Delivery of Care - Continued 15. Inequalities in locally available services and local differences in social and cultural demands will make good medical care dependent on the existence of a diversity of delivery systems which are appropriate, responsive and acceptable to the populations they serve. 15. Inequalities in locally available health services and local differences in social and cultural demands will make good medical care dependent on the existence of a diversity of delivery systems which are appropriate, responsive and acceptable to the populations they serve. 16. Because of the great need for increased numbers of health professionals, national health insurance should be designed in such a way as to encourage and not discourage their recruitment and education. 17. Successful recruitment of the increased numbers of physicians and other personnel who will be needed to deliver comprehensive medical care to all citizens will be facilitated greatly if the option to participate in a variety of delivery systems is open to them. 18. Continuing improvement in the efficiency and effectiveness of health care delivery systems should be encouraged through flexible methods of payment and financing so that change is encouraged rather than impeded. 19. Incentives should be developed to encourage adequate distribution of medical care providers and facilities. Health Education of the Public 20. Health education of the public is essential to assure adequate and proper utilization of medical care facilities and personnel; a national health insurance program should provide funds for health education programs, both generally and in connection with the delivery of medical care. Coverage (Benefits) 21. National standards for compre hensive health insurance should be established; they should include adequate coverage for child health supervision, maternal and newborn care, and acute and chronic illness. 22. Ultimately, coverage should be for the complete range of preventive and therapeutic medical and dental services rendered by, under the supervision of, or on order of a physician or dentist, whether such services are delivered in or outside of a hospital or other medical institution. 23. Such total medical and dental coverage will probably become economically feasible only as the health-effectiveness of old and new preventive and therapeutic practices, as well as the efficiency, appropriateness, and acceptability of old and new components of health care delivery, more accurately identified. are Dental Services 24. Dental services, with emphasis on preventive services, should be provided initially under a separate fund and should give priority to services for children. Payment and Financing 25. Every effort should be made to reduce the administrative costs of paying for medical care; these may run 25 percent or more of the consumer's health care dollar, and 6 percent or more of the provider's gross receipts. 26. As with methods of delivery, some methods of financing and paying for health care are appropriate for certain areas or populations, others for others; a diversity of methods should be maintained. 27. The administrative costs of health care financing and payment are least with direct payment from the consumer to the provider at the time of delivery of the health service, or with direct prepayment by the consumer to the provider for contracted services; this method also tends to reduce the cost of the care itself by promoting a sense of mutual responsibility for its cost and success, and should therefore be encouraged. 28. Where direct payment is impossible, the least expensive method of financing and payment for a given population or area should be determined and utilized. 29. Experience suggests that costs of third party payments can probably best be minimized by maximizing the personal responsibility of the consumer, by using the administrative expertise of the health insurance industry on a competitive basis, and by minimizing the administrative role of government. 30. It is of paramount importance that adequate financial support of medical research and of the teaching and training of physicians and other health personnel be provided; this financing should be developed in close conjunction with any national health insurance program. Quality Assurance and Cost Controls 31. An effective peer review mechanism must be integrated into the national health insurance program so as to (1) maintain quality, (2) evaluate utilization of both ambulatory and institutional health services, (3) assess appropriateness of fees and charges, and (4) offer adjudication. 32. Review of the quality of the pro fessional aspects of care is the responsibility of appropriate professionals, but assessment of the utilization and delivery of care, 35. Because of the importance of health supervision, especially to children, its costs should either be provided as an initial benefit without direct cost to the consumer, or they should be included in the calculation of deductibles. 36. Although the best method of control of overutilization and cost overruns traceable to providers is quality assurance through peer review, the use of reduction of selected payments is preferable to across-the-board reduction of payments or categorical exclusion of certain services. 