Child Health Care at a Crossroads – PediaCast CME 107
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Description
Dr Kelly Kelleher visits the studio as we consider the current state of child health care in America. He recently served on a National Academy of Medicine Committee tasked with identifying opportunities for reform… and recommending evidence-based solutions for improvement. Tune in to learn more!
Instructions to obtain CME/CE Credit
- Read this information page.
- Listen to the podcast.
- Complete the post-test at Nationwide Children’s CloudCME.
CME credit expires 3 years from this episode’s release date.
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- Still have questions? Contact CMEOffice@nationwidechildrens.org
Topics
Child Health Care
Healthcare Reform
Presenters
Dr Mike Patrick
PediaCast and PediaCast CME
Nationwide Children’s Hospital
Dr Kelly Kelleher
Chair for Innovation in Pediatric Practice
Nationwide Children’s Hospital
Learning Objectives
At the end of this activity, participants should be able to:
- Describe the role of the National Academy of Medicine Committee in shaping the future of child healthcare.
- Analyze key findings from the committee’s report, including challenges and opportunities in pediatric healthcare.
- Evaluate major policy recommendations related to financing, public health, and accountability in child health systems.
- Apply strategies from the committee’s recommendations to improve pediatric healthcare in clinical and community settings.
Links
Improving the Health and Wellbeing of Children and Youth through Health Care System Transformation
New Report Provides Road Map for Policy Changes to Transform Child Health Care and Meet the Challenges of the Youth Health Crisis
Disclosure Statement
No one in a position to control content has any relationships with commercial interests.
Commercial Support
Nationwide Children’s has not received any commercial support for this activity.
CME/CE Information
In support of improving patient care, Nationwide Children’s Hospital is jointly accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for the healthcare team. (1.0 ANCC contact hours; 1.0 ACPE hours; 1.0 CME hours)
Nationwide Children's Hospital has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.0 AAPA Category 1 CME credits. Approval is valid for 2 years from the date of the activity. PAs should only claim credit commensurate with the extent of their participation.
As a Jointly Accredited Organization, Nationwide Children's Hospital is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. Nationwide Children's Hospital maintains responsibility for this course. Social workers completing this course receive 1.0 continuing education credits.
Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs.
Contact Us
CMEOffice@nationwidechildrens.org
Episode Transcript
[Dr Mike Patrick]
This episode of PediaCast CME is brought to you by Nationwide Children's Hospital.
Hello everyone and welcome once again to PediaCast CME. It is a continuing medical education podcast for healthcare providers.
This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. It's episode 107. We're calling this one child healthcare at a crossroads.
I want to welcome all of you to the program. So, we have a different sort of episode for you this week, but it is an important one because we're going to closely examine the state of child health in the United States. And I think that we can all agree that on many levels, the American healthcare system is fantastic, and it is also broken in many ways.
And yet we do have an opportunity to fix and improve the ways in which it is broken. But first we have to identify the specific problems, shine a light on them, think about them, put our minds together to arrive at workable solutions. And this is particularly important as we consider the health of children and teenagers because the system for them is just as broken, if not more broken than it is for adults, but in different ways and requiring different solutions.
Well, this was the charge of the National Academy of Medicine Committee on Child Healthcare, which was tasked with evaluating the state of pediatric healthcare in the United States, identifying key challenges, opportunities for reform, and providing evidence-based recommendations for future improvements. So, what did the committee find and what recommendations have they shared? Well, we are fortunate to have a member of that committee, the National Academy of Medicine Committee on Child Healthcare.
He is with us today. It is Dr. Kelly Kelleher. He is the chair for innovation at Nationwide Children's Hospital, and he will be with us shortly to talk about child healthcare at a crossroads.
Don't forget, after listening to this episode, you can claim free Category 1 CME credit, really easy to do. Just head over to the show notes for this episode over at pdacastcme.org. You'll find a link to the post-test in the show notes.
Follow that link to Cloud CME, click on the materials tab, and there you'll find the post-test taken past that test and the Category 1 credit is yours, absolutely free. And we do offer credit not only to physicians, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. And it's because Nationwide Children's is jointly accredited by all of those professional organizations that we can offer credits you need to fulfill your state's continuing medical education requirements.
Of course, you want to be sure the content of the episode matches your scope of practice. In this case, it's really going to apply to everyone because if you practice, you are involved in the child healthcare system. Complete details for the credit are available at pdacastcme.org.
Also, I want to remind you the information presented in every episode of our podcast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. Also, your use of this audio program is subject to the PDACAST CME Terms of Use Agreement.
