AVAILABILITY,
EFFECTIVENESS.
AND
ECONOMY
OF CHILD
HEALTH
SERVICES
Allan M. Butler, M.D.
Professor of Pediatrics Emeritus, Harvard Medical School, Boston
4
( Received August 7, 1968; revision accepted October 16, 1968.)
The Annual Ross Lecture to the Association for Ambulatory Pediatric Services, Atlantic City, New Jersey, April 30, 1968.
ADDRESS: Tashmoo Farm, Vineyard Haven, Massachusetts 02568.
PEDIATRICS, Vol. 43, No. 2, February 1969
T
HE critical state of medicine in theUnited States has been amply
docu-mented by the National Conference on
Medical Costs, June 1967,1 and the Report
of the National Advisory Commission on
Health Manpower, November 1967.2
spite of our wealth, science, technology, medical schools, hospitals, research facili-ties, and budgets; our relatively high ratio of 1 doctor per 700 people; and the exem-plary quality of our best medicine, interna-tional health indices give the United States not only poor, but also falling ratings-due of course to the poor education, nutrition, socioeconomic circumstances, and health care that result in the high mortality and
morbidity of 30% of our population.
RETURN ON
THE HEALTHDOLLAR SPENT
Meaningful and accurate comparative costs of medical care are hard to come by. But the following approximations give an order of magnitude of costs that, with our relatively poor health ratings, indicate a
poor return on the health dollar in the
United States. In 1963 the medical care of the 45,000,000 people of Great Britain cost approximately $4,000,000,000-or $90
per person-while the medical care of
our 180,000,000 people cost approximately $33,000,000,000-or $194 a person. In 1965
Great Britain spent roughly 4.5% of its
Gross National Product on health care as
compared to our 6%-and her per capita
Gross National Product was, of course, less than ours. The United States is now spend-ing approximately 6.3% of its annual Gross National Product of approximately $800,900,000,000, or $50,000,000,090 on
an-nual health care. This is $250 a person per year for our 200,000,000 people. And the
National Advisory Commission on Health
Manpower2 projects
(
without further Viet-nam war inflation)
annual health care costsin 1975 approximating 7% of our then
$1,300,000,000,090 Gross National Product. This is $91,000,000,000, or $400 a person,
for our estimated 225,000,000 people, unless something is done to improve our system of delivering health services.
THE
NEEDTO IMPROVE
The National Advisory Commission cites three major deficiencies in our present
prac-flees as reasons for our unacceptable costs: 1. Most health insurance encourages doctors and
patients to choose hospitalization even when other
less costly forms of care would be equally effec-five.
2. Health professions are generally paid fee-for-service and there are no strong economic incen-fives to encourage them to avoid providing unnec-essary care.
3. Hospitals charge on the basis of costs, which places no penalty on inefficiency. Moreover, under the present system of hospital management effec-five control of hospital costs is difficult.’
The Commission concluded: “If the
needs for health care are to be met, the health system must be organized to employ its resources with more wisdom and effec-tiveness. The two areas which appear to offer the greatest potential for improvement are :
(
1)
reducing unnecessary(
or unnec-essarily expensive)
medical care; and (2) increasing efficiency in the provision of hos-pital care.”2Health Services, December 1967, gives a shocking picture of the state of urban
health care resulting from that city’s costly multi-agency administration and financing. And, more important, it makes practical and specific recommendations for unifying the city health administration and delegat-ing to the administration authority in plan-ning and coordinating health facilities and setting a single high standard for city and voluntary health services. However, the responsibility of delivering services is to re-main with the providers of service, thus preserving the voluntary initiative, pluralis-tic, and competitive character of United
State’s “free enterprise.”
SOCIAL PEDIATRICS
Mention of health care for all is pertinent to the health care of children, for their health depends on the health of their fami-lies and communities. And, with 30% of our
families receiving poor care, improvement family care is clearly needed.
In his paper, “Gaps in the Nation’s Ser-vices for Children,” Dr. Julius Richmond
emphasized the need of grappling “with
those social problems that have up to now
impeded the delivery of medical care to
low-income families and similar groups.” In calling attention to the lack of immuniza-tion, dental care, and medical supervision of the 35,000,000 children in low-income families, he indicated how environmental deprivation affects the child’s health, growth, and development.
