One effective way to decrease overall costs would be to guarantee preventive health care services for all the state’s children.

In child health, prevention is the cornerstone. Prevention is cheaper than treatment of illness, healthier children grow up to be healthier adults, and health care for children is much cheaper than health care for adults. Health care for children is an investment; healthcare for adults is often payment for services long overdue.

We need to re-order our priorities, which will make the cost of health care much less in the long run. First we must offer universal access to preventive services. As long as we have a system that creates disparities in access to care, holes in health care will cause pockets of illness in every community, and these spread like wildfire through families, to newborns, the elderly, and the chronically ill, and through schools, churches, stores, and public transportation to whole communities.

Massachusetts needs to guarantee access to certain preventive child health services. The plan must be universal, simple to administer, seamless, and provided by health care professionals who know the children and have their medical records.

This guaranteed care could be limited to three basic services: first, interventions and medications that have proven to be most valuable. We have this data. Vaccines, for instance, are the most beneficial public health interventions since clean water. All children should be guaranteed full immunization. Impartial groups of experts, such as the Centers for Disease Control and the American Academy of Pediatrics, already designate which vaccines are essential for all children.

A second guarantee should be for services that a) screen for costly health care problems such as genetic disorders, diabetes, anemia, lead poisoning and TB, which if caught early cost much less than if caught late; or b) decrease accidents or conditions such as obesity. Thus all children should have access to their own health professionals for a pre-defined sequence of routine visits for preventive care. These screening tests have been chosen nationally and shown to be extremely cost-beneficial.

A third guarantee should be that all children have access to urgent and emergent care when they are acutely ill or injured. We know that early care prevents progress of asthma, infections or mental illness to severe and costly states. This care should include certain medications and therapies known to be effective. Minimum standards and the appropriate use of tests and medication have been established, but such basic medications and therapies should be available without exception in order not to create disparities in basic care.

This major shift to prevention is needed because of the Commonwealth’s need to decrease health care costs. We can accomplish this by establishing a three-tiered system.

The first tier is for guaranteed services agreed to be essential and cost-effective. Access, from the family’s perspective, must be universal, free, paperless, and feeless. A national template for Early Periodic Screening, Diagnosis and Treatment (EPSDT), the child health component of Medicaid, could provide guidance for such a schedule, but needs updating.

For coverage of second-tier services, the care and management of more chronic and acquired conditions, individual policies can be offered by insurance companies, who can compete on the open market for employers and individuals. These plans would offer a whole range of additional benefits, and can incorporate their beloved premiums, deductibles, and co-pays.

The third tier, coverage for disasters and overwhelmingly expensive services, needs to be considered in yet a third way, because as science and technology advances, many different options will arise, and ethical as well as financial issues become more central.

If we honestly want to save money, we need to establish basic health assurance for children in this state. To do that, we need to consider such a tiered service structure. We cannot afford to let barriers, financial or physical, hinder access to the most essential, most cost-effective services required for general child health.

Sean Palfrey, M.D., a pediatrician at Boston Medical Center, is a past president of the Massachusetts Chapter of the American Academy of Pediatrics (AAP), Founder and Director of the Immunization Initiative of the Massachusetts Chapter of AAP, and a Clinical Professor of Pediatrics and Public Health at Boston University School of Medicine.

One approach that I feel should not be used to accomplish this mission, as it relates to physicians, has become known as “tiering,” a process that, in theory at least, is supposed to improve physician performance as it relates to efficiency and quality. This program, currently using claims data from health plans, is being used now by the State’s Group Insurance Commission for its 285,000 state employees and retirees. Similar physician rating programs have come under fire (and the object of lawsuits) by physicians in Washington state and Connecticut. And New York’s Attorney General has called the practice into question, saying it could be deceptive and confusing.

I am not opposed to cost and quality measurements. Indeed, I welcome whatever information that will help me improve patient care and outcomes. But I am concerned about unintended consequences of the current system of tiering; I believe it is simply the wrong approach.
Some of the flaws: The current system uses years old claims data; the data has little clinical relevance; physicians are not given the data for validation before it is made public; little information is available to physicians, and in too many cases, the information that has been available has contained errors. Also, the health plans providing the data vary so much in their methodology, that the same physician, rated with the same data, can be placed in different tiers by different plans.

Furthermore, for group practices, individual tiering creates costly administrative havoc for patients and office staff trying to accurately assess different co-pays for different physicians in the same group covering each other’s patients. Since the data available to physicians and patients is not actionable for physicians to improve cost and quality, the system is essentially punitive for both physicians and patients and does little to improve the overall system of high quality efficient care. The result is confusion for physicians and patients and potential harm to quality care and the doctor-patient relationship.

To its credit, the Group Insurance Commission and insurers have listened to the concerns of physicians and instituted many changes. But the potential for unintended consequences still exists: Physicians’ reputations could be harmed, access to care delayed, and costs unfairly shifted to patients. While we continue our dialogue and exchange perspectives with the GIC and health insurers to reach common ground, let me offer an alternative way to measure cost and quality.

National leaders on quality improvement such as Dr. Donald Berwick have emphasized that successes on improving quality in other industries such as airlines have focused on re-engineering the system rather than on blaming the individual (i.e., victim as well) and only trying to change individual behavior. In the health care industry, Blue Cross has been a leader in this model by providing positive incentives to physicians to do electronic prescribing. As an example of a systems change, this prompts physicians to prescribe less costly generic drugs and monitor drug interactions, side effects, and allergies and eliminates the risks of patient harm from hand-writing problems with drug doses.

We are all agreed on the same goal – to improve quality, control costs, and enhance patient care. We need to make sure that the tools we use to reach that goal are the right ones. Dolores Mitchell, Executive Director of the state Group Insurance Commission, in a September 4 posting on this site, said “In the last analysis, giving patients information is the best consumer protection – and the best road to lasting health care reform.”

No argument there. But that will happen only if that information is accurate, reliable, timely, meaningful enough for patients to benefit, and significant enough for physicians to act on and improve patient care.

Michael W. Yogman, M.D. is a pediatrician in Cambridge, Mass.

Carl A. Soderland, M.D., M.P.H.
Division Chair, Community Medicine, Lahey Clinic and
Medical Director, Lahey Northshore