Access, cost and quality in pediatrics

This contributed Q&A is the fourth in a content series as a lead-in to Becker’s 9th Annual CEO+CFO Roundtable: Nov. 9-11, 2020. During this premier gathering of the country’s most distinguished and accomplished healthcare executives, Becker’s will present the inaugural Future of Pediatric Healthcare Forum in collaboration with Phoenix Children’s and other terrific pediatric leaders.

Phoenix Children’s is honored to work with Becker’s in elevating the conversation of pediatrics as a substantive component of the overall healthcare value chain. Over the next several months, we are excited to bring you a robust offering of informative and insightful pediatric content. We encourage healthcare leaders to engage in the dialogue and participate in The Future of Pediatric Healthcare Forum by RSVP'ing your spot here.

Becoming a world-class health system and continually improving performance depends on solving medicine’s triple constraint of access, cost and quality. But these three concepts look a lot different in the pediatric realm than in the adult care environment.

In this three-part Q&A, Phoenix Children’s leaders discuss the access, cost and quality dynamic.

In Part I, Jared Muenzer, MD, Physician in Chief of Phoenix Children’s Hospital and Chief Operating Officer of Phoenix Children’s Medical Group, explores access to care for pediatric populations.

Question #1: From a broad perspective, what does care access mean for you as Physician in Chief of Phoenix Children’s Hospital and COO of Phoenix Children’s Medical Group?

I define access for our patient families as the ability to connect with the services they need across our 31 pediatric sub-specialties. It also means securing an appointment in a timely manner, receiving the highest quality care and understanding any next steps following the visit.

Question #2: Can you talk about how care coordination impacts access?

We’re always looking at how to simplify the care coordination process for families in order to enhance (rather than impede) access, from straightforward patient cases requiring a single primary care visit to medically complex patients who see multiple subspecialists and require ancillary services like physical therapy or radiology.

For example, if a gastrointestinal physician is treating a patient and determines the child needs treatment through another sub-specialty, who handles the scheduling? How does the patient’s medical history flow through our system in a way that’s useful and actionable for other clinicians? At Phoenix Children’s, our goal is to remove any logistical barriers to ensure patients receive the best care possible in a timely and efficient manner.

Question #3: From the patient family perspective, is there a difference in access for a child who needs a 4-year annual well visit and a patient undergoing a complex congenital heart surgery?

Certainly, the more complex the patient’s health, the more detailed the process to ensure we’re delivering high-quality care. That said, our goal is to make the process seamless and effortless for our families. We continue to develop and implement strategies to remove all of the hoops people typically need to jump through in healthcare, like getting a referral or information from a primary care physician, obtaining EMR records or finding an insurance document.

Our care teams handle this upfront work in order to reduce the burden on families, whether they’re coming in for a simple PCP visit or preparing for a complex surgery. Our information technology teams are creating systems that make this work seamless and simple.

Question #4: Speaking of technology, COVID-19 pushed virtual care front and center. Did your telehealth transition impact access to care or complicate the logistics in any way?

Like most health systems, our goal at the beginning of the pandemic was to utilize telehealth as much as possible.

As COVID-19 erupted, our IT department created a dashboard that enabled our enterprise to transition 6,000 weekly patient visits to telehealth. This transition was completed in under 10 days. To make that happen, our care teams needed to quickly differentiate patients who would need to come onto campus for a visit – like a child with cancer needing chemotherapy or imaging – vs. those who could be treated appropriately via telehealth.

The dashboard simplified this process for our schedulers, who were able to shift the majority of our patients to telehealth quickly and efficiently. At the same time, utilizing virtual care has reduced the number of people in our hospital and clinics and enabled us to provide the safest possible healthcare environment for patients requiring in-person treatment.

The IT department took it a step further with a dashboard that helped us resume elective surgeries in May after our governor lifted restrictions. Our first step was to reschedule the highest-priority elective procedures – like pectus excavatum, cardiac surgery and scoliosis repair. The system incorporated COVID-19 test scheduling for each patient, automated OR reservations and ensured adequate supplies of PPE. The considerable logistics of patient surgery during the pandemic are essentially built right into the dashboard.

The dashboard made all of the difference: During the months of June and July – and amid a surge of COVID-19 cases across Arizona – we performed 166 more elective surgeries than we did over the same time frame in 2019.

