Pediatric primary care: sinking

Navigating the Storm: Pediatric Care's Perilous Journey Out to Sea

Not long ago, pediatric care was a cornerstone of the medical community—a place where a family's growth journey was intimately shared with their pediatrician. This voyage was laden with personal interaction, thorough evaluations beginning in the newborn ward, and continuous care supporting a child's health at every developmental milestone. Families who once steered through the waters of childhood with a trusted pediatrician now find themselves adrift, entangled in the riptides of an unrecognizable system. Pediatricians struggle as well to see how we got here.

It seems patients feel like they are paying more and getting less, while pediatricians feel like they are working harder and getting less.? Pediatric care has lost its view of the lighthouse as we drift out to sea.?

The Dwindling Beacon of Pediatric Care

Pediatric practices, erstwhile beacons of childhood wellness, have seen their radiance fade. In the 1970s, a pediatrician's income reflected a stable, fulfilling career and fueled a practice capable of supporting a robust team—nurses, front office staff, and ancillary staff—who, together, braved every health storm along with their families. The pediatrician, acting as captain, deftly navigated the vessel of care across hospital rounds, managing both acute and chronic conditions, offering a level of service in the office that now seems legendary.

The Erosion of a Foundation

Today, this bedrock is crumbling, as pediatric practices confront changing winds and diminishing resources. Salaries that once rode the currents of a fairer payment system are now stranded by economic shifts, with the costs of inflation and operations rising relentlessly. The fee-for-service model, favoring efficiency, tests and procedures over thoroughness, continuity and relationships, has necessitated the casting off valuable assets—staff, services, and the core of comprehensive pediatric care. Just look at this graph on pediatric income compared to inflation.

The Storm of Financial Necessity

In response to the gale of dwindling financial payment, pediatricians have had to navigate anew just to try to survive:

• Diluted Care and Less Resources: The once high horsepower engine of pediatric care has become challenged as practices substitute experience and training for less costly staff. See the salaries below. How would you staff? We all row harder but don’t get nearly as far as we once did without the same level of expertise and more falling onto the pediatricians.

• Shift Work: Pediatricians now commonly work in set days or shifts, concentrating on routine child visits, preventative care and extended hours to maintain practice viability and address physicians "work-life" balance.? Continuity is being replaced by care convenience for patients and for "providers".? ??We miss our relationships don't we?
• Shifting Away from Procedures: Essential procedures and chronic disease management, once foundational to the practice, are now delegated to urgent care facilities, emergency departments, and specialists.? We can't allow these things to slow us down nor do we have the staff or resources to offer this care. We are telling our patients that care elsewhere is equivalent to or better than what we used to provide in our offices.
• Hospital Rounds Lost: The revered tradition of hospital rounds, including those with newborns, has been relinquished, often viewed as excessively time-consuming for the financial rewards it brings. We miss out on these key connections in times of patients greatest need.

This evolution, propelled by an unforgiving economic current, has diluted the once rich experience of pediatric care.?

The Tidal Wave of Burnout

The relentless surge of financial demands has compelled pediatricians to retract from the roles that once defined their profession, impacting their well-being. Hospital rounds and thorough consultations have become unaffordable luxuries, fueling a rise in physician burnout and a decline in the joy derived from practicing pediatrics.? The pediatricians now think in terms of hours and days worked, not interesting patients or great interventions or interactions. ?We count RVU’s not relationships any more.?

The Ripple Effects

The transformation's ripples are deeply felt by families longing for the solace of a known face and consistent care, and by pediatricians mourning the obscured calling to shepherd children through health challenges amidst administrative and financial storms. Our patients now must spend more time seeking appointments, traveling to referrals, waiting for in-basket replies and picking up prescriptions than they used to spend in real time in the exam room with their pediatrician.

The Survival Tactics

Pediatricians, in their quest to keep their practices buoyant, have had to steer through economic waters as adept “business” owners often times more than as pediatricians.? We are pushed to manage our practices with increasing attention to financial needs over our needs and our patient needs:

• Navigating Financial Shoals: Reducing Medicaid patient numbers and concentrating on better-reimbursed services and higher paying patients to stay solvent.
• Expedited Care: Shortened appointments and efficient throughput have become critical tactics overshadowing better care and relationships.?
• Marketing for Vital Revenue: Seeing patient engagement as marketing tactics to ensure we capitalize on the regular visits and immunization schedules as economic lifelines.? Sick care and managing chronic disease is much less a priority. ?
• Adding Revenue: Charging for nurse calls, piercing ears, ordering more in-office tests, or converting to a subscription model are ways many will try to drive revenue. Cash pay hinders perceptions and realities of the care we offer.
• Moving to Better Pay:? We can do well in the suburbs with commercial payment where we and our patients have the luxury of more resources.? Rural health clinics offer better payment as well, but will add more risk to our work-life balance and more worry to our ability to recruit staff and refer patients greater distances. ?
• Working Harder: Practice owners now demand more from themselves and their staff to meet increased patient volumes.? Focus on “pay for performance” metrics and RVU’s are our key indicators.?

