Wednesday, April 6, 2016

The Primary Pediatrics Laboratory

World!  Listen up!  Here is an innovative proposal, and you are getting it for free!  Oh, the wonders of the internet!

                              The Primary Pediatrics Laboratory

An Innovative Proposal For Dynamic Progress In Primary Care Pediatrics


I have a friend who is a Silicon Valley CEO with small children.  His own doctor was at Palo Alto Medical Foundation, so it was natural for him to enroll his children there as well.  The children are healthy but with some of the usual problems, including allergy, and he and his wife have many of the usual parent questions.  As high achievers themselves, they naturally try to find the best for their family, especially since they view raising their children as their most important responsibility.  What happened with them is very interesting.

For a while they continued at PAMF.  A couple of times I got some phone calls from the mother of the family for rather typical children's health issues.  I was very happy to answer them – we are friends, and I never mind questions – but it made me think that maybe they wasn't getting all they needed from their pediatrician.  Then I heard from them that they had not only left PAMF, but they had left Silicon Valley for a very expensive concierge pediatrician in San Francisco.

They told me the story of why they left.  One incident occurred when their eldest child, who is allergic, was sent for an allergy consultation.  When they visited their primary pediatrician to follow up, he looked to his computer, eventually was able to find the allergist's report and to read it, and they then discussed it.  But somehow it didn't resonate with the family.  By contrast, when they visited the concierge pediatrician, he sent their little girl to two different allergists, talked to them personally, and then discussed the two reports with the parents personally, and they jointly came up with a plan.  The difference was stark.

Now, technically, which care was better quality?  It's hard to tell; who knows?  But what is very clear is the nature of the doctor-patient relationship.  One was more distant, even though it was probably competent.  The concierge practitioner, however, was clearly involved and personal, and the idea of getting two separate opinions, and the idea that the primary pediatrician spoke personally to both of them, bespeaks a commitment to involved and personal care that is unmistakable.  Even if closer examination were to reveal that the actual advice of the allergist at PAMF were identical to the other two, and that the essential difference of PAMF and concierge was really marketing with no difference in technical quality, nonetheless, quality is not just technical.  Quality is also feeling and connection.


This vignette brought many thoughts to mind. 

One, we know that the concierge medicine and direct primary care are growing quickly.  This family's decision puts a face to the statistics

Two, while the market is producing concierge practices, why aren't the major medical centers and teaching institutions involved?  Is the market too small to be concerned?  Is there nothing to teach or to be learned from concierge-style practices?  Are these institutions afraid of the stigma of not caring about costs and serving the upper income segment well – in other words, is equality trumping quality? Are the large institutions missing a boat?

So I pondered, and that pondering led me to the proposal I am presenting with this paper.

A Proposal for Academic Pediatric Medical Centers to Found New Programs, Primary  Pediatrics Laboratories (PPL)

It seems to me that there is in fact a great deal to learn from the movement to concierge care.  Concierge care seems to offer accessibility, involvement, and intensity that is beyond the reach of current models.  It has something to teach us about the economics of primary care – what degree of increase of funding is necessary to achieve higher quality?  It might also have something to teach us about technical quality of care.  The best way for great institutions to learn about concierge care would be not only to study it, but to emulate it, to compete with others in serving patients with concierge-style care – in short, to learn more by doing.  By actually doing it, since medical centers have so many more resources than the typical concierge practice – not just financial, but technical resources, expertise, and brain-power as well – it's quite possible that the medical centers would come to invent new ways to deliver care that would lead the world of pediatrics.

How could this be done?  I would propose that a medical center establish a concierge-style practice that could be called The Primary Pediatrics Laboratory (PPL), which would be a concierge-style practice centered beginning at a single site.   The PPL would need its own Board and budget.  It would raise money not only from fees and medical center resources, but from grants from companies and individuals who want to be part of significant advance in providing care, using and developing hi-tech and hi-touch systems, some of which might be the core competency of some of the donor companies and individuals.  Unlike most other current primary care organizational efforts, it would not be centered on lowering cost.  Instead, it would intend to invent prototypes of new paradigms of care.

The objectives of the PPL program would be:

  • to provide care to patients at the very forefront of the best of concierge care
  • to invent and pioneer new technology and other new techniques in the service of personal care
  •  to conduct research on high level primary care with the development of new services and techniques
  • to teach selected residents in pediatrics what the best in primary care looks like
  • to transfer many of the techniques from SPPL to associated networks and faculty practices
  • and to conduct research on the transference experience and scalability of the innovations

Part of the idea of the PPL would be to bring together the highest quality minds and experience for this best in the world effort.  Because of the mission, PPL should attract personnel of the very highest calibre.  The Board of Directors would be composed of some of these high-grade minds, from the worlds of academic medicine, medical practice, organizational and business theory, and the world of technology.  Parents should also probably be represented, and maybe even a teenage patient.

The physician staff would be composed of experienced physicians recruited from the private world and the academic world, including some of the best young faculty or recent graduates who have been devoting themselves to primary care, and who believe in the mission of strong primary care.  For this effort, it would be important to transcend the traditional rift between academia and practice.  It would also be important for experienced and very skilled administrators to be part of  the PPL, and for clinicians and administrators to work closely together.

The beginning PPL should at be composed of 5-10 clinicians, mostly pediatricians but also advanced nurse practitioners.  For adolescents, the PPL would offer the option for patients to be seen by an adolescent specialist at the PPL office.  The ratio of clinician to patients would be about 1:500.  It is possible that some of the patients who would be accepted into the PPL could be connected to the initial donors, either company employees or family members, etc.  In addition, “scholarship” support would be available for other families not so financially blessed.  The patients would be expected to share in the running and research of the PPL, giving feedback and suggestions. 

