A Look at the Private Practice of the Future

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must be to help all children achieve optimal function physically, mentally, and socially.

REFERENCES

1. Gatrad AR. Attitudes and beliefs of Muslim mothers and others toward pregnancy and infancy. Arch Dis Child. 1994;71:170-174

2. US Bureau of the Census. Statistical Abstract of the United States 1993. 113th ed. Washington, DC: US Government Printing Office; 1993

3. William T. Grant Foundation, Commission on Work, Family, and Citi-zenship. The Forgotten Half: Pathways to Success for America’s Youth and Young Families. Washington, DC: W. T. Grant Foundation; 1988

4. Hamburg DA. Today’s Children: Creating a Future for a Generation in Crisis. New York: Times Books; 1992

5. Cobey HC, Kelly N. Health Volunteers Overseas: a Guide for Short Term Volunteer Medical Workers in Developing Countries. Washington, DC: Health Volunteers Overseas; 1993

6. Wilson WJ. The Truly Disadvantaged: the Inner City, the Underclass, and Public Policy. Chicago: University of Chicago Press; 1987

7.Starfield B. Effects of poverty on health status. Bull NY Acad Med. 1992;68:17-24

8. Gold MA, Perrin EL, Futterman D, et al. Children of gay and lesbian parents. Pediatr Rev. 1994;15:354-358

9. Palfrey JS. Community Child Health: an Action Plan for Today, Westport, CT: Praeger Press; 1994

10. Haggerty RJ, Roghmann KJ, Pless IB, ads. Child Health and the Commu-nity. 2nd ed. New Brunswick, NJ: Transaction Publishers; 1993

11. Starfield B, Saltzman E. The health care delivery system. In: Hoekelman RA, ad. Primary Pediatric Care. 2nd ad. 1992

12. Starfield B, et al. Psychosocial and psychosomatic diagnosis in primary

care of children. Pediatrics. 1980;66:159-167

13. New York City Department of Health. Report of the Mayor’s Commission on Child Health. New York: New York City Department of Health; 1988 14. New York City Department of Health. The Future ofChild Health in New York City. Report of the Mayor’s Commission on the Future of Child Health in New York City. New York: New York City Department of Health; 1989 15. Stein RE. Chronic physical disorders. Pediatr Rev. 1992;13:224-230 16. Mrazek PJ, Haggerty RJ, eds. Reducing Risks for Mental Disorders:

Fron-tiers for Preventive Intervention Research. Washington, DC: National Academy Press; 1994

17. The Infant Health and Development Program. Enhancing the outcomes of low-birth-weight, premature infants: a multisite, randomized trial. JAMA. 1990;263:3035-3042

18. Olds DL, Kitzman H. Can home visitation improve the health of women and children at environmental risk? Pediatrics. 1990;86:108-1 16 19. Pedro-CarrollJL, Cowen EL, Hightower AD, et al. Preventive

interven-tion with latency-aged children of divorce: a replication study. Am I Community Psychol. 1986;14:277-290

20. Starfield B, Bergner M, Ensminger M, et al. Adolescent health status measurement: development of Child Health and Illness Profile. Pediat-rics. 1993$1:430-435

21. Weitzman M, Doniger A. Pathways to a Coordinated System of Health Care and Human Services for Children and Families. Rochester, NY: University

of Rochester School of Medicine and Dentistry, Department of Pediat-rica and the Monroe County Health Department; 1994

A Look

at the

Private

Practice

of the

Future

Lawrence F. Nazarian, MD

ABSTRACT. Powerful trends that have influenced

pe-diatric care in recent decades will sweep us into the new century. By looking at the major forces at work

today, we can predict where we will be 10 years from

now. As infectious diseases continue to decline, psy-chosocial disorders will take a larger share of the

pe-diatrician’s efforts. Technology will allow more

effec-From the Panorama Pediatric Group and the University of Rochester School of Medicine and Dentistry, Rochester, NY.

tive management, but it will require strong

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pediatri-cians take an active and committed role in shaping the evolution of care systems, thereby making the future what it should be for children. Pediatrics 1995;96:812-816.