Dr. Charles Lowe5 in his paper, “Science and Public Policy: Child Care,” documents
the interrelation of the degree of education, health care, poverty, and unemployment, the unemployment costing the nation in un-productivity, not counting health care, some $30,000,000,000 per year.
Dr. Robert Haggerty, in his article
“Community Pediatrics,”6 discusses the need of pediatrics to include “knowledge of the social and political structure of a
com-munity as these affect the delivery of health care. It [i.e., community pediatrics] is con-cerned with manpower to meet the medical
needs of a community and with quantity of service as well as quality.” And, as mdi-cated by a recent study of Yankauer, Con-nelly, and Feldman,7 many pediatricians believe that quantity and quality can be in-creased simultaneously by increasing par-ticipation of allied health personnel in pro-viding health services.
THE SHORTAGE OF PEDIATRICIANS
Private pediatric practitioners are car-rying too heavy a load in caring for
proba-bly no more than 40% of children in the
United States. And, with present methods of practice, no possible increase in pediatri-cians over the next 10 years can signifi-canfly increase the availability and effec-tiveness of child health services, even if that method were economically acceptable.
In 1964 the pediatricians of a growing suburb in California discussed the dilemma of the increasing demand for pediatric ser-vices. They felt themselves faced with the alternatives of refusing to accept more
pa-tients or of lowering the quality of their
services. Though they arrived at no solu-lion, they indicated little interest in the possibility of increasing their effectiveness by converting their solo practices to group practices with increased use of visiting and public health nurses.
But, ways must be found to enable more children and families to have a family phy-sician who knows their educational, social, and economic circumstances, while benefit-ing by pediatric specialists or consultants
available for the services they are uniquely qualified to provide. Fortunately, ways are being found.
examina-tions, give the immunizations, supervise the nutrition, appraise the growth and develop-ment, and run the conferences without a
doctor present. Also, the county health de-partment and the county hospital could jointly employ a full-time, salaried
pediatri-cian, who would be on call if any nurse found anything that worried her on examin-ing a child at a conference. Within a month
the county supervisors accepted the sug-gestion, a well qualified pediatrician of the Children’s Hospital of Los Angeles ac-cepted the joint appointment, and the Child Health Conferences have been func-tioning well for almost 4 years without a pediatrician’s presence. The county hospital has also benefited by this salaried
pediatri-cian being on its pediatric staff.
PRIMARY HEALTH SERVICES
In 1965 Dr. Julius Richmond4 wrote, “Ex-cept for the relatively few pediatricians in
the field of public health and institutional programs, pediatricians in this country mainly have provided care to the middle
class children. Since approximately 35 mil-lion of the children of the United States live in poor families, it is apparent that
some reorganization of the services will be needed, if most of them are to receive high quality medical care. It seems unlikely that medical education in its current form can meet this need. A program of training professional aides will certainly be one step toward the resolution and rationalization of
this problem. Pediatricians and other physi-clans may become the directors of teams of aides; something that traditionally we in
medicine have not been inclined to talk
about during the educational process.”
The Mile Square Neighborhood Family
Health Center affiliated with the Presbyte-nan-St. Luke’s Hospital of Chicago is one example of a reorganization of health ser-vices utilizing doctors as directors of teams of aides; this center is increasing the avail-ability and quality of primary health ser-vices and the return on the health dollar spent in an urban poverty area. Health
teams of the pediatric service of the
con-ter consist of one pediatrician, six family health workers, and two nurse-pediatricians
(whose training at the hospital and center qualifies them to perform routine history
taking, screening physical examinations, an-ticipatory guidance in growth and develop-ment, accident prevention, nutrition, im-munizations, and treatment of minor
disor-ders and diseases
)
. Public health nurses are also used for out of clinic care. The clinic isbudgeted on the basis of $100 per year for each person registered for primary health care by the center. Physicians receive from
$18,000 to $26,000 plus fringe benefits, which compares favorably with the net earnings of pediatric practitioners. They enjoy the privileges of staff members of the
Presbyterian-St. Luke’s Hospital. Specialists of the various hospital services provide spe-cialist services at that center or hospital as requested by the center pediatricians.
