By PAULINE W. CHEN, M.D.
Published: January 22, 2009
Like many other Americans this past Tuesday, I was moved by President Obama’s inspiring call to duty.
"Now, there are some who question the scale of our ambitions, who suggest that our system cannot tolerate too many big plans,” he said during his inaugural address. “Their memories are short, for they have forgotten what this country has already done, what free men and women can achieve when imagination is joined to common purpose and necessity to courage.”
One of the "big plans" of the Obama administration will be to revamp the nation’s health care system. But are these ambitions big enough to help the country’s smallest patients?
It has been hard over the last year not to feel that health care coverage for our neediest young people could have benefited from a “big plan.”
In May, the Commonwealth Fund, a nonprofit health policy research group, published a report that detailed striking health care disparities between states. The report found, for example, that three-quarters of children have regular medical and dental preventive care in Massachusetts, but less than half of the children in Idaho do. Whereas only 55 per 100,000 children are hospitalized for asthma in Vermont, South Carolina has a staggering hospitalization rate of 314 per 100,000.
More recently, the Kaiser Family Foundation summarized the role of Medicaid, the federal program that aids the poor, and the State Children’s Health Insurance Program. Roughly 30 percent of the nation’s children depend on these programs, but another 11 percent remain uninsured.
That’s 8.9 million American children who have no health insurance.
Last year, there was a big plan to try to change those numbers. But two bipartisan attempts in Congress to expand children’s health coverage withered after presidential vetoes.
This year, it appears that a revised and more comprehensive version of the State Children’s Health Insurance Program will likely pass, supported by the new president. After the House passed the bill last week, Mr. Obama said in a statement, “This coverage is critical, it is fully paid for and I hope that the Senate acts with the same sense of urgency so that it can be one of the first measures I sign into law when I am President.”
I am thrilled by the prospect of better health care coverage for children. At the same time, however, I understand the concerns of critics who ask if we are just throwing more money at the larger problem: our broken health care system.
As the President said on Tuesday:
“The question we ask today is not whether our government is too big or too small, but whether it works.... Where the answer is yes, we intend to move forward. Where the answer is no, programs will end.”
In at least one part of the country, North Carolina, the answer has been yes.
Since 1991, primary care physicians, administrators and state legislators there have worked to create and support a state Medicaid program called Community Care of North Carolina. The program has not only offered high-quality, patient-centered care for the state’s neediest children and adults, but has also saved millions of dollars in health care costs.
Based in part on the idea that each patient should have a “medical home,” the Community Care program assigns each Medicaid patient to one of 14 community health networks. Each network in turn is organized and operated by physicians, nurses, hospitals, health departments and departments of social services.
Patients receive primary care and preventive health measures coordinated by the various professionals in their network, and physicians and others receive fees for their services. In addition, each network receives $3 per patient per month to help implement additional programs like after-hours office care, nurses on call and community-based care coordinators for patients with complex issues, including children with cerebral palsy or cystic fibrosis.
North Carolina, in conjunction with independent consulting groups, has documented the savings for state taxpayers with this innovative program. In asthma management alone, Community Care of North Carolina saved an estimated $3.5 million dollars over three years. With diabetes care, the program saved an additional $2.1 million dollars over the same time period.
The most striking difference, however, between Community Care of North Carolina and other state Medicaid programs is the complete absence of insurance companies. Most states partner with an insurance company to deliver care to Medicaid patients; any residual profits go to the insurance company. But in North Carolina, state Medicaid administrators and health care providers manage the program exclusively and then funnel profits directly back into patient care.
I recently spoke to Dr. David Tayloe, the president of the American Academy of Pediatrics and a practicing pediatrician in North Carolina. Dr. Tayloe has been actively involved with Community Care of North Carolina since its inception.
“We have been able to have an effective collaboration between state government and physicians,” Dr. Tayloe said to me over the phone in a deep baritone voice that accentuated his rich Southern accent. “We basically have a not-for-profit administrative program for Medicaid, and the real winners are the children and the families.”
I asked if there might be something different about North Carolina compared to other states, something that made it possible to run a program like Community Care.
“If you look at the fundamentals of the program,” Dr. Tayloe replied, “they could be adopted by other states. There’s nothing holding a state back from saying ‘We want community-based care.’ Any state Medicaid program that commits the dollars to it can do it.”
“We’ve done it for 17 years,” he added, “and we’ve saved a lot of money for the state. No one in our general assembly even thinks about going to another system of care anymore.”
I asked Dr. Tayloe what had inspired him to become so actively involved with his state’s Medicaid program. He paused to think, then talked about his father, who had practiced pediatrics in North Carolina for over 40 years, and about his own lifelong desire to care for any child that walked into his practice.
“With the shortage of primary care physicians in the U.S., we are at risk of allowing our system of health care to deteriorate such that our most needy and deserving children do not have access to good pediatricians,” he added via e-mail the next morning. “This is what Community Care of North Carolina is all about — paying for a system that assures patients access to the best in primary care — a real medical home.”
He continued, “I envision a medical system in which the poorest at-risk children have access to the best and the brightest we have in medicine — on the front lines in our communities.”
Dr. Tayloe’s work and his words, even via e-mail, reminded me of the President’s message I had heard on Tuesday:
“We have duties to ourselves, our nation and the world, duties that we do not grudgingly accept but rather seize gladly.”
Click here to join the discussion on the Well blog, “In Health, Still Leaving Children Behind.”
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