THE NATURE OF PRIVATE PRACTICE

IN THE FUTURE

Changing Patterns of Disease

A decade from now, the impact of infectious

dis-eases will continue to decline while psychosocial

disorders increase in importance.

A classic scenario in pediatric practice is the rush to the office in the dead of night to see the lethargic,

febrile child who has been stricken with meningitis.

Since the widespread use of the Haemophilus

influen-we vaccine, however, this scene is played out far less

often. Invasive Haemophilus disease has joined the

ranks of polio, measles, mumps, and rubella. Per-haps varicella will be next. Even some noninfectious

diseases have retreated, such as Reye syndrome,

pro-viding an example of how epidemiology and educa-tion can collaborate.3

We will always contend with new or newly

prom-inent conditions, such as Kawasaki disease, which

may have been hiding among the victims of

mea-sles4; Lyme disease; and acquired immunodeficiency

syndrome, which is helping our ancient adversary

tuberculosis stage a comeback.

But because the old diseases affected so many

children and the new conditions are, for the most part, uncommon or amenable to modern treat-ment, the net effect of these subtractions and

ad-ditions has been a striking reduction in the amount

of time and effort the practitioner must spend in

caring for seriously ill children, and this trend will continue.

The workday seems as long as before because a

host of psychosocial disorders demand our

atten-tion. Haggerty first described the new morbidity more than 20 years ago;5 all of us in practice can

vouch for the accuracy of his insights. Elsewhere in

this issue (see pages 804-812), he makes it clear

that these conditions will maintain their

impor-tance in pediatric care. Because we attempt to treat

the whole child and to encourage families to bring

all concerns about their children to us, and because

we are not as busy fighting infection, we find ourselves helping children who suffer from learn-ing disabilities, attention deficit disorder, behavior problems, depression, eating disorders, substance

use, pervasive developmental disorders, and the

ravages of family dysfunction. These challenges

are estimated to constitute up to 25% of office

visits at present.6 Their share of our time and effort

in the future will only increase.7

New Technology

New techniques will allow us to treat illness more

effectively, but keeping ourselves and our families

educated wifi take constant diligence.

What we do is influenced strongly by advances in

technology. Asthma is an old disease, but how

dif-ferently we treat it than even 10 years ago! In the

office, we can measure children’s oxygen saturation

without breaking their skin, reverse bronchospasm

with a small nebulizer and safe medications, and

send them home to be treated with a machine of their

own, asking them to monitor their condition with a

peak flow meter.

The field of genetics provides a good example of

the explosive increase in knowledge. We have

al-tered the cellular mechanisms of bacteria to produce

insulin, and we are progressing toward the reality of

gene therapy in patients.8’9 Currently, we help

fami-lies who are grappling with genetic disease, advising them on family planning’#{176} and teaching them to help

their susceptible children avoid environmental

haz-ards.

Listing examples of modern medical magic is easy.

Keeping up with those advances will take dedication

and work. The preparation of scientifically based

practice guidelines by organizations such as the

American Academy of Pediatrics will be of consid-erable help to the practitioner,’1 and modern elec-tronic techniques wifi enhance learning and

commu-nication among clinicians.

Other Trends

We will have more children with chronic illnesses

to care for while we expand our efforts at prevention.

Families will get more sophisticated in medical

mat-ters. Some of us will have young adults sitting in our

waiting rooms not as parents, but as patients.

As graduates of the intensive care nursery and

children with multiple birth defects or chronic

ill-nesses such as cystic fibrosis and cancer are given

longer and richer lives, the need for pediatricians to

collaborate with specialists in their treatment will

expand, reversing a trend that occurred earlier in this

century when the development of specialties led to

reduced involvement of the generalist with these

children.’2

Preventive care, always a major component of

what pediatricians have delivered, is accepted as

more important than ever and already extends

be-yond immunizations and injury prevention into

at-tempts to detect and ameliorate the psychosocial

dis-orders that have moved into our arena.