Such neighborhood primary health
cen-ters have also been established in New York, Boston, Chicago, Philadelphia, Den-ver, Los Angeles, Palo Alto, California,
Mound Bayou, Mississippi, and probably other communities. It is reported that New York is budgeting $100 million for the de-velopment of such centers over the next 5
years.
How do parents react to the
nurse-pedia-trician? At a meeting of parents of Head
Start Chicago children, dissatisfaction was expressed with the health examinations
given their children at Health Department health stations. Their complaints included overcrowding, length of waiting, and hur-ned examinations by doctors, who were res-idents in training and some of whom did not speak English well. The parents wanted their children to be examined by a pediatri-clan. But, when it was explained that
pe-diatricians were in short supply, would have to come from an affluent suburb to spend a few hours examining children they
had never seen, would never see them or their parents again, and knew little about
the social and economic problems of the
satisfactory. So the question was asked, “How about having your children examined by the private practitioners of your
commu-nity?” The answer was, “Oh, no. We don’t want our children examined by those doc-tors.” And, when asked, “Are you saying
that the doctors who care for the more
wealthy of your community are not good enough to examine your children?”, the answer was, “Yes, doctor, that is just what
we are saying.”
It was agreed that they were up against a shortage of well qualified doctors, and it was then agreed that the best thing would be to have the Head Start screening physical examinations done by nurses work-ing full time in the community who were
trained to do such examinations.0
THE PEDIATRICIAN AS FAMILY
PHYSICIAN OR CONSULTANT
Whether we like it or not, with our pres-ent shortage of physicians, allied health personnel must be used to free pediatri-cians and internists to do what they alone
can do. So, why not establish neighborhood primary family health centers in our af-fluent communities to lessen the load on pe-diatricians and, hopefully, free some to give families in poverty areas the benefit of the
pediatrician’s special knowledge?
A pediatrician comments, “After 9 years of pediatric practice, partly solo and partly with a three-man group, I am convinced that this type of practice is not destined to survive. Too often the pediatrician is con-fronted with a family epidemic or a serious psychological problem which he cannot
ad-equately treat as a pediatrician. Coopera-tion of an internist taking care of the adults
in the family may be slow in coming or may be grossly inadequate. Commonly, those treating adults have similar problems when trying to enlist cooperation of the
pe-diatrician. Compound this with the
inter-* Since this lecture, registered nurses given a 13-day training in screening physical examinations
gave Head Start screening physical examinations in Chicago to the satisfaction of the participating
pe-diatnicians.
vention of the obstetrician, who has no
knowledge of the thinking of the internist or the pediatrician, and one has a com-plicated communication problem. Little wonder that the average patient feels that the profession consists of isolated specialists
whose interests stop at definitely prescribed boundaries. Little wonder that people shop around among physicians in hopes of find-ing that specialist who will cure the organ
complaint-they have already resigned themselves to the fact that he is not
inter-ested in them as people.”
Dr. George Silvers writes that the dissat-isfaction of both families and doctors with family care by a pediatrician and an inter-nist “may be related to the lack of a quali-fled family physician. . . . The families
men-tioned a degree of confusion as to where to turn for advice. . . .The doctor, well trained
as an internist, found difficulty in being a family advisor. . . . because part of the fam-ily were not under his care. . . . To be a family advisor one should have the respon-sibility for the entire family. . . . Unfortu-nately there is as yet no specialty that en-compasses this kind of family practice.”
Dr. Charles Lowe5 writes, “The training program and professional education we now prescribe for the pediatrician fit him for no proper function in modern health care. He has far too much training to be a superior public health nurse and far too lit-tie to be a consultant.” And, it might be added that he has not the time to attempt to do both. There is a growing consensus that he should be a consultant in such fields as genetics and eugenics, congenital
de-fects, neonatology, and the neurology and hematology of children.
THE PRIMARY PHYSICIAN
How then shall we produce primary fam-ily physicians who will supervise the group practice teams of allied health personnel in providing community primary family health services?