You can find that also over at pdacastcme.org. So, let's take a quick break. We'll get Dr. Kelly Kelleher settled into the studio. And then we will be back to talk about the state of child healthcare in America. It's coming up right after this. Dr. Kelly Kelleher is a distinguished professor of pediatrics, psychiatry, and public health at the Ohio State University College of Medicine and Chair for Innovation in Pediatric Practice and Vice President of Community Health for Nationwide Children's Hospital. He's also a member of the National Academy of Medicine Committee on Child Healthcare, which is tasked with evaluating the state of pediatric healthcare in the United States, identifying key challenges and opportunities for reform, and providing evidence-based recommendations for future improvements. He's here to discuss the work, findings, and recommendations from this committee as we consider child healthcare at a crossroads. But before we jump into our topic, let's offer a warm PDACAST CME welcome to our guest, Dr. Kelly Kelleher. Thank you so much for being here today.
[Dr Kelly Kelleher]
It's great to be here, Mike. It's good to see you again.
[Dr Mike Patrick]
Yeah, good to see you as well. I think a great jumping off point is going to be just a little more detail on the National Academy of Medicine and their Committee on Child Healthcare. What exactly is this organization and a little more background on the committee that you've been working with?
[Dr Kelly Kelleher]
Yeah, I think it's wonderful to talk about that because it's such a black box when you hear National Academy of Medicine committees. And the National Academy of Medicine is actually part of the National Academy of Science, Engineering, and Medicine. It's established, I'm pretty sure, by President Abraham Lincoln as advisory to the government and to other public policy institutions and businesses.
And since that time, it is a nonpartisan advice and expertise provided to, in this case, sponsors from the government mostly and from the healthcare system. And really meets in a consensus finding with public evidence gathering, reports, and then summaries of the evidence that eventually yield, in this particular case, a consensus committee. Which means the committee had to come to consensus on the findings and recommendations.
[Dr Mike Patrick]
And just in terms of the inner workings of a committee like this, does it have to be unanimous or is there like give and take and, you know, how aggressive does it get in the room?
[Dr Kelly Kelleher]
It gets pretty entertaining sometimes. You know, the wonderful thing about it is that the diversity of the committee allows for a lot of opinions to be expressed. And those opinions are pretty strong sometimes.
And most of us go in with some crazy ideas on our head about what we'd really want to see change. If you could do anything and wave a magic wand, what should it be? But in the end, the committee also has to review testimony, expert evidence, and actually summarize that evidence to say why they came to certain recommendations.
So, you can't go out on a limb. National Academy committees are not going to propose, you know, wild change without any evidence. So that's the point.
It's evidence based.
[Dr Mike Patrick]
So, you can have whatever ideas you want, but it's going to be measured against something that is definitive. So, you can have opinions, but you have to be able to back those opinions up with evidence.
[Dr Kelly Kelleher]
Right. And I think one of the things that's been really useful for the Academy over time is that the committees are evolving to include greater diversity of opinions. You know, even some of my early committees were almost 100% physicians.
And now we're seeing, you know, people from a wide variety of walks of life, executives, business leaders, community representatives, certain subpopulations that have been underrepresented, parents of children with chronic illness. So, a wide variety of opinions. And of course, that makes for a much richer report.
[Dr Mike Patrick]
Yeah, yeah, yeah, absolutely. And you have more representation of the stakeholders, which is not just physicians as we as we consider health care. So, then what is this committee in particular charged with accomplishing?
[Dr Kelly Kelleher]
Right. So, this committee was, as any report, sponsors are sought. Sponsors come forward and say, we are seeking answers to the following questions.
And in this case, it was a wide group of sponsors focused on pediatrics because people had noted that the National Academy of Medicine put out several child reports over the past five years. Very influential reports on neurons to neighborhoods, a report on SSI, supplemental security income for children. There have been four or five different reports, but really health care was not the central theme of any of them.
They were all focused on early childhood learning or SSI or other policies, Medicaid, but not health care per se. And so, the American Board of Pediatrics, the American Academy of Pediatrics, the Bureau of Maternal Child Health, the Children's Hospital Association, a few foundations all stepped up and said, we really need a report to say where health care should be changing because there have been several adult reports on where health care is going. But child health care has been left out of most of those.
Yeah, yeah.
[Dr Mike Patrick]
Now, why was this important now? You know, it seems like this has been important for a long time, but why was this why was this organized and brought together now, post pandemic and in our current state of affairs?
[Dr Kelly Kelleher]
Yeah, great question. And, you know, those of us in the field, of course, always think now is the right time for child health care. But for the rest of the world, you know, this year and these past couple of years have been some striking things have occurred that have really jolted the system.
