. Could we get more kids connected to primary care? Could we have nurses offer reassurance and guidance instead of online prescription writers? Could us physicians and clinicians stop signing up to offer lesser care virtually with random patients?

We should stop all the fragmented offerings to the same child. A child can be seen by so many different providers in so many different ways, and there is rarely anyone overseeing the care. Primary care providers rarely receive notes from these providers or have any communication. It's randomly random to get any information. If we can't stop the fragmented offerings, could we raise co-pays and costs for those demanding care without relationships? Could we pay providers more who have a continual relationship? Could relationships be recognized and paid across state lines?

We should ensure children are seen by well-trained and experienced clinicians. Kids are not little adults, and although I didn't outline this in the diagram, kids being cared for by random providers who have little training or experience contribute to worse outcomes. Retail, urgent cares, and emergency departments are not all the same. We should be transparent with the qualifications of the "providers" that children are seeing. I am amazed at how many children I see after they have seen a random provider and come to the ED on unnecessary medications or with missed conditions. All care is not the same, and "buyer beware" shouldn't need to be part of our healthcare system. Could we outline what it means to be a pediatrician? pediatric nurse practitioner? family practice? and can we empower families to be enlightened to who they will see prior to a random visit?

We should outline the return on investment (ROI) of investment in all these offerings that seem to attract investor dollars. The investors may find some revenue or lots of revenue in driving more and more care, but our system, our clinicians, and our patients are losing. Let's invest in how we can strengthen relationships. Could we add clinical outcomes to the due diligence of investors? Could we ensure clinicians are part of the teams who receive investment?

Finally, policy should follow the outcomes we want to achieve. If we want better outcomes with lower costs, then it's time we pay more for continuity. Why can't established relationships be paid for chronic care management, care coordination, integrated mental health, virtual care visits, nurse triage, and more? I can take care of a child for 18 years, but when they go across a state line, should they find a random provider? or if my patient lives 5 miles away but is across a state line, I can't offer them care virtually? Odd, don't you think? Could we ensure relationships, continuity and primary care are part of every policy?

Overall, we are failing faster and faster. The chaos of consumerism and convenience is the wrong path for children's sick care, primary care and an even worse path for our mental health crisis. It's really time to rethink our approach to healthcare and the continual chaos that we keep supporting.

Note: As a reminder this newsletter is written from my experience and perspective. The newsletter does not imply or relay the opinions of others.  The intent is to offer an avenue for dialogue and discussion around important topics in healthcare and healthcare innovation from one doctor’s perspective.  I am a physician and so can only write from my perspective. If you are clinician, provider, nurse or whatever my goal is to enable you to agree or disagree. I have no intention to suggest or imply that only the physician perspectives matter.  They do matter but as part of a larger dialogue that can foster better health outcomes.