288
CHILD
HEALTH
care. One way to do this would be to have the outpatient departments of our teaching hospitals become the hospital’s primary family health service with responsibility not only to run the outpatient ambulatory ser-vice but also to have the responsibility of following the patient who is admitted to an inpatient service. This responsibility would
not be in terms of treating his illness, but of knowing what is happening to him as a per-son and to the family, where he is going on discharge, and how his needs will be met. The primary family health service will also have the responsibility of staffing the hospi-tal-affiliated neighborhood primary health center, nursing home, and home care
ser-vice. And the senior staff of this hospital service will have rank, status, and salary similar to that of the senior staff of other hospital services and “will-be” professors
and associate professors on the medical school faculty who are teaching what they are doing. Then, the many students who come to medical school to help people-wit-ness the interests of the Student Health
Or-ganization-will find the stimulus for pur-suing that purpose and will not be seduced
by specialists to pursue an intellectual in-terest in applying new science and technol-ogy to a special field of medicine.
Fee-for-service remuneration of the indi-vidual physician has been and is a deter-rent to primary family health practice as it results in earnings depending on illness rather than weliness and therefore provides little economic incentive for preventive medicine. The inequitable disparity in
re-muneration for services requiring similar responsibility, time, and professional competence#{176} is an inducement to go into the specialty fields of high fee-for-service remuneration, such as surgery and some other specialties. To compensate for this disparity, the primary physicians may be
tempted to defer needed referral of patients or to become general practitioners, doing what they are not professionally qualified to do, what they have not the supporting facilities to do, or even what need not and,
hence, should not be done. Fee-for-service also commonly entails the cost of separate billing by each physician for each service rendered and separate payment for each service received. The undesirability of fee-for-service remuneration of physicians is fully discussed in The Purchase of Health Care; Payment, Control and Qua.lity.1
Thus, to develop and improve group practice primary family health care, fee-for-service solo office practice should be phased out as there develops group practice of physicians and allied health personnel with pooled income from which salaries are paid as determined by one’s group practice peers. Admittedly, salaries will be less than the higher fee-for-service incomes; but, medicine should not be a high money mak-ing business. The extent that it is such a business today is one of the major obstacles to realizing the potentialities of health care
in the United States.
REALIZATION OF POTENTIALITIES
If we are to realize these potentialities, authority must be delegated by our demo-cratic process for the regional planning and coordination of our health facilities. For ex-ample, licensure of hospitals and other
health facilities should be dependent upon their meeting recommendations of govern-ment regional hospital review and planning councils and upon hospitals having a hospi-tal planning committee. Accomplishment of this would be promoted by making Federal
Medicare and Medicaid payments
contin-gent upon establishment of a single State Health Planning Agency, Regional Hospital Review and Planning Councils and a uni-fled system of hospital cost accounting.
As commented by the National Advisory Commission on Health Manpower,2 current reimbursement of hospitals on the basis of costs means underwriting open-ended, non-competitive costs with little or no incentive
for efficiency or competitive control of
ARTICLES
289dollar spent. Medicare and Medicaid pay-ments to hospitals or organizations
provid-ing prepaid comprehensive medical care
could be changed from a cost reimburse-ment basis to one which will permit sharing the savings achieved by effective control of utilization and economy in providing ser-vices.
The changes in delivery of our health services as outlined here introduce nothing
new. They are changes now taking place that should be further implemented. And, with their implementation, control and re-turn on our health dollar spent should be such as to permit this affluent society to finance a universal national health
insur-ance plan that would make a single high standard of health care available to all, young or old.
In doing so, let us not ignore our tradi-tion of paying for services according to the individual’s ability to pay. Since this should not be estimated by the physician, who has neither adequate information concerning the patient’s ability to pay nor the authority to tax, and since charging according to abil-ity to pay would be difficult, if not imprac-tical, for private insurers, the universal health insurance would perhaps be financed
most equitably and economically by our
progressive income taxation. Humiliating and costly means tests would be eliminated.
There would be no complaint that the
wealthy were not paying enough for health services, as complained by some regarding Medicare.
To assure appropriate accountability in the expenditure of the public’s funds, the government would have the responsiblity for setting standards and for regional plan-ning of health facilities. The responsibility of delivering the services would remain with local private and governmental pro-viders of services, thus preserving the vol-untary initiative, pluralistic, flexible, and competitive character of free enterprise in the United States.
Thus, in this affluent nation, the right to health care could be implemented without
a monolithic plan, the indignity of a means test, or the humiliation of charity. And, if the public by the democratic process elects to accomplish such universal health insur-ance, it is the responsibility of physicians to see that the public have available a high single standard of health care for all at an acceptable return on the health dollar spent.