Amidst the Swell: Pediatric Practices and the Mirage of Rescue

In the once calm waters of healthcare economics, pediatric practices stood as refuges of tranquility and idealistic care delivery. As the financial waters rise, these havens are washing away, leaving pediatricians signaling distress. The once-clear path to comprehensive care is now shrouded by the fog of survival tactics, choppy waters and ships taking on water.?? More pediatricians are now considering options for very tempting yet deceptive lifelines.

The Illusion of the "Coast Guard"

In their search for sanctuary, pediatricians confront the formidable decision of partnering with larger health systems or private equity firms—a choice that may offer brief respite from financial turbulence but often at the expense of a need to drive more care, more tests and more referrals.

• Selling to Hospitals : Appears as refuge, promising stability and relief from the pressures of private practice, yet it may erode the autonomy and essence of personalized care.
• Private Equity's Embrace : Offers a financial life preserver to those struggling, but such arrangements may place profit over care, potentially leading to further reductions in care quality and scope.
• Early Retirement and Quitting: An option, once unthinkable, is now a reality for many pediatricians disenchanted with both the present landscape and the paths forward.? Without vision for a new direction, dry land seems out of sight in the choppy seas.

A Call to Chart a New Course

For half a century, pediatric care has been an ecosystem teeming with life. Today, it is endangered. We must revalue our services, transform reimbursement models, and reassert the pediatrician's essential role in society.

We must navigate back to the safety of trusted waters. The depth and continuity of care, once defining our profession, now risk being lost beneath the waves. We long for the era when children's health was our guiding star.

Urgent action is required as the tides of change rise. Pediatricians must rally together to set a fresh course:

• Rethinking the Voyage: It's time to redirect financial resources to reinforce the vital patient-physician bond, the heart of pediatric care.
• Building New Vessels: Our journey requires innovation in our financial approaches to care, the forging of solid community partnerships, and the pursuit of partnerships that will keep our mission buoyant amidst the shifting currents.
• The Collective Crew: United, our collective strength will navigate pediatric care back to its esteemed legacy, reallocating resources from hospital-centric models to the foundational realm of primary care which drives the value equation.
• The Payment Imperative: The traditional fee-for-service model is unsustainable for us and detrimental to our patients. Escalating costs, diminished outcomes, and increased burnout necessitate a transformative way of thinking and operating.
• Rowing faster to Burnout:? We cannot think of more ways to cut value, work harder and fragment care to drive efficiency.? The vision of short term investors is inherently flawed.? Rolling together practices already at their bare bones breaking point and asking them to row harder in high tides will only break pediatric practice faster. ??We must refuse the false hope of “adding efficiency” short term as a way to better care long term.? We must drive relationships, continuity and strong team based care if we ever hope to get back to shore.?
• Our Neediest and their Voice: Ignoring the plight of uninsured children or those on Medicaid is not an option. We must address the disparities in care they face, ensuring they receive the attention and funding necessary for equitable treatment.

A Call to Raise the Sails

Our story need not end in tragedy but can be one of resilience and rebirth. United, pediatricians have the power to turn the tide. We can navigate back to a haven where children's health is our compass. The journey is daunting, but the urgency to raise the sails for pediatric care has never been more pressing.

In the coming weeks, we will outline ways to build a new and sturdier ship. How we can move dollars back to primary care. Care for our patients and ourselves and improve patient outcomes.

We need a bold vision to chart a new course back to shore.

Note:?As a reminder this newsletter is written from my experience and perspective.?The newsletter does not imply or relay the opinions of others.??The intent is to offer an avenue for dialogue and discussion around important topics in healthcare and healthcare innovation from one doctor’s perspective.??I am a physician and so can only write from my perspective.?If you are clinician, provider, nurse or whatever my goal is to enable you to agree or disagree.?I have no intention to suggest or imply that only the physician perspectives matter.??They do matter but as part of a larger dialogue that can foster better health outcomes. Edited with ChatGPT.

Physicians income 1975 and 1984