37. If recruitment and good distribution of primary care physicians is desired, across-the-board percentage reduction of payments is a particularly poor method of cost control, since it hits hardest the providers of primary care who have the highest overhead costs, especially if they are providing care in populations with low financial resources. Administration 38. A nonpolitical National Health Insurance Board of professionals in health care and health care financing should be established to set policy, regulate, and supervise the program; the flexibility provided by regulation, as opposed to legislation, is highly desirable. 39. The Board should be advised by committees of representatives of consumers, providers, and the health insurance industry; pediatricians should be included on any committee advising on matters which might affect child health, child health care, ог child health care delivery. 40. Free and fair competition among various delivery and payment systems should be encouraged and evaluated in order that the most effective can evolve and be identified. The United States has the capability of providing outstanding health care for its children and youth, It does so for a significant number of children. But, health care is borderline for some children; and, for others it is essentially nonexistent. PURPOSE The American Academy of Pediatrics, an organization of more than 11,500 pediatricians expert in the health care of children, supports the concept that every American child has the "right" to receive high quality, comprehensive health care regardless of his social status, area of residence, or economic position. It has now become necessary for the Academy to develop a statement that adequately summarizes its efforts as a leading advocate for child health care. ADDRESSED TO WHOM Although the recommendations in this statement are addressed to those in the health profession, they have been formulated specifically for public officials in policy-making positions and for those responsible for the enactment of legislation relating to the health care of children and for the funding of child health programs. STUDY IN PROGRESS The Academy is currently developing a study of the problems associated with the delivery of health care to children. The "Report on the Delivery of Health Care to Children," which is to be completed by December 1970, will provide needed data on such issues as health manpower for the care of mothers and children, trends in ambulatory and hospital care, effects of legislation on child health services, and future funding of child health care programs. PART II IMPORTANCE OF BUILDING ON CURRENT Health care in the United States is pluralistic because there are varying patterns of delivery and payment. The delivery of health care is determined by geography, population density, consumer choice, tradition, econom ics, physician choice, and other, frequently intangible, factors. The patterns of delivery range from solo practice to enormous multispecialty groups. The patterns of payment range from fee-for-service to closed panel prepayment plans and facilities supported by local, state, and federal governments. Many "new" approaches to the delivery and payment of health care are being tested. These approaches are experimental and should remain so until they can be assessed and categorized properly. Our present pluralistic system of delivering health care services should be the foundation on which to build and improve child health care in America. It is unrealistic to presume that a prompt improvement in child health care would occur if we discontinue America's pluralistic method of delivering health care services and substitute a "monolithic health care delivery system," where all health care is delivered and financed by the same method. In fact, such a substitution might lower the quality of health care received by many children. A more rational approach would be to strengthen present services and methods of delivery, particularly those which have proved themselves to be of value by experience, study, and controlled experiments. PART III FOCUS ON CHILDREN There are approximately 80 million young people (under 20 years of age) in the United States; this is approximately 40% of the population. Primary attention should be given to the development of a national health plan for children because improving the health of child and youth is a corridor to better health for the entire population. Current medical knowledge indicates that the greatest opportunity for protecting the health of people potentially exists in the perinatal period. Failure to strive for optimal health for all children allows developmental problems to go undetected, and an unhealthy child becomes an unhealthy adult and a burden on society and an overburdened health care system. PART IV Health care for all children should be available, comprehensive, and of high quality. A. COMPREHENSIVE CARE DEFINED Comprehensive pediatric care consists of all services given to infants, children and adolescents to establish and maintain optimal health. Comprehensive care is extremely important during the perinatal period because the child's