Media communication has undergone a revolu-tion; parents are more knowledgeable as they are bombarded by medical information, appropriate and inappropriate. They are better able to work with us as colleagues in the care of their children and better

able to challenge us. Not only must we keep our

knowledge current, but we must share that

knowl-edge with parents in ways that they understand. No longer are pediatricians just physicians for

in-fants and children. We have developed adolescent

medicine into an effective and growing discipline,

and we are extending our horizons into young

adult-hood.’3 It is relevant that adolescents and young

adults have low rates of physical disease but signif-icant psychosocial morbidity.

THE STRUCTURE OF PRIVATE PRACTICE A decade from now, fewer pediatricians will be independent, autonomous practitioners. Pediatric care will be given through a wide variety of delivery

at Viet Nam:AAP Sponsored on September 1, 2020

www.aappublications.org/news

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schemes. The anatomy and physiology of each

sys-tern will be determined by fiscal, political, and

de-mographic factors, and there will be significant

dif-ferences among them.

Issues of Autonomy

The truly independent practitioner, alone or with

partners, makes all decisions about physical plant,

personnel, office routines, and finances, in addition

to having complete control over clinical judgments ranging from treatment protocols to referrals to

re-cordkeeping. Pediatricians who fit into that category

today are an endangered species; in another decade,

they will be rare indeed.

A clinician who chooses to maintain an

indepen-dent practice must deal with federal, state, and local

regulations that control everything from worker’s

compensation to waste disposal. Even on clinical

issues, we are beset with rules stipulating how to

educate parents about immunizations, how to

per-form a proper urinalysis, and how to keep a legally

sound medical record. The motivation behind most

of these requirements is honorable, and compliance

with them is likely to improve a particular aspect of

care. But the overall effect of these uncoordinated

demands on the practitioner can be demoralizing, if

not paralyzing, and it wifi push many pediatricians out of the traditional private setting into other sys-tems.

If pediatricians join a health maintenance

organi-zation, they acquire a new set of rules covering

ev-erything from referrals to billing. They must conform to patterns of recordkeeping, patient satisfaction, and

utilization that produce favorable report cards. Health maintenance organization membership helps

in terms of marketing and cash flow, but the net

administrative burden becomes much heavier.

Another alternative is to work for an organization, such as a hospital or health center, that will remove extraneous responsibilities and will guarantee a sal-any, leaving the clinician free to practice medicine. When that freedom materializes, the physician is

blessed. The situation turns sour if the organization

goes beyond managing employee benefits and

de-mands that productivity be increased or insists that

aides can do a given job as well as nurses. The

relationship between responsibility and freedom wifi always exist, and physicians who are simply

employ-ees may find no voices in decisions that are rightfully theirs to make.

It is clear that more and more practitioners must

join health delivery systems; there are simply not

enough patients outside of these organizations.

Possessing the potential for providing good care

while containing costs, this movement has

as-sumed tidal wave proportions, and it is not going

to lose strength unless radical government

inter-vention occurs, which seems highly unlikely in the

next decade.

Managed care has brought into prominence the

pediatrician’s function as case coordinator. Under

optimal conditions, case coordination directed by a

parent organization will improve care by setting proper standards, guiding clinicians, and monitoring

physician performance fairly. Relationships with

families will thrive in an atmosphere of

collabora-tion.

When quality of care is superseded by business

considerations, however, the generalist gatekeeper

will suffer. Unreasonable limits on services and

re-ferrals wifi put the case manager in the middle.

In-appropriate patient demands and utilization, fueled

by inflated marketing, will dissolve carefully

estab-lished relationships between physicians and

pa-tients, turning trust into conflict.

