The cost of healthcare fragmentation is a steep one, both in cost and patient outcomes. When most laypeople plan for specialized care, they anticipate a straightforward process. If a patient has a heart condition, they can make an appointment with a local cardiologist; if they have a mental health concern, they can reach out to a local psychiatrist. It should be that simple – but in many cases, it isn’t. The fragmentation of our current healthcare system makes it difficult for patients to locate, access, and afford necessary specialty care, even with comprehensive insurance.
For parents with children, however, the struggle is even more pointed.
Integrated networks — collections of post-acute specialists, hospitals, and primary physicians — that focus on coordinating and providing comprehensive care are rare enough for adults. For children, they are considerably sparser. This isn’t to say that integrated networks for adolescents don’t exist; however, they do tend to center on children with complex or rare conditions. A child with leukemia, for instance, might have a psychiatrist, palliative specialist, oncologist, and primary physician pre-established on their care plan. The parent of a child with more common cases of asthma or ADD, in contrast, would likely need to locate their specialists independently.
The parent’s search can be frustrating, to say the least. Researchers at the Children’s Health Fund currently estimate that around 20.3 million children living in the United States “lack access to care that meets modern pediatric standards and expectations.” It is worth noting that these researchers are referring to basic care. The numbers for those lacking access to specialty care, let alone integrated networks, are far fewer. The causes of this shortfall are myriad and include a lack of insurance, affordability concerns, cultural or language barriers, and a lack of qualified care professionals.
All of the above factors are troubling, but I want to focus on the issues presented by the last. Relatively few doctors choose to enter pediatric subspecialties, and the lack often leads to longer wait times and greater accessibility problems for younger patients. A 2017 survey from the Children’s Hospital Association found that the waiting period for certain specialties spanned weeks. Pain management and palliative care topped the charts at 12.1 weeks, while adolescent psychiatry stood at 9.9 and dermatology at 8.3. The same report also found an alarming trend towards vacancy in pediatric departments; for example, a full 46.9% of surveyed hospitals reported absences in pediatric psychiatry. Given that an estimated one in five children experiences mental health disorders at some point during their lives, the shortage is concerning.
As a specialty impacted by fragmented care and understaffing, pediatric mental healthcare is one the most illustrative case studies for the problem as a whole. As mentioned above, it’s a specialty that many children need – and yet, some studies show that a full 75-80% of children who need mental healthcare do not receive it. Without proper treatment and medicine coordination, these conditions can impact their short- and long-term physical health, leading to poorer health and social outcomes in adulthood. The main problem in many regions lies in understaffing.
Pediatric psychiatrists are relatively rare. Professionals who can diagnose – much less effectively treat – complex conditions such as autism or schizophrenia are in even shorter supply. Those who do practice in the field often flock to patient-dense metropolitan hubs, leaving less populous areas underserved. The issue is particularly pressing in rural regions, as one policy brief recently published by the National Rural Health Association found; in a survey of over a thousand rural counties with populations between 2,500 and 20,000, nearly three quarters lacked a psychiatrist and 90% lacked a pediatric psychiatrist.
Additional surveys have found that over 90% of psychiatrists and 80% of professionals with MSW degrees exclusively serve urban areas. This leaves the brunt of the responsibility for mental health care on primary care providers’ shoulders – and many of those doctors lack the expertise and provider networks they would need to adequately address the caseload. For parents and caregivers, the lack of geographically close providers and integrated healthcare systems pose a real barrier to care, leaving many without the treatment they need to maintain their physical and mental health.
There is no easy solution to the care fragmentation and understaffing problems in pediatrics. As matters stand, doctors are not incentivized to choose a pediatric specialty as their career focus. According to a recent survey conducted by MedScape, pediatric specialists ranked second-to-last in specialty compensation and had an average salary of $212,000 in 2018. This figure is significantly lower than the average salary for physicians overall ($329,000) and falls behind adult-specific practitioners in fields such as cardiology ($423,000) and dermatology ($392,000). The comparably low compensation pediatricians receive may deter medical students who might have chosen the specialty otherwise. The sheer quantity of work, too, might pose a deterrent: Medscape also found that 44% of pediatricians regularly see between 76 and 124 patients per week, while nearly 10% see more than 150 patients weekly.
However, there is a way that pediatric specialists could better align their compensation to match their efforts. In the adult medical sector, some providers have found success with global capitated arrangements. These allow providers to build their own high-quality and low-cost networks to their patients’ benefits and institutes a compensation model that incentivizes pediatricians to keep their patients well and out of the hospital. With global capitation, a provider organization receives a single, fixed payment that encompasses all of the healthcare services a patient might receive. If the provider can keep costs low by helping that patient maintain good health through high-quality care, their compensation — their share of the overall profits — will be higher.
Global capitation models are rare, even for adult-centered healthcare. However, their potential to improve both the quality of care patients receive and properly align the compensation pediatricians receive with their efforts cannot be overlooked. If implemented, these solutions could make it easier to connect caregivers with the specialists their children need and encourage more medical students to move into pediatric specialties and work in chronically underserved regions.
Global capitation is only one potential answer to the problem of pediatric care fragmentation. However, if we don’t attempt to put the puzzle pieces of specialized healthcare into an integrated whole in some way, more children will continue to lose out on the care they need to live healthy lives.