One is for the first time ever, we're seeing child mortality worsening in the United States, not in the rest of the world, but in the United States in particular. And, you know, we are on track with chronic disease, obesity, mental health problems to have the first generation of children whose health is worse than their parent. Another shocking study came out of the Defense Department, noting that about 70 percent, somewhere they estimate as high as 77 percent of all young people would not be eligible for the military because they need a medical, mental health, obesity or other problems with their health.
And so, and a number of business leaders have put out warning flags that they will not have an adequate workforce to continue to grow and be productive. So, you know, the nation is also looking to find out where are going to be the people to care for the growing number of elderly and there aren't enough healthy children in the pipeline. So, the shocking numbers just woke everybody up.
Unfortunately, we should have been focused on this all along. But, of course, the pediatric health care system has always been wagged by the tale of adult health care, which is a legacy system. So, we've not really designed a health care system, which has left a lot of fragmentation, lack of focus on what kids really need compared to adults, et cetera.
[Dr Mike Patrick]
Yeah. Yeah. So, and I think it is important to note that suddenly we have a five-alarm fire, but at least people are paying attention.
And that's really the most important thing. So, as you're as you're putting a committee like this together, you had mentioned that there's a lot of different disciplines represented and there's a lot of diversity. Can you describe the structure of that committee just with a little bit more details?
[Dr Kelly Kelleher]
Yes, very much so. Thanks. The committee is actually so, as I mentioned, it's an evidence gathering body, but it has two chairs.
And we were very ably chaired by Dr. Jim Perrin, who's won the St. John Award this year at the Pediatric Academic Society meetings. And Dr. Tina Chang from Cincinnati did an outstanding job. And they chair the experts who are gathered from all across the country and pulled in by the staff.
And then the committee is also staffed by full time workers at the National Academy of Medicine who help provide background materials, organize the meetings, establish the credentials for everyone, help work on ensuring there's no conflicts of interest and provide a lot of the writing support for our various pieces that have to be all woven together.
[Dr Mike Patrick]
And then how does that committee then come together to actually develop recommendations?
[Dr Kelly Kelleher]
It's a great, great question. So, the committee does some initial communications about obvious sources of evidence, obvious sources of evidence for the questions that have been raised, such as what is the future of health care? What are the future financing tools?
What kind of accountability will we have in the future? What new innovations are coming down the pipelines that are likely to change practice radically? Even what financing mechanisms we need to think about.
So those initial background materials are brought together. And then the committee conducts a series of expert presentations. The beginning of each meeting is an open meeting for the public.
Experts present their opinions. Committee queries them and ask questions. And then besides their presentations, people from the public are invited to send comments and make comments on the presentations or materials that are being presented.
And finally, the materials all gathered and put into books, briefing books for each meeting when we talk about various topics. And then subgroups of the committee actually proceed to sort of outline writing and on various topics, which we put together in response to the questions of the sponsors. And so, it's a not everybody writes the same and different people play leadership in writing or not, but everybody hopefully gets opinion.
The materials reviewed, each section reviewed by the whole committee. And it's also then all put together with the help of the staff. And then it gets sent out to an independent set of reviewers.
You know, this I believe there were 18 reviewers who donated their time to review the whole thing and make comments on the various components. And then revisions are done in response to those comments. And then finally, the committee agrees to sign off on it once those two steps are complete.
[Dr Mike Patrick]
Yeah. And there's really three sort of stages in this as you're writing it. You have the findings, but then as you take all of those data points, then you come up with a conclusion based on all of that data.
And then the piece that I'm really interested in is going from the conclusions to actual recommendations. How does that happen?
[Dr Kelly Kelleher]
Yes. Well, with great, great intensity. Usually.
So obviously when you're talking about all of child health care, it's a voluminous topic. And, you know, our report is long. It's 600 pages.
But the recommendations really are very, you know, supposed to be very few in number. And so, what we do is, you know, when you study all child health care, there could be, you know, thousands of findings, things that we actually see in the literature that are pretty clear. And we say this is a finding.
Well, when you bring a bunch of findings together, you might conclude conclusions that we have, you know, there's a trend toward private equity and health care. And we need to talk about that. Or AI will radically alter the practice of health care for children in the future.
And here's some, you know, conclusion about it. It needs to be equitable. It needs to be this, needs to be that.
Then our recommendations would be what to do. And they have to be recommendations. Take the next level step and say, who is the target audience?
Has to be specific. What's the specific action you're requesting of them? And what's the timeframe for it?
So, it and it also has to pass the everybody agrees test. So based on the evidence and conclusion.
[Dr Mike Patrick]
Yeah, absolutely. Well, let's actually dive into some of the findings. And where are we in terms of the U.S. health care system and our performance for children? Where exactly are we right now?
