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For Love, for Money, or for Both?: Which Way Will We Choose to Transform Children's Health Care?

For Love, for Money, or for Both?: Which Way Will We Choose to Transform Children's Health Care? Both the American people and the physician community hold internally conflicting views about health care and the medical profession, respectively. We are uncertain as a people whether access to high-quality health care is a fundamental right, such as freedom of speech, or a commercial service, such as hotel accommodations. We are uncertain as a medical profession whether our work is a calling or a job. These ambivalences are reflected in the current policy emphasis on and the public and professional queasiness about pay for performance. The goal of the health care system is to continuously improve the health and well-being of the American public; the needs of our economy dictate that this effort be done in such a way as to achieve the greatest benefit at the lowest cost.1 Countless studies document the shortcomings of the health care system: the dramatic variability across regions independent of patient need; the failure to deliver services well established to produce better results; the insensitivity of those services to patient and family needs and desires; the frequent errors resulting in unnecessary harm; the differences in care owing to patient race, ethnicity, or economic well-being; and the use of services known to be ineffective.2-5 These failings of our system, documented in pediatrics as well as in adult care, persist despite innumerable reports and a variety of strategies such as capitation and public accountability to promote reform.6 These latter efforts have led to a professional workforce that is demoralized by the high administrative burdens and increasing external oversight of clinical practice.7 These widespread defects in quality of care cry out for the application of quality improvement methods. In industries as varied as automobile manufacturing, telecommunications, and banking, use of quality improvement methods results in more reliable, higher-performing products, often at lower cost. Industries adopt these approaches not out of an abstract desire for quality but because they lead to dramatic financial benefits.8 Businesses are able to translate greater reliability and efficiency to increased market share, higher prices, and greater profits. In health care, in contrast, there is no consistent business case for such a focus on quality.9 This logic has led to widespread efforts to realign the incentives in health care so that quality and financial well-being are better aligned. These approaches are broadly encompassed under the rubric of pay for performance. Numerous studies and review articles are now seeking to assess these approaches and answer the question of whether pay for performance works as an approach to improving quality of care.10,11 This is a naïve question, as simplistic as the question of whether managed care works. A better question is what incentives in which settings are most likely to lead to desirable results—improved quality, reduced costs, and better health outcomes—while minimizing undesirable outcomes such as gaming rather than improving, competing rather than sharing, selecting healthy patients rather than managing a population, and adding even greater administrative burden to the most administratively complex health care system in the world. This nuanced question acknowledges that