ability to develop optimally in the future can be adversely affected by poor care. The following services should be included: 1. Perinatal Care a. Prenatal Care (1) Diagnosis and management of antenatal pathology (2) Parent counseling b. Neonatal Care (1) Supervision of the normal newborn infant (2) Diagnosis and treatment of low birth weight and/or preterm infants and other infants at high risk, including acutely ill infants in the neonatal period (3) Family planning services 2. Preventive Care a. Periodic assessment of health status b. Immunizations c. Anticipatory guidance and counseling d. Screening tests for vision, hearing, intellectual development, and for specific disease where indicated 3. Illness Care a. Diagnosis and treatment of: (1) Disorders of growth and development (2) Acute illness (3) Chronic illness (a) Rehabilitation of physical and/or mental, congenital and/or acquired abnormalities C. STANDARDS OF HEALTH CARE Standards of health care consistent with current knowledge have been developed and promulgated by the American Academy of Pediatrics. Examples of such standards are in a number of Academy publications, including: 1. Standards of Child Health Care (1970) 2. Standards and Recommendations for Hospital Care of Newborn Infants (revised 1971) 3. Report of the Committee on Infectious Diseases (1970) 4. Care of Children in Hospitals (1970) 5. Disaster and Emergency Medical Care (1971) 6. Report of the Committee on School Health (1966) 7. Day Care Standards for Infants and Children Under Three Years of Age (1970) 8. Adoption of Children (1967) PRIORITIES PART V Establishment of priorities for child health care is essential. At this point in time, the American Academy of Pediatrics would support the following list of priorities: A. ANTENATAL CARE All necessary steps must be taken to insure that future generations are wanted and are as free as possible from the handicaps of prematurity, congenital malformations, and preventable, antenatal deficiencies. Therefore, the Academy placed the strengthening and extension of maternity care services at the top of its list of priorities. B. POSTNATAL CARE Health benefits of infant care from birth through the first year (including regular examinations, assessment of growth and development, early diagnosis, anticipatory guidance, counseling in nutrition, and immunization) are of equal importance. C. HEALTH CARE FOR 1-5 YEARS The Academy urges that care be available to children between one and five years of age because early detection of illness, visual and auditory defects, aberrant physical and emotional development, and learning disorders make early remedial action possible. Adequate nutrition and environmental safety are critically important in the first five years, and a continuing program of anticipatory guidance is a crucial, preventive measure. D. HEALTH CARE OF SCHOOL CHILDREN AND ADOLESCENTS The Academy plans special emphasis on delivering health care to children from birth to age five; but, the unique medical problems of school age children and adolescents should not be minimized. PART VI Certain important factors should be considered in the development of programs to meet the needs outlined in this statement. These factors include: A. AIMS OF SPECIAL RELEVANCE IN HEALTH CARE PROGRAMS FOR CHILDREN 1. Identifying and providing special care components which require attention because of the unique physiological, pathological, and psychosocial characteristics of childhood. 2. Instituting preventive services at the earliest possible age to maintain optimal health of child ren. 3. Integrating optimal health care for children and youth with the health care given to the parents. B. AIMS RELEVANT TO ALL HEALTH PROGRAMS, INCLUDING THOSE THAT SERVE CHILDREN 1. Combination of preventive and curative services 2. Integration of health and welfare services 3. Introduction and maintenance of mechanisms to safeguard and promote the quality of care 4. Coordination of care, regardless of place of residence or locale of care 5. Provision of sufficient flexibility in program plans to meet the needs of the geography, the time, and the specific group treated. C. GENERAL CONSIDERATIONS IN PROGRAMS FOR CHILDREN AND MOTHERS 1. The physical, mental, emotional, and social aspects of health care are intimately intertwined and cannot be considered as separate. 2. There are special health and sickness risks for mothers for nearly a year during and after pregnancy. The risks for the child involve some 20 years of growth, development, and maturation. 3. Children at high risk include the unborn, the handicapped, and the poor in the inner city and rural areas. 4. Illness, accidents, nutritional deficiencies, and environmental hazards affecting the child population have far-reaching consequences for the individual and for society. 5. Types and constellations of service and priorities vary by age and stage of growth, development, and maturation. 6. The most far-reaching effects for mother, child, and society will come from practicing preventive medicine at all of the following levels: health promotion, specific protection, early and adequate diagnosis and treatment (including screening), limitation of disability, and rehabilitation. |