[Dr Kelly Kelleher]
Well, no surprise, you know, to anybody, I don't think. But, you know, the health care system provides some of the world's most sophisticated care for specialty conditions on the planet. No doubt about it.
And many of the great discoveries still happening in pediatric health care are happening in the United States because of the unbelievable research that's being done in health care in the United States. We also see amazing innovations happening right now. And I mentioned a couple, but, you know, all the uses of exome and genome testing and neonates and things that are coming down the pipeline, seeing the amazing uses that people are applying for all the new technology and digital tools for families and engagement, but also digital tools in clinician decision and system decision making.
So those are all moving along amazingly fast and certainly are going to affect our practice within the next few years. There are longer term things as well. Data interoperability, innovations, things that will happen in the cloud that, you know, I think we'll see fairly soon.
[Dr Mike Patrick]
And what are some of those major shifts that you think are on the horizon?
[Dr Kelly Kelleher]
Well, I think, for example, you know, we expect that team based care will be facilitated greatly by a lot of the technology that's coming along as people are better able to practice at the top of their license so that medical assistants, nurses, nurse practitioners, physicians, they'll work more effectively as teams to care for whole panels of patients and groups of patients across sites and more flexibly. We won't be so site bound. We won't be so office bound and working with patients more continuously in relationship rather than visit based.
So, moving from a visit-based system to a person-centered system and a family centered system will really help children especially.
[Dr Mike Patrick]
Yeah, I would think that there's a big role then for telehealth as a part of that.
[Dr Kelly Kelleher]
Absolutely. Telehealth is going to be central for a lot of families. It's also central for a lot of providers and clinicians.
Who find themselves very isolated and needing, you know, Project Echo and other things that reach out to clinicians is great for education, but we need more and more real time, more and more both synchronous and asynchronous. So, and there'll be a need for more podcasts for education, Mike. So, you're, you know, you're going to be more in demand.
[Dr Mike Patrick]
Yes, yes, that's that is good news. Now, in terms of, you know, there's the actual function of providing health care, but then that health care also has to be paid for. Are there challenges in getting this a new sort of framework actually paid?
Because it would seem that the visit model is how we are reimbursed.
[Dr Kelly Kelleher]
Absolutely, absolutely. So, the challenges are large for change. I think some of the rapid transitions in our environment that are happening right now in Washington and at the Statehouse and in other places around the country are precipitating new thoughts about that.
And people, you know, with every challenge comes opportunity. So, I think we may see some transitions more quickly than we think. But there's already several models out there that don't rely on visit-based models and have shown some pretty good outcomes, some innovations.
More importantly, there's an agreement that population health outcomes, the ability to include all patients in your accountability is a way to be paid much more sustainably. So, what I mean by that is right now, everybody can say, oh, my patients are very satisfied, and they all got good care. But that's just the ones that showed up.
You know, we know a lot of patients either aren't coming, aren't able to access or have trouble accessing care. And a large proportion, I mean, for example, somewhere between 40 and 50 percent of adolescents don't get routine care. As just a simple example, there are, it's true at every other age, but it's very particularly true for adolescents in our system.
And many communities feel disenfranchised. So, if we were to require population level metrics where outcomes were determined based on the entire population rather than just who showed up, I think it would change how we focus our attention.
[Dr Mike Patrick]
Yeah, yeah, absolutely. You've talked about the privatization of particular parts of the health care system. And then there's also especially in kids whose families are in a financial position that they're not able to afford privatized health care.
There's a whole public health care system kind of in parallel. What role can a partnership between the private ventures and the public ventures, you know, come together to help the whole system?
[Dr Kelly Kelleher]
Well, I think there's two aspects to that, your question, and I'd love to talk about it a lot more. But there's the aspects of public and private health care, how those systems work together. And then there are aspects of public and private entities within a community that can come together to improve child health.
And so, the first is a good example is our own. And it featured in the report is our own Partners for Kids Accountable Care Organization for Children. And in the ACO, we have private pediatric practices that are networked with community health centers and academic medical centers to all provide care to a population of 500,000.
Not quite, but 500,000 Medicaid children and world children. So, you know, coordination across those systems, the ability to coordinate, for example, behavioral health delivery and primary care settings, regardless of the settings or because of the settings and modifying in each type of setting. For the particular patients, that's an example of public private collaboration and data sharing that can go a long way.
Yeah. On the other side, we have community agencies, we have public and private entities in the community that can come together to actually improve the health outcomes for kids. And we do that by, for example, when, you know, the Columbus Partnership works with the mayor's office and works with Nationwide Children's Hospital and other than that public health department to all come together to work on infant mortality in the Celebrate One initiative.
And, you know, sometimes it's donating money, sometimes it's donating data, sometimes it's communications to all your employees and the private system. And they come together around what we call Celebrate One, which is an infant mortality prevention. Initiative locally.
