I have made several observations as to why developmentally challenged people are losing out in our health care systems. Given that there are 11 million children in the United States with an emotional, developmental or behavioral condition, we really can’t afford to neglect this important issue.
My first observation is that primary care remains a chronically undervalued component of health care delivery in the U.S. Despite the 60 million Americans who lack access to primary care, the proportion of U.S. medical graduates going into primary care continues to drop (by 30% last time I checked). Primary care is often presented to medical students as being poorly paid, lacking prestige and stressful. Primary care clinicians, including nurse practitioners and physician assistants, are time-pressured and poorly remunerated for the complex work that they carry out. In this context, let us consider the many children and adults with developmental challenges who, especially in the absence of specialist services, rely on primary care as the cornerstone of their health care.
Secondly, much of the work in delivering care for individuals with developmental challenges falls outside of the office visit and into the land of poorly or wholly unremunerated work. There is often considerable work completed outside of the office visit, such as phone calls, emails and meetings. This work, for totally unfathomable reasons, remains frequently unrecognized and uncompensated by our current health care models. If we are going to grow the services available for people with developmental challenges, then we are going to need to recognize the time and effort that clinicians invest in the care of these individuals. Such recognition will allow for health care systems to grow and develop these services.
Finally, our health care models disproportionally favor specialists, especially those who are procedurally focused. This situation has arisen partly because of the flawed way in which we calculate physician compensation (by a small committee of largely specialized, and procedurally focused, physicians). The specialists that many children with developmental challenges need do not undertake many surgical procedures, although length and scope of training is comparable to procedurally-focused specialist peers. Specialists such as developmental pediatricians, child and adolescent psychiatrists, and child neurologists are not only undervalued, but, as a result of such flawed systems, also in critically short supply.
The fact of the matter is that until we stop penalizing clinicians for working in primary care, for investing time in coordinating care and for providing the holistic, longitudinal care that our patients so badly need, then we cannot expect change. The developmentally challenged, including people with autism, are losing out in the current systems. I have long known that behavior is partly determined, through conditioning, by a practice of reward and punishment. It’s high time we drop the stick, and offer primary care some carrots.
Arshya Vahabzadeh child and adolescent psychiatry resident. This article originally appeared in The American Resident Project.
