In her well-researched and well-written article (“Push for Primary Care Raises Alarm Among Mental Health and Disability Advocates,” CT Examiner, April 20,2022), Emilia Otte discusses the debate over financial support for primary care health services as addressed by HB 5042. I am impressed that such discussion and debate is often limited to the admittedly important financial implications of prioritizing funding for primary care services at the potential expense of impeding access to specialty and sub-specialty health care. As noted in the article, both advocates and proponents of the bill offer cogent evidence in support of their positions. I respectfully suggest that an exclusive focus on health care finances is too narrow a perspective and that the issue of support for primary care services requires a broader framing that also encompasses the opportunity (and imperative) of enhancing the efficacy of such care.
For example, we know that 80 to 90 percent of the outcomes that we seek for children, i.e., their optimal health, development, and well-being, are not driven by the quality of the health services that they receive but rather by social, environmental, behavioral, and genetic factors.
My clinical career has included decades of delivering pediatric primary care services, as well as providing specialty care for children’s developmental and behavioral issues. My research, academic, and public policy interests have long focused on the question of how we may best transform child health services to strengthen families to promote their children’s optimal health, development, and well-being. As a result, I view primary care services through the lens of child health care. I respectfully suggest that, in general, while primary care services are typically effective in addressing a wide array of diseases and disorders, services related to prevention and promotion in support of optimal health, development, and well-being have not kept pace with our increasing understanding of the drivers of health. For example, we know that 80 to 90 percent of the outcomes that we seek for children, i.e., their optimal health, development, and well-being, are not driven by the quality of the health services that they receive but rather by social, environmental, behavioral, and genetic factors. Furthermore, in child health care, the explosion in our understanding of brain development, early child development, and the “biology of adversity” (i.e., toxic stress, adverse childhood experiences, social determinants of health) demands that we transform the manner in which we deliver such care to ensure that we are optimally impactful. In reality, much of the content of health supervision services today dates back to the middle of the last century. This cannot be optimal with respect to harnessing our impressive knowledge gains and achieving the intended outcomes.
As a member of the Office of Health Strategy (OHS) Primary Care and Related Reforms Work Group, I do not believe that increased funding, in isolation, is the answer to strengthening primary care services. Rather, funding must be accompanied by true reform, with much more emphasis on embedding efficacious and innovative models of health care delivery, a particular focus and prioritization on children (and families), and the imperative of linking primary care transformation with the health enhancement community (HEC) component of the OHS State Innovation Model (SIM). I am also concerned that we are squandering our opportunity to strengthen advocacy for increased support based on our failing to take advantage of our current capacity to demonstrate the cost savings, cost benefits, and ROI, both short- and long-term, of a transformed model of care delivery.
funding must be accompanied by true reform, with much more emphasis on embedding efficacious and innovative models of health care delivery…
I am not confident that the current model of primary care services warrants increased support without transformation. The goal for such transformation must include promotion of all individual’s optimal health, development, and well-being. We must judge the efficacy of transformation efforts on the outcomes that are achieved. For too long, we have relied on measures and metrics of care simply because they are available, rather than because they reflect optimal health, development, and well-being, much akin to the proverbial looking under the lamp post for the lost keys because that is where there is light. In contrast, consider the merits of our holding ourselves accountable for the extent to which our provision of care strengthens families’ resiliency, social connections, and capacity to promote their children’s optimal social-emotional development, all factors that are measurable and known to contribute to the best outcomes. Furthermore, we have innovative models of care and resources at our disposal that can produce such outcomes. For example, in Connecticut, we can enhance the capacity of health services by promoting access of all families and providers to such under-utilized and under-supported resources as the Office of Early Childhood’s Help Me Grow and United Way of Connecticut’s Child Development Infoline, a specialized call line of 2-1-1 Connecticut.
I am confident in the relevance and feasibility of such reform, as evidenced by impactful work in other states, the number of relevant initiatives being advanced by federal agencies, and the proven efficacy of different models of care delivery. We have the capacity to truly transform health care services to advance the health, development, and well-being of all. The debate over finances obscures the real issues inherent to true reform. We must broaden our framework for this critical discussion beyond the dollars to focus on how we may best achieve meaningful outcomes.
Dworkin is Executive Vice President for Community Child Health at Connecticut Children’s, Founding Director of the Help Me Grow National Center, and Professor Emeritus of Pediatrics, UCONN School of Medicine