So, child health is not a health care support. It's really a community support and everybody needs to be involved, and we should stop talking about this if we can fix it in the doctor's office because we can't.
[Dr Mike Patrick]
It seems that one thing you really have to have is a person or a panel of people who are sort of in charge of bringing public and private resources together because it's not going to happen on its own. And if you rely on the clinicians to do it, like they're so busy, you know, how do you do this? And so, it would seem that recruitment at the community level of someone who can organize such a thing is going to be an important part of making it happen.
[Dr Kelly Kelleher]
I think what we've learned is that the communities that have done the best job of improving child health outcomes and initiatives to do so have what's called a backbone organization. They have someone who in an organization that is providing the meeting place, the gathering, the staffing, the data management, the quality improvement, the outreach. And, you know, in Columbus, we're fortunate that the hospital is very involved in doing so.
Cincinnati, Cincinnati Children's has done the same. But in other places, it may be the public health department. So, in Minnesota, we had some examples presented there.
In Oregon, there was actually some models where the managed care companies were taking some leadership role. So, it's community dependent. And I think that's what's complicated in some part with recommendations is no one solution will fit every city in the country.
[Dr Mike Patrick]
Yeah, yeah, that makes sense. One thing that we hear about is Medicaid reform. That's just kind of a buzzword that you hear in the news.
Even what exactly or how does Medicaid need reformed?
[Dr Kelly Kelleher]
Well, you know, Medicaid pays for half of all child births in the United States right now and takes care of almost half of a young children. It is the payer for 40 to 45 percent of all children in the United States. And the majority of those with severe and disabling conditions.
So, Medicaid is the is that along with CHIP, you know, the supplemental program that was passed years ago to join that for kids who are not quite as low income. These programs are the safety net for most children. And right now, we have a lot of good evidence on what works and we're not implementing it.
What works we know is, for example, continuity of enrollment. When children are disenrolled frequently, they miss preventive care. When children are disenrolled frequently, they lose medication continuity, and they lose specialist continuity.
So, we know that routine enrollment, we know that facilitating enrollment. We lost many eligible children to Medicaid during the recent unwinding of the public health emergency after covid when many people were disenrolled, but many of them were still eligible. They just didn't know it or didn't understand the process of reenrolling.
So many children became uninsured. And then similarly, we know that the benefit coordination needs to be there. Medicaid is a great laboratory for improving outcomes for the entire population.
And Ohio, Oregon and Virginia, a couple other places are taking some innovative steps to do that.
[Dr Mike Patrick]
Yeah. And I would imagine that that too, those steps are going to be very specific for individual states, individual communities. And as you said before, what works in one place may not work well in another.
And there's not necessarily one size fits all.
[Dr Kelly Kelleher]
Well, we do have some pretty good data on things that do and don't work. For example, I think in the report we talk about, you know, work requirements for parents having been very successful for the most part. We know that continuous enrollment has been successful, especially successful in improving maternal outcomes, too, in the early years right after delivery.
We know that that making sure that children have coordinated behavioral health services is very important. So, we do have a lot of research out there that what works. But I agree with you, local adaptations to fit within the context of existing, you know, health care organization matters.
Yeah.
[Dr Mike Patrick]
Yeah, absolutely. What is the role of pay for performance in pediatric care? I think that's another one of those buzzwords that we've heard recently.
Yeah. What is what is that exactly?
[Dr Kelly Kelleher]
Yes. So great excitement originally about what was called pay for performance and equity bonds. Can we pay people enough to have good outcomes?
And, you know, the idea here is, for example, if you, you know, pay obstetrical services well enough for successful outcomes, reducing infant and maternal mortality, then, you know, that would make them provide better care, do better outreach, include more accessibility, be more attentive to people. We do think that pay for performance works in some situations for adults because there are some expensive outcomes. Transplants, for example, if you know to pay people for successful transplant maintenance, you know, transplant teams follow up patients more effectively, include more diverse representatives.
So, the idea here is paying for an outcome. Pediatrics is particularly challenging in that regard because we don't have enough high cost, expensive cases that are predictable and somebody by changing medical care could do it. We do have plenty of situations where we could change housing or the education system or other things and improve outcomes, but not classic medical care improvements.
So, pay for performance traditionally doesn't work. But there are some new pilots out there that are trying to wrap together health care outcomes, educational outcomes, child welfare outcomes and say, could we do pay for performance in a community to improve the well-being of children?
[Dr Mike Patrick]
Yeah, it would seem that there's some factors outside of the system's control that also impact outcomes. So, it's not necessarily always the medical team, I guess you'd say at fault, but there's all sorts of issues at play. And I would imagine from the provider standpoint, sort of being penalized for poor outcomes that might not really be your fault might not sound fair.