THE BROADENING RESPONSIBILITIES
OF PEDIATRICIANS
But, there will be other responsibilities, for the social responsibility of physicians, as of scientists, broadens ever more with their increasing ability to affect health and
suf-fering and human evolution. Today,
ad-vances in science are giving physicians means of alleviating genotypic metabolic flaws by early recognition and treatment and thus enabling those suffering such flaws to mature and have children. In thus
affect-ing
the natural selection of genetically in-herited characteristics that has resulted in extraordinary sell-varying andself-produc-ing evolution and survival of the fittest, physicians are incurring the responsibility of altering human evolution. Tomorrow, they may be modifying individuals by re-placing organs, by altering cell nucleotides,
and by asexual propagation or vegetative reproduction. Such an accelerating cultural
evolution creates problems in human evolu-lion that are sociologic as well as biologic.
Thus, physicians in decisions of daily practice are incurring the heavy responsi-bility of increasingly participating for bet-ter or worse with Divine Providence in de-termining the future of manldnd.
And, pediatricians have a particular re-sponsibility in their contacts with children, namely, to see that in their growth and de-velopment they have a respect for others
and themselves; a growing reverence for
ment of great diagnostic value, yet often a
ADDRESS: 300 Longwood Avenue, Boston, Massachusetts 02115.
eter. But, even rectal temperature readings
PEDIATRICS, Vol. 43, No. 2, February 1969
our pediatric practice, they do unto others as they would that others would do unto them.
What a responsibility! But what an op-portunity!
REFERENCES
1. Magraw, R. M.: The Purchase of Health Care;
Payment, Control and Quality. Report of the National Conference on Medical Costs.
Washington, D.C. : Department of Health,
Education and Welfare. Superintendent of Documents, U.S. Government Printing Office, pp. 286-295, June 27 and 28, 1967.
2. Report of National Advisory Commission on Health Manpower, Vol. 1. Washington, D.C.:
Superintendent of Documents, U.S.
Govern-ment Printing Office, 1967.
3. Comprehensive Community Health Services for
New York City: Report of Commission on the
Delivery of Personal Health Services. New
York City: Office of the Mayor, December 1967.
4. Richmond, J. B.: Caps in nation’s service for children. Bull. N.Y. Acad. Med., 41:1237,
1965.
5. Lowe, C. U. : Science and public policy: Child-care, Med. Opinion Rev., 4:21, 1968. 6. Haggerty, R. J.: Community pediatrics. New
Eng. J. Med., 278:15, 1968.
7. Yankauer, A., Connelly, J. P., and Feldman, J. J.: A survey of allied health worker utilization
in pediatric practice in Massachusetts and in the United States. PEDIATRICS, 42:733, 1968.
8. Silver, C. A.: Family Medical Care. A Report
on the Family Health Maintenance
Demon-stration. Cambridge, Massachusetts : Harvard
University Press, 1963.
9. Butler, A. M. : Innovations in U.S. Medical Care. Center Diary No. 18, Santa Barbara,
California: Center for the Study of
Demo-cratic Institutions, 1967.
DIAGNOSIS
AND
TREATMENT:
CHILDREN
WITH
FEVERS
Thomas E. Cone, Jr., M.D.
Department of Pediatrics, Harvard Medical School and The Children’s Hospital Medical Center, Boston
In the infant the temperature rises on the most trivial cause; it may be lumpy faeces in the
in-tesfine, it may be a slight coryza. I have seen cases where even some irritation of the skin seemed sufficient cause; as the child grows older, similarly but less often, constipation, some slight deviation from a customary diet, or even some unwonted excitement may be sufficient cause for a rise in
temperature.’
Sir George Frederic Still
S
explanation of some of the causesof fever in the infant and child may not be acceptable to the contemporary practi-tioner, but none would doubt that the clini-cal thermometer has been both an
instru-source of undue parental anxiety. Ever since Traube2 in 1850 first recommended routine daily recording of the temperature of ill children, the normal diurnal variations of body temperature in infants and children
remain of clinical interest-and at times mis-understanding. Parents and some physicians forget that no one temperature reading can be given as normal for all children at all times.