New Paradigm Needed for Primary Care

A recent blog post of mine, in which I describe a visit with a family whose toddler was not sleeping, was reposted on another blog, kevinmd.com (which offers an excellent collection of articles related to health care). It received the following comment:

How exactly does a general pediatrician bill for a “full 50-minute visit” to discuss toddler sleep problems. No insurance company would pay for it anyway. Most private practice pediatricians would be out of business with this sort o advice. This doesn’t seem very realistic for the general pediatrician

Another wrote that, "This is exactly the kind of visit that can be delivered with a cash-only practice."

This is absolutely not true. I have been taking care of children in this way for many years in the setting of a busy small town pediatric practice. All insurance companies reimburse for a 50 minute visit for a behavior concern. I use standard pediatric billing codes. As I am the identified "behavioral pediatrician" in the practice I devote several hours a week to these longer visits. For many years I did this in addition to the full range of pediatric care, including check-ups, ear infections, sick asthmatics, etc. About 4 years ago I stopped doing primary care, not because this model of care did not work, but only because the needs of my 2 school age children made taking call very difficult.

This rather angry fatalistic attitude of these two readers brought to mind a terrific article from last week's New York Times entitled Delivering Better Primary Care It addresses the impending onslaught of 40 million new patients into a primary care system that is already overburdened and undervalued. Much of the article is devoted to an interview with Dr.Richard J. Baron, who has written extensively on the subject and has developed an innovative model of care for patients with chronic illness. I quote here in its entirety the end of the interview.

Q. What are the lessons from your experience?

A. I think that we primary care practitioners need to think about redesigning our practices not so much around the payment system but around what we think are the opportunities to add value to our patients. It’s going to be a different kind of primary care in the future. If we free ourselves to ask what we can do to make a difference for patients, I think we will find ourselves full of ideas.

The policy people on the other hand have to figure out how to encourage people to unlock themselves and give better value in primary care. They cannot expect that to happen in a system that so punishes people who are trying to do this.

People do not make the best doctors or policy people or advocates from a position of anger. We have to think more about what we all want and how we can move toward that.

I wholeheartedly agree with Dr. Baron. I have written at length in my blog and elsewhere about the wealth of research demonstrating how supporting early relationships will promote children's healthy emotional development. It is imperative that we find a way to apply these ideas on a large scale in the primary care setting. This will involve some significant changes, in the medical education system, in the way primary care is reimbursed and in the value placed on listening. But simply saying that it won't work is not an option.