[Dr Kelly Kelleher]
We certainly heard that from the clinicians. Clinicians did not want to be held liable for things they quote could not control. But, you know, when we've used that argument for a long, long time to hide in our offices and not go out to patients, not include community health workers, not include family issues on transportation.
You know, we said, oh, the patient was noncompliant, or they didn't show up. They were a no show, or they didn't follow my orders, you know, not considering whether our system and our services were the best provided. Moreover, when we say that the quote the medical system doesn't control it, well, the medical system is 22 percent of the U.S. economy. If we can't control things or figure out ways to improve things, then who can? So, I think I think there's a balance here we have to find. And I think the balance is that, when possible, you know, and some of the state Medicaid agencies are beginning to get close to that, saying not all outcomes should be paid for performance and certainly not all conditions.
But the health care system has to do a better job of considering social factors.
[Dr Mike Patrick]
And along with that, so the two things that we've really talked about here, sort of the reform of the system. And if you're going to have pay for performance like those have to evolve together, because without that change in the system, you're not really going to be able to do as good of a job of having great performance.
[Dr Kelly Kelleher]
That's right. And, you know, the interesting thing for me was the exciting number of innovations that were occurring all around the country. Lots of people are experimenting with states are experimenting with new ways to pay.
So, for example, California and Delaware were doing innovations in maternal infant diet payments to try to get good care for both. And, you know, and Ohio and Oregon were trying to incentivize the managed care organizations to do more prevention care by doing the quality withhold that was very focused and very intensive compared to the traditional low-level incentives. There are other places doing some experiments with team-based care and reimbursing differently on that.
So, again, some places are doing it, but they're doing it in pockets. And how do we make it scalable? And how do we teach other sites how to embrace some of these things?
[Dr Mike Patrick]
It would seem one way to do that is the public health system, just because every community has one. And, you know, there is because it's a government run office that there could be some coordination amongst public health agencies across the entire country. Is that sort of network being utilized to try to create this change?
[Dr Kelly Kelleher]
Yeah, that's a great call out. And in fact, the best public health agencies we saw and heard from around the country were ones that were partnering with the health care instruments around them. They were partnering with primary care.
They were partnering with hospitals. And in those places, for example, a couple of cases, child vaccination rates were increased. And, you know, you saw that there was lower prevalence of food insecurity.
So, we know that public health is probably the right place to coordinate with health care, whether who should be in charge, who should drive things. I mean, all those things could be negotiated. But it's clear that the combination of health care and public health data together tells us a lot more about how children are doing in a community and areas where we might need to intervene.
Yeah, yeah.
[Dr Mike Patrick]
What's the significance then of school-based health programs? Because that's another thing that has some government control. It's a place that most kids touch during, you know, a typical day.
So, it seems like if we're really interested in them not falling through the cracks, meeting them at school may be a good idea. And I know we have a pretty advanced school-based health system here in Columbus. But how does that look across the country?
[Dr Kelly Kelleher]
You know, it's hit and miss. School based health systems are occasionally threatening to the local pediatricians who say, I don't want, you know, my patients to go there. I want them to come here for their shots and other things.
And that's fine. The best school-based health systems actually coordinate with local clinicians. And so, and I know we do that here because, you know, checking with the local community, asking each student at the school before they get care, who's your pediatrician or your clinician?
So, I think coordinating with local primary care is key. But having said that, there are innovations in both state funding. So, there's been some really innovative state funding in some states and in other states.
The FQHCs, for example, can get very high levels of reimbursement for wraparound services, both behavioral health and primary care in schools. And so, some of them have taken huge advantage of that around the country. And so, I think it's critical, especially because we're missing certain groups of people who do not access the routine primary care system.
So, schools plus our primary care system may be able to coordinate and reach all those kids. But again, this is a place where if we don't share data and information. So, you know, I mentioned public health and the connection with primary care.
Well, now schools and primary care have to do the same. Yeah, yeah.
[Dr Mike Patrick]
What is a peer-led model of care?
[Dr Kelly Kelleher]
Yeah, this is, you know, we are experiencing some major shortages of primary care services across the country. And speaking of the National Academy, their recent report on primary care really, you know, paints a picture of a system. And it's being disrupted right now and is suffering because of both lack of investment in some places and then certain kinds of investment that actually reduce the number of clinicians and others.
So, in response, what we've tried to really see is that the how are we going to extend and complement systems services that are out there? And the peer systems are adult peer to peer. So, family members coming in and helping family members of other children in the health care system, you know, either teaching them, for example, how to work through the IEP process for their kids to go to school or oh, I had a kid who was in the crisis unit as well at the psych hospital.