Financial Issues

The pediatrician of the future is much more likely

to be paid through an insurance plan and much less

likely to be reimbursed by a fee-for-service

mecha-nism than a present-day colleague. Financial factors

will exert strong influence on patterns of care. In the past, very little that the pediatrician did was

paid for by insurance. Managed care and the

recog-nition of value in preventive medicine have led to

major expansion of covered services,14 which is good

for children and for their physicians. Reimbursement

of the pediatrician has, at the same time, become

more complicated, with four major systems currently

viable: fee-for-service payment directly from the

pa-tient, fee-for-service reimbursement from a

third-party payer, salary, and capitation.

In evaluating payment systems, one critical

con-sideration is the ability to relate service to payment. Fee for service provides the best correlation, allow-ing the physician to see exactly how each component of care is being reimbursed. A salary will provide fair

reimbursement if the conditions of employment are

spelled out in detail and if changes in responsibilities are linked to salary adjustments. A skillful analysis

of practice patterns can determine whether a

capita-tion scheme will reimburse at the same rate as a

fee-for-service arrangement. If, however, there is a

significant increase in patient use, which is likely in the early years of a new plan,15 the capitated physi-cian will be underpaid.

The other crucial aspect of payment schemes is

their influence on the dispensing of care. Fee for

service provides a financial incentive for providing

more care, whereas salary and capitation might

in-fluence a provider to reduce the intensity of services, for better or worse.

In a fee-for-service system, payment issues will

influence office scheduling. Time-consuming

proce-dures that are poorly reimbursed must be kept to a

minimum, and nonreimbursed services, such as

phone calls, must be evaluated critically. If one can

afford to spend only 15 minutes on a health

super-vision visit, one must be selective about what is

discussed and examined at that time. The demands

of maintaining a modern office will drive up

over-head and will force the practitioner to think hard

about everything he or she does.

Availabifity of outside services for our patients

will be affected significantly by a system’s financial

ground rules. Mental health care or speech therapy

may be severely limited. There will be limits on

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and rules about hospital admissions will be

particu-larly stringent and vigorously enforced. New

tech-nologies may be slow in gaining approval, even when scientific proof of their efficacy is available. Conversely, efficient management will conserve

re-sources and will allow for wider distribution of

ap-propriate services, dispensing more care-meaning-ful care-for each dollar spent.

Because control of costs and regulation of medical

care will inevitably be stronger influences than they

are today, salary and capitation systems will replace

fee-for-service reimbursement, and the link between

financing and dispensing of care will get even stron-ger.

Relationships With Other Clinicians

Competition and financial pressures will require

pediatricians to work with each other and with other

specialists in the area of health care delivery. Pedia-tnicians must adjust to expanded roles of

nonphysi-cian providers. Inpatient responsibilities wifi become fewer over time.

Pediatricians are known for their congeniality and

their ability to work together. The evolution of new

health care delivery schemes will offer unique

op-portunities for collaboration. As the element of

corn-petition becomes more important in dispensing

health care, however, allegiances with organizations

could take precedence over bonds with other

practi-tioners, turning pediatricians against each other.

Even cooperation requires caution, however, because

groups of physicians working toward common goals

must beware of antitrust laws. Family practitioners, with whom pediatricians ordinarily share so much, must become even closer, especially in smaller corn-munities, to ensure that they remain colleagues rather than turning into adversarial competitors.

Pressure to minimize referrals to specialists and to

do more in the office will increase, saving the

orga-nization money and improving one’s own report card. At the same time, referral to an outside

pro-vider will be a tempting way to avoid services that

are time consuming and poorly reimbursed. Parental

demands to have their children see specialists will

grow, leading to conflict for the pediatrician who is

caught between opposing forces. Telephone,

facsim-ile, and computer communication offer ways to

re-place some direct consultations by specialists. If done

right, these electronic techniques may ease the strain while saving money without compromising quality,

as long as clinicians cooperate.