The services offered by the PPL would be as attentive as the most attentive concierge practices.  The exact services would be developed by the Board and staff in the planning stage.  The services would have to include 24/7 connectivity with the physician on call (as opposed to some concierge practices that apparently have 24/7 coverage by the actual personal physician.)  The actual personal pediatrician would be available if necessary 24/7 if the on-call doc needed to call him or her.  Appointments would be same day available on a very convenient basis, etc.  In addition, every technological advance would be available, including several types of telehealth.  Cognitive aides such as the Isabel program would be used.  The EMR resources of the medical center would be a part of the PPL, but would have to be open to customization for the PP.  Classes of all sorts would be offered to patients and parents and support groups would be utilized.  The Board and all staff would be challenged to develop even more services.  Specialist consultation could offer the opportunity for immediate telephone availability while the patient is in the office, very prompt appointments would be available, and nationwide consultation for difficult cases would be possible.  Population health would also be practiced, as the PPL viewed its patients collectively, assessed those groups at risk, educated those groups who had the need (e.g., adolescents and sexual/reproductive health, behavioral health, and preventive medicine.)

Internally at the PPL, procedures to promote quality would be the best possible, and would exceed any of such practices in the private concierge world.  Consistent review among clinicians of their cases and charts at conferences with others of the group would be effected.  Attention would be paid to diagnostic errors and the cognitive errors that engender them.  HEDIS, P4P measures, NCQA Medical Home, and other quality markers would be observed, but the quality of the PPL would be such that the PPL would blow by those markers and set its own standards.  Attention to administrative practices in the office would be extensive.  Again, the idea would not be to save money.  Overstaffing by conventional measures would be the rule.  The idea would be to produce a gold-plated practice, the best possible. 

In time, the PPL could expand to other sites with special emphases as they develop.  It wold be expected that as certain lines of service would start to yield fruit, the principals might want to found another practice that could work on those lines intensively, and one would also hope that demand for the PPL services would fuel expansion.


Financing the PPL should be relatively easy.  Concierge practices typically charge patients a yearly fee of $1,000 to $2,000 per patient, and they collect fee for service as well.  In addition, funding the research agenda and the startup costs should be supported by donating individuals and industry, which would then look forward to cooperating with the PPL on some projects and sending many of their family and employees to the PPL for care.  Proper budgeting would produce a program that would not lose money, and the goal would be to turn a modest profit.

The Research Agenda

To give an idea of what the research agenda might be like, here are some imaginary titles for papers that could emanate from the PPL. 

Comparative Costs and Benefits in the Primary Care Armamentarium: Telehealth, 24 hour On-call, and Immediate Scheduling Compared and Contrasted
The Primary Pediatrics Team: Acceptable Roles for Advanced Practice Nurses in a High-functioning System
How High-tech High-touch Primary Care Impacts the System: Reactions of Specialists to the New System of Primary Care
Coordination of Care in the Hospital: How Primary Pediatricians Can Work with Hospitalists If They Have Time
Is More Expensive Primary Care More Costly?  An Inquiry into the System-wide Effects of Hi-tech High-touch Primary Care
Proactive Prevention in Pediatrics: the Use of Technology in Promoting Health Behaviors in Adolescents
Sensing Depression and Drug Use: How New Technologies Can Send Warning Signals to Primary Pediatricians
Technology and Medical Practice: Is the Doctor Necessary for a Technology-based Family?
Ideal Primary Pediatrics: The Dimensions of a High-functioning system
Sharing the Medical Record with the Patient When You Have Time: Does it Make a Difference?


The payoffs  of the PPL for the medical center could be many. 

It is always good to be a world leader.  Currently there are few universities or hospitals that are making significant strides forward in primary care organization and quality.  Hospital-based services and specialty procedures and research still reign supreme, as the primary care day is dawning only fitfully.  Most medical centers are caught up in ACOs, coordination of services, introduction of EMRs and other such matters.  There is no group that I am aware of setting its sights on what would be the PPL objectives. 

The PPL could cement the relationship between the local business and technology community to the benefit of both, in many ways.  Just having the availability of prime grade pediatric care for the personnel of the donating institutions could yield great dividends.

The PPL could enhance the image of the medical center as “the” place for children's health.

The PPL concepts and techniques, when spread to the associated networks, would serve to further enhance the market share of those networks, and lead other practices to join it.

The idea of a primary care “lab,” perhaps even reminiscent of Bell Labs and Xerox, could stir enthusiasm for the sponsoring medical center worldwide.

It would probably be good at this point to mention a potential negative.  Many think that the whole concept of “concierge” is too financially driven, and that it is in some sense even ethically compromised, since the profession of medicine  professes its ideal to serve everyone.  I believe that this argument could be countered by asserting that equality should not be the enemy of quality, and that such an effort seeds elements that are readily adoptable by other systems.  In addition, when the market is telling us that there is a place for concierge care, it is important to listen and to respond in a way that allays the ethical concerns that might arise. 


This paper obviously is a quick sketch designed to provoke the imagination to think about a new pathway.  The concept outlined here isn't being done anywhere that I am aware of.  I believe that the PPL would be consonant with the goals of excellence set by ambitious academic medical centers in their other fields of concentrated effort.  Marketing would be easy, as would financing.  There is no reason to think that embarking on this program would detract from other medical center efforts; in fact, the opposite would probably be true.  Interaction with the specialty departments, for instance, would give a sense to them about what it means to truly serve patients to the highest degree.

In sum, I believe this proposal would be an opportunity for a major pediatric medical center to steal a march on the academic and hospital fields and emerge an innovative leader in primary care, an area that is increasingly recognized as important, but where research and practice still languishes.

Budd N. Shenkin, MD, MAPA

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