And here's things that are going to come up for you once they leave. And what do you need to think about? And here's a family management plan.
So, peer adult peer models are peer to peer. And then there are also near peer models, which are recent adolescents. So, you know, college age kids who do certification and training to help adolescents then and work on things like, for example, developing a no one eats alone at the cafeteria club at high school or work on societal anxiety and depression that occurs in schools.
So, we have different kinds of peer models. And those peer models are getting certified by states like New York. They have a formal certification program under the Department of Nursing and getting paid for through Medicaid.
So, again, we need to extend the model. We need to substitute for some clinicians where they're simple interventions. But it's an emerging field.
But the evidence so far is pretty strong.
[Dr Mike Patrick]
Because at the end of the day, we're interested in health outcomes. I mean, we want kids to be healthy. We want them to live longer.
We want them to be able to serve in the military. We want them to be able to join the workforce, all those things. And how you get there, you know, traditionally, it's been you go see a physician.
But as our population grows and we aren't keeping up, especially in primary care, with being able to provide those physicians, we have to find alternatives because we are interested in the outcomes. And so that may mean some models in certain areas that are very different than what we're used to. And, of course, there's always going to be some pushback when that happens.
However, if we keep our eye on the fact, it's the outcomes that matter, then we can sort of justify these, you know, nontraditional forms of providing care.
[Dr Kelly Kelleher]
I think that's right. Exactly. You stated much more clearly than I did.
And but the challenge is when these discussions is that although most of us who are clinicians are in the room saying exactly what you just did, that we really want the child to be better here. For many of the non-clinician players in the room, this is a business. And, you know, to some extent, we're threatening the business by adding low cost, non-health care interventions.
And so, for example, in behavioral health, we have clear evidence that exercise matches or exceeds the value of antidepressants in treatment of early anxiety and depression. And yet it's hard to get exercise paid for. You know, exercise programs paid for, but you can get drugs paid for.
And again, there are very powerful influences that, you know, have to participate in these discussions to change things.
[Dr Mike Patrick]
Yeah. Yeah. How then do you take a capitalist society who is, you know, very fond of a private health care system and not, you know, one size fits all like we see in Canada and the United Kingdom?
How do you still let there be financial incentives so that it can grow within our current system?
[Dr Kelly Kelleher]
Well, I think the number one is we have to be smarter about the incentives. And rather than making the incentives about all about the trying to get private pay patients into exclusive settings and, you know, all competing for that. If we make the incentives about population health outcomes, then we have a chance because now we're talking about the entire population being served.
Another big thing that we have to do is agree that there's going to be that the business community has to come together and agree that this is important. And we actually had members of the business community here in Columbus testify before the committee saying how this was important for their future workforce planning. And we have to have healthier children, and they think it's important enough to try to influence the system.
So, they were willing to participate in solutions. And that's the kind of, you know, if we get the business community on board and we have political representation on board and we engage communities that have been disenfranchised for a long time, I think we might have a coalition of the interested to make some serious change.
[Dr Mike Patrick]
So, you really do have to get public and private working together on this and not only in the health care system, but in private business and in, you know, just government in general. Absolutely. And you have to have champions at each of those levels as well.
[Dr Kelly Kelleher]
Yeah. And we we've been blessed here in Columbus to have that, you know, locally and now how to figure that out. I mean, we have to do more, obviously, but we've had real champions in the business community step up and say, no, this is important.
We need to do affordable housing, more affordable housing for kids. And we need to do more parent hiring in neighborhoods that are affected. And we need to do more to prevent violence in the community.
So, I've seen it happen with large corporations. We just need to make sure it happens more universally.
[Dr Mike Patrick]
Yeah. And then that speaks really toward population health. Just one last thing.
What exactly is population health and how does this impact where we are in terms of providing health care to children?
[Dr Kelly Kelleher]
Yes, I've mentioned that a couple of times. So, you know, traditionally health care was about thinking about my patients. Me as a pediatrician, seeing patients and they're my patients and how am I doing and getting paid that way and accountable that way.
Then it became, oh, how's my practice doing? And then it was, how's my health system doing? And then it's how's the insured population?
We've realized that each of those is too narrow a view and we have to have some metrics. And in fact, the National Academy of Medicine started publishing 2015 about the need to have community level indicators of accountability for health care systems that we need to be able to say across the entire community. My patients or not, at least some of our metrics have to be how well the system is performing.
And it involves two measures. First, the mean or median health of the children in our community. And you can measure that a variety of ways.
But then also how much inequity there is, which groups are being left out or which are most vulnerable. So those are the two aspects of population health that when we think about from that perspective, then number one, we're ensuring that all the children are included. And number two, we have growing evidence that the fewer disparities and inequities there are, the healthier all the children are.