The role of health care providers who are not physicians will become increasingly important. We will have to cultivate our relationships with nurse

practitioners, physician assistants, psychologists,

and the many therapists who share in the

treat-ment of our patients. Getting to know individual

providers and what they can do for our patients

will be essential to good care. Particularly impor-tant is a comfortable match between patients and

mental health providers; current trends make it

clear that the need for psychologic services can

only increase.

With a growing office load, the practitioner will

have less time for hospital care. As technology

ad-vances, the ability to handle complicated inpatient

disease becomes more difficult. Office-based

practi-tioners might be happy to pass responsibility to the

specialist or to the generalist who has chosen to work full time in the hospital. At the same time, the

prac-titioners will miss the involvement and the

continu-ity that come with seeing their own patients through

their illnesses. They may make courtesy visits, but

they will not be compensated. Although flexibility in

the treatment of inpatients will allow the generalist

to maintain a role, future practitioners will most

likely spend less time in the hospital than they do

now;16 however, the primary pediatrician wifi con-tinue to play an important role in the patient’s tran-sitions into and out of the hospital.

QUALITY OF CARE IN PRIVATE PRACTICE

Advances in knowledge will allow us to bring

better health to our patients. New health care

deliv-ery systems have the potential to improve care or to diminish its quality significantly, depending on their motivation and structure; they have similar potential

for affecting the lifestyles of pediatricians favorably or unfavorably.

How will these changes affect the care our patients receive? Certainly advances in technology, especially in prevention, will allow us to improve the physical health of children. Further involvement with psycho-social disorders will enhance our skills, and research in these areas will give us new techniques for dealing with such conditions.7 Many causes of family and

emotional problems are beyond the realm of

medi-cine; as these morbidities are better understood,

however, pediatricians will be better able to act as

private citizens to make beneficial changes within society.

Managed care wifi be a blessing or a curse. When a health delivery organization is dedicated to giving

excellent care, which certainly is compatible with

cost containment, the new structure of medicine can be a boon. Management based on scientifically

grounded guidelines will be in the best interest of all,

as Bergman has discussed elsewhere in this issue (see

pages 831-835). Elimination of ineffective therapies

will leave more resources for what works. Pooling of

data will be a powerful aid to good clinical research.

Monitoring of clinical patterns will be used to

edu-cate clinicians to do an even better job.

If agendas other than providing optimal care take precedence in the management of a health

care system, disaster will result. The pediatrician

who is deluged with patients having psychosocial

problems, who is not compensated adequately for

conference time, and who is restricted in referrals

will be in an impossible position. If a child requires

the services of a pediatric cardiologist, and the

insurance company denies the request to go out-side the plan, improper care will be combined with conflict.

When an insurance plan removes financial

bar-riers to pediatric care, the way is paved for long-term relationships that benefit children, families, and physicians. When an employer abruptly

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changes plans and makes it necessary for that

fam-ily to switch to a new office, both care and human relations suffer.

The same ambiguous outcomes will occur in the

lifestyles of pediatricians. As disease is conquered

and new ways of delivering care are devised, the true joy that comes with serving our patients can be

ex-perienced. If politics and power struggles prevail,

what should be a noble pursuit could become a burdensome and bitter chore.

INFLUENCING THE FUTURE

We can watch the future roll toward us, or, seeing

the forks in the road ahead, we can devote ourselves to ensuring the best possible outcomes.

As disease patterns change, and new tools for

diagnosis and treatment come our way, each of us

must be dedicated students. We have seen already

how computers and information networks can

fa-cilitate learning. Rigorously prepared guidelines

for clinical management already exist, and they

will be commonplace in a decade. If we keep

par-ents educated at the same time, our care of their

children will be enhanced. That same spirit of

scholarship must be applied to the area of health

care delivery; valuable background material is

available from many sources, including the Amer-ican Academy of Pediatrics.’3”4”7

Methods for delivering care are changing. We

must be active instruments of these changes, which

will require time and hard work above and beyond

our clinical responsibilities. Variety in health care

systems is healthy, and local needs will vary tremen-dously; physicians should encourage creativity and

flexibility. At the same time, physicians must be

leaders to ensure that the critical goal of providing

optimal care dominates every system. Pediatricians must continue to be advocates for their patients, who have little or no voice in the organizations affecting their quality of life.

