Column: Family-centered medical home eroding

In the past two years, Hawaii pediatricians have been struggling to maintain “the medical home” ideal for children. HMSA’s “payment transformation” program has de-valued and undervalued the services that pediatricians provide for their children and families. This has caused aberrations in pediatric practices that hurt the medical home.

The American Academy of Pediatrics, in its policy statement about the medical home concept, says it “believes that the medical care of infants, children, and adolescents ideally should be accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.

“It should be delivered or directed by well-trained physicians who provide primary care and help to manage and facilitate essentially all aspects of pediatric care. The physician should be known to the child and family and should be able to develop a partnership of mutual responsibility and trust with them.”

But HMSA’s insurance changes are negatively affecting the medical home:

>> Practices that once used to open on Sunday to care for sick children no longer do so.

>> Practices that would offer to keep the doors open later to accommodate the unexpected late illnesses no longer do so. Instead patients are more likely to be referred to urgent care clinics.

>> Many in-office diagnostic testings are now referred to outside laboratories resulting in higher costs and longer wait times for results.

>> A community-initiated program for primary care pediatricians to manage the initial care of broken bones with diagnostic testing and splinting under the training and follow up by pediatric orthopedics, thereby avoiding unnecessary urgent care or emergency room visits, has been shunned by HMSA.

>> Many normal newborns are now cared for by hospitalists instead of the primary care pediatrician.

>> Only in Hawaii under Payment Transformation, are physician fees for administering vaccines disconnected from the actual administration of the vaccine, creating financial hardships on pediatricians who strive to immunize all children at every opportunity (as evidenced by the recent mumps outbreak).

>> Only in Hawaii are primary care physicians (PCPs) left with no means to fund innovation and improvements to improve and expand the services for their patients.

The list goes on. Primary care pediatricians are demoralized by the mal-alignment of their professional desire to be the family-centered medical home for their patients and the restrictions imposed by the rules and consequences of Payment Transformation.

In addition to the undermining of the medical home, there is emerging a worrisome rumbling within our medical community about the tenuous status of primary care in Hawaii. In our pediatric community, about 30% of the primary care pediatricians are age 60 or older and are likely making plans for retirement in the not-too-distant future. Many other primary care physicians are stressed beyond their capacity to rebound and are looking for alternatives that usually involve caring for fewer patients or not caring for them at all.

Pediatricians in our state seek to work collaboratively with HMSA to build a better health care system that recognizes that children have unique health care needs and are not miniature adults; that proactive early prevention and intervention is the key to better health; and that engaged, aligned, relationship building clinicians are the most valuable resource a health plan can offer its members.

Our community is seeing an erosion of the medical home as pediatricians are forced to modify their practices to survive under this current health care model. Parents, legislators, employers, government and union officials should want to support quality, family-centered, continuous, comprehensive, coordinated care by primary care pediatricians in Hawaii. Take a stand to enable pediatricians to be the medical home for your child.

Calvin C. J. Sia, M.D., FAAP, is past chairman of the National Center for Medical Home Implementation advisory committee; Galen Y.K. Chock, M.D., FAAP, is a Honolulu pediatrician.