[Dr Mike Patrick]
And one area in particular that comes to mind as we think about this is infant mortality rates. And oftentimes those do affect certain populations more than others. And so, when you do take a look at population health and you're looking at the big picture, then those disparities really start to become glaring.
And then you can come up with solutions once you've identified those issues.
[Dr Kelly Kelleher]
Yeah, absolutely. We have several areas where we're improving outcomes. And you think about things like waterborne illnesses and things like that in this country or our response to some of the emerging zoonoses.
But for infant mortality, a classic example, we've shown a steady decline in infant mortality, although it's paused a little bit across the country. But there's still a two to threefold increase for certain subpopulations depending on where you live. And, you know, it's two in some places, two times as high, and it's three to four times as high in others.
So, it's shocking when you tell people most people don't believe it. But if you look at the numbers, it's really clear.
[Dr Mike Patrick]
Well, this has been a very interesting conversation, and it will be even more interesting to sort of journey forward and see where this all goes, because hopefully it's going to make a difference. That's what we need. It's going to be a wild ride, Mike.
Yes, yes, absolutely. So, Dr. Kelly Kelleher, thank you so much for being here today. We do have some show notes.
We do have some great links in the show notes this week. Number one is an article from the National Academies of Sciences, Engineering, and Medicine called Improving the Health and Wellbeing of Children and Youth Through Healthcare System Transformation. And another one, the new report provides roadmap for policy changes to transform child health care and meet the challenges of the youth health crisis.
That is an article also from the National Academy of Sciences, Engineering, and Medicine. We'll put links to both of those in the show notes for those who want to dive in a little bit deeper. But once again, Dr. Kelly Kelleher, Chair for Innovation and Pediatric Practice at Nationwide Children's Hospital, thank you so much for stopping by today.
[Dr Kelly Kelleher]
It was great, Mike. Thank you.
[Dr Mike Patrick]
We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast CME a part of it. We really do appreciate that. Also, thanks again to our guest this week, Dr. Kelly Kelleher, Chair for Innovation in Pediatric Practice at Nationwide Children's Hospital. Don't forget, you can find PediaCast CME wherever you get your podcasts. We are in the Apple Podcast app, Spotify, iHeartRadio, Amazon Music, Audible, YouTube, and most other podcast apps for iOS and Android. Our landing site is pediacastcme.org.
You'll find our entire archive of past programs there, along with show notes for each of the episodes, CME information, our terms of use agreement, and that handy contact page if you have a comment or would like to suggest a future topic for the program. Also, reviews are helpful wherever you get your podcasts. We always appreciate when you share your thoughts about the show, and we love connecting with you on social media.
You'll find us on Facebook, Instagram, Threads, LinkedIn, Twitter, X, whatever you want to call it, and Blue Sky. Simply search for PediaCast. So, you have listened to the podcast.
Now, be sure to claim your free Category 1 Continuing Medical Education credit. Really easy to do. Just head over to the show notes for this episode at pediacastcme.org.
You'll find a link to the post test in the show notes. Follow that link to Cloud CME, click on the materials tab, take and pass the post test, and the Category 1 credit is yours. Super easy, right?
And again, we do offer credit to many pediatric professionals, including doctors, nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. Of course, you want to be sure the content of this episode matches your scope of practice, which it most likely does. Complete details are available at pediacastcme.org.
Also, don't forget about PediaCast. It's our evidence-based podcast for moms and dads. Lots of pediatricians and other medical providers also tune in as we cover pediatric news, answer listener questions, interview pediatric and parenting experts.
Shows are available at the landing site for that program, pediacast.org. Also available wherever podcasts are found. Simply search for PediaCast.
Another thing you might want to share with your patients, if you look up PediaCast on YouTube, we have begun a new video education series. They're really short videos on important topics for parents as they think about child health. So, things like fever, for example.
We talk about the recent measles outbreak and the MMR vaccine. We've talked about eczema. And again, they're short, you know, two-to-four-minute kind of things that may be helpful as educational materials for your patients.
So, please do share PediaCast with your practice, and that's a new resource over on YouTube. We also have a faculty development podcast. So, if you are practicing in academic medicine, this is from the Center for Faculty Advancement, Mentoring, and Engagement at The Ohio State University College of Medicine.
It's called FAMEcast, and the landing site for that program is famecast.org. Also available wherever podcasts are found. Just search for FAMEcast.
And again, that is a faculty development podcast from The Ohio State University College of Medicine. Thanks again for stopping by. And until next time, this is Dr. Mike saying, stay informed, keep it evidence-based, and take care of those kids. So long, everybody.