The chances of success are enhanced if we treat other physicians, nonphysician health providers, and

administrators as colleagues, starting with the

as-sumption that all are endowed with the right

mo-fives. A sharp eye and a healthy dose of skepticism

are appropriate, also. In keeping with tradition, we

pediatricians must relate as sisters and brothers, al-ways fond of a good pillow fight but dedicated to

each other and our cause.

Above all, if we keep in mind the children, who are

the future, we will mold pediatric practice into its

proper shape.

REFERENCES

I. Schoendorf KC, Adams WG, Kiely JL, Wenger JD. National trends in Haemophilus influenzae meningitis mortality and hospitalization among children, 1980 through 1991. Pediatrics. 1994;93:663-668

2. Givner LB. Woods CR, Abramson JS. The practice of pediatrics in the era of vaccines effective against Haemophilus influenzae type b. Pediatrics. 1994;93:680-681

3. Anonymous from the Centers for Disease Control. Reye syndrome surveillance-United States, 1989. JAMA. 1991;265:960

4. Glode MP, Meissner C, Melish ME. Kawasaki syndrome. AAP Pediatr Update. 1994;15(3):1-9

5. Haggerty RJ. The changing role of the pediatrician in child health care. Am JDis Child. 1974;127:545-549

6. Rickert VI, Jay MS. Psychosomatic disorders: the approach. Pediatr Rev. 1994;15:448-454

7. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. The pediatrician and the “new morbidity.” Pediatrics. 199392:731-733

8. Marsy MD, Mitan K, Clemens P. et al. Progress toward human gene therapy. JAMA. 1993;270:2338-2345

9. Levine F, Friedmann T. Gene therapy. Am I Dis Child. 1993;147:

1167-1174

10. American Academy of Pediatrics, Committee on Genetics. Prenatal genetic diagnosis for pediatricians. Pediatrics. 1994;93:1010-10l5

I 1. Bergman DA. Quality improvement: buzz words or boon? Pediatr Rev. 1993;14:208-213

12. Hessel SJ, Haggerty RJ. General pediatrics: a study of practice in the mid-1960’s. JPediatr. 1968;73:271-279

13. American Academy of Pediatrics, Committee on Child Health Financ-ing. Scope of health care benefits for infants, children, and adolescents through age 21 years. Pediatrics. 1993;91 :508

14. American Academy of Pediatrics, Task Force. Report on the future mle of the pediatrician in the delivery of health care. Pediatrics. 199L87:401-409 15. Szilagyi PG. Roghmann KJ, Foye HR. et al. The effect of independent

practice association plans on use of pediatric ambulatory medical care in one group practice. JAMA. 1990;263:2198-2203

16. Menna VJ. Inpatient care: the general pediatrician’s future. Pediatr Rev.

1990;12:165-166

17. American Academy of Pediatrics, Committee on Child Health Financ-ing. Principles of child health financing. Pediatrics. 1993;91:506-507

How

Can

Pediatric

Care

Be Provided

in Underserved

Areas?

A View

of Rural

Pediatric

Care

Gregg Broffman, MD

ABSTRACT. Building on the concept that the future is not what it used to be, this article will address the delivery of primary care pediatrics in rural America. I will discuss the demographic differences that exist today between urban and rural areas, the differences in practice style and lifestyle in different geographic are-nas, and the unique hardships created by those

differ-ences. The strengths and opportunities that are avail-able now and that will be in the future will be reviewed. I will discuss the application of those op-portunities in an attempt to construct a framework for a successful transition into the “new future.”

Pediatrics 1995;96:816-821.

From HealthCare Plan, Springville, NY.

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1995;96;812

Pediatrics

Lawrence F. Nazarian