Value Based Healthcare Delivery Course at Harvard Business School.

Anna Ruman, MD
Resident in Pediatrics at Massachusetts General Hospital

PGY-3

01/21/2020

Anna Ruman, MD

Last week, I participated in the value-based healthcare delivery course for Partners trainees at Harvard Business School. I wanted to reflect on a few key takeaways from the course as relevant to my own pediatrics practice.

First, the idea of segmenting a heterogeneous patient population into IPUs really resonated with me. I spent some time thinking about how I would do that in a pediatric primary care practice. The goal would be to cluster patients with similar medical or social conditions into certain clinic slots – both temporally and physically – so as to provide a care experience specific to these patient’s condition or needs. Some of the clusters that could be easily imagined in primary care pediatrics would be: asthma, obesity, behavioral health (or even subgroup further into ADHD), newborn, and other medically complex. Having an asthma clinic twice per month would allow A) an asthma educator’s time to be concentrated in a more cost effective way, particularly if the educator is shared between health centers; B) a pulmonologist to come for subspecialty clinic to the primary care site to see patients – again, in a clustered, cost effective way; C) for multidisciplinary obesity care to be organized around clinic afternoons specific designed for obesity – nutrition, clinical psychologist, group visits, etc; D) for group breastfeeding and lactation visits on newborn mornings; E) for appointment slots to be longer for medically/social complex clinic sessions and perhaps social work to be available; F) for embedded behavioral health visits/brief substance use interventions/etc. to be available in a primary care clinic session designed for ADHD management. Other efficiencies and benefits for patients could easily be imagined and would allow clinics to improve delivery of high quality healthcare, particularly through tracking outcomes for these particular patient groups, at a lower cost.

Second, I’ve also been reflecting on the challenges of placing value on different preventative health interventions, particularly within pediatrics, as part of the larger questions of reimbursement and health care provider compensation. According to our current model, we don’t place very much value as a society on keeping children healthy.  We don’t invest in cost-effective interventions to raise children into healthy, economically productive adults. Whether discussing pediatrician compensation, lack of access to early childhood education, or comprehensive sex education and access to reproductive healthcare for adolescents, our healthcare system operatives with such perverse incentives. Adult providers (as well as hospitals and pharmaceutical companies) take care of sicker patients at younger ages for higher compensation/reimbursement if our society does a mediocre job at pediatric care. And I do feel that pediatricians either are left out of or haven’t seized their place in many healthcare policy discussions nationally. We take care of the most vulnerable patients with the lowest reimbursement rates on average, and we deliver tremendous value to the healthcare system and to society for every asthma exacerbation prevented and every adolescent provided with comprehensive substance use treatment. It’s time for pediatricians to be at the epicenter of the value creation movement – we can provide incredible value to patients at low cost to the system, and far past due for pediatric healthcare, whether delivered by pediatricians or other providers, to be recognized by players throughout our system as the way forward in building a healthier society.

Lastly, I’ve also realized that as a resident, I have taken care of many high utilizers of pediatric healthcare, whether NICU babies or children with complex medical conditions. One of my favorite parts of the course was learning about CHOP’s home health network. As a pediatrician working with home care companies, I would do anything for organizing high quality home healthcare to be a more streamlined process that’s both better integrated with EMR and more attentive to pediatric-specific home care needs. It would be fascinating to study the Massachusetts pediatric home care market and see if there would be an opportunity for a new entrant into that space – one of the pediatric hospitals in the area, for example. If these kids have better access to home care, particularly for basic labs, fluids, feeds, and medications, we could prevent many hospital admissions and reduce costs for the care of this population, thereby increasing value for patients and families.

I’m very appreciative for the opportunity to have participated in this course, and I plan to integrate value based care into both my current clinical practice and broader career objectives going forward. Thank you again!