PREVENTIVE HEALTH FOR CHILDREN WILL HELP TO CONTROL COSTS by Sean Palfrey, MD

Many people have written in this space about cost control, and agreement is widespread that doing so is critical to the success of the new state health plan.

One effective way to decrease overall costs would be to guarantee preventive health care services for all the state's children.

In child health, prevention is the cornerstone. Prevention is cheaper than treatment of illness, healthier children grow up to be healthier adults, and health care for children is much cheaper than health care for adults. Health care for children is an investment; healthcare for adults is often payment for services long overdue.

We need to re-order our priorities, which will make the cost of health care much less in the long run. First we must offer universal access to preventive services. As long as we have a system that creates disparities in access to care, holes in health care will cause pockets of illness in every community, and these spread like wildfire through families, to newborns, the elderly, and the chronically ill, and through schools, churches, stores, and public transportation to whole communities.

Massachusetts needs to guarantee access to certain preventive child health services. The plan must be universal, simple to administer, seamless, and provided by health care professionals who know the children and have their medical records.

This guaranteed care could be limited to three basic services:

first, interventions and medications that have proven to be most valuable. We have this data. Vaccines, for instance, are the most beneficial public health interventions since clean water. All children should be guaranteed full immunization. Impartial groups of experts, such as the Centers for Disease Control and the American Academy of Pediatrics, already designate which vaccines are essential for all children.

A second guarantee should be for services that a) screen for costly health care problems such as genetic disorders, diabetes, anemia, lead poisoning and TB, which if caught early cost much less than if caught late; or b) decrease accidents or conditions such as obesity. Thus all children should have access to their own health professionals for a pre-defined sequence of routine visits for preventive care. These screening tests have been chosen nationally and shown to be extremely cost-beneficial.

A third guarantee should be that all children have access to urgent and emergent care when they are acutely ill or injured. We know that early care prevents progress of asthma, infections or mental illness to severe and costly states. This care should include certain medications and therapies known to be effective. Minimum standards and the appropriate use of tests and medication have been established, but such basic medications and therapies should be available without exception in order not to create disparities in basic care.

This major shift to prevention is needed because of the Commonwealth's need to decrease health care costs. We can accomplish this by establishing a three-tiered system.

The first tier is for guaranteed services agreed to be essential and cost-effective. Access, from the family's perspective, must be universal, free, paperless, and feeless. A national template for Early Periodic Screening, Diagnosis and Treatment (EPSDT), the child health component of Medicaid, could provide guidance for such a schedule, but needs updating.

For coverage of second-tier services, the care and management of more chronic and acquired conditions, individual policies can be offered by insurance companies, who can compete on the open market for employers and individuals. These plans would offer a whole range of additional benefits, and can incorporate their beloved premiums, deductibles, and co-pays.

The third tier, coverage for disasters and overwhelmingly expensive services, needs to be considered in yet a third way, because as science and technology advances, many different options will arise, and ethical as well as financial issues become more central.

If we honestly want to save money, we need to establish basic health assurance for children in this state. To do that, we need to consider such a tiered service structure. We cannot afford to let barriers, financial or physical, hinder access to the most essential, most cost-effective services required for general child health.

Sean Palfrey, M.D., a pediatrician at Boston Medical Center, is a past president of the Massachusetts Chapter of the American Academy of Pediatrics (AAP), Founder and Director of the Immunization Initiative of the Massachusetts Chapter of AAP, and a Clinical Professor of Pediatrics and Public Health at Boston University School of Medicine.