Question #5: Amid a national physician shortage, it seems as though some patients will experience difficulty with access because there simply aren’t enough providers to meet the demand. How does Phoenix Children’s Medical Group address this challenge?

Our leadership team found that some patients were being admitted to the emergency department in order to access specialty care. These patients were having difficulty securing the appointments they needed in the timeframe they desired, and were coming in through the ER as a last resort.

Three years ago, we launched the Safe Transitions Program, which places case managers in the ER to help connect patient families to the specialists they need across all 31 divisions – without an admittance to the emergency department. This program has been a huge success in a number of ways. Not only has it helped us avoid a large number of observational admissions, which has freed up resources for true emergencies and kept ER costs down, but it has become a highly efficient way to link patients with the specialist care they need. Satisfaction among our patient families has increased dramatically, too.

Another way we’re helping to solve the access issue is through our One Call Physician Assistance Line, which gives primary care pediatricians in the community a direct line to Phoenix Children’s specialists.

Question #6: How does a pediatric health organization continue to address access issues as their physical footprint expands?

The best answer here is to create efficiencies within the system to counterbalance increased patient volumes. One example is promoting a top-of-license model. This approach allows doctors to maximize their time by handling the most complex cases while enabling advanced practice providers to operate at the top of their license. At Phoenix Children’s, this means physician assistants and nurse practitioners are handling patient care whenever possible – either independently as appropriate or in partnership with our physicians.

A good example is our developmental pediatrics division. In Arizona, autism diagnosis is often a long, complex and arduous process. Parents sit on waiting lists for weeks or months, unable to access the extra services that would benefit their children until a formal diagnosis is made. It used to be that our developmental pediatricians would spend inordinate amounts of time on testing. Now, the testing is handled by our incredibly capable NPs, PAs and psychometrists. Meanwhile, our physicians are spending their time evaluating tests and delivering care to patients. Removing the constraints on testing means more kids can move through the system.

Of course, this shift has also required communication with families to ensure they understand why they do not need to consult with a physician at the testing stage. It’s not a difficult sell since families can get in for testing and begin accessing services so much more quickly. The success of this approach is clear in the patient satisfaction scores our NPs and PAs have received. They have delivered at every single level.

Question #7: Does access to care change as the healthcare system moves from fee-based to a value-based model?

The short answer is no, it should not change. As healthcare providers, we should be doing what is best for our patients at all times, including effective and efficient care coordination inside the hospital and in outpatient settings. By providing the highest-quality care for patients, the value-based proposition will take care of itself.

Question #8: How does access to care in pediatrics differ from access to care for adults?

There are many differences between adult and pediatric health systems. An adult patient who needs a consultation on high blood pressure will make an appointment, meet with a physician, fill a prescription and take the medication. For the most part, adults are responsible for their own care.

This isn’t the case for kids. There are many variables that can complicate access for pediatric patients, including a dependence on caregivers to seek out and access care. Family dynamics, financial stability, physical location, work flexibility, and parent/caregiver health all can impede access for children.

The adults also are responsible for implementing care. If a child needs a daily medication or therapy regimen, he/she relies completely on parents or other caregivers. If the adults don’t do their part to follow through on a care plan, the child’s health might be compromised. This is why we work so hard from our end to simplify access to providers and connect with families on a regular basis. Our most pressing priority is to ensure kids are getting what they need from Phoenix Children’s and at home.

Question #9: What does the future look like for care access?

The patient will dictate where, how and when they access healthcare services. This will require a truly patient-centric approach – and one that will rely more heavily on technology and mobility.

The pandemic has made it clear that telehealth will represent an increasing share of patient and physician engagement. That said, equally important is providing in-person health services in areas where patient demand is high. This could include neighborhood sites-of-service, traditional medical office facilities, campuses and mixed-use designs. Access to care is evolving at a breakneck speed. Our charge is to listen to patients and ensure we’re providing the care they need – when, where and how they need it.

Phoenix Children’s is committed to the health and well-being of all children. We look forward to collaborating and sharing information, insights and best practices with the Becker’s community and patrons of Becker's 2020 CEO/CFO Roundtable: The Future of Pediatric Healthcare Forum.

If you enjoyed Part I of Access, Cost and Quality in Pediatrics, please look for Part II, which will focus on costs in pediatric healthcare. We look forward to connecting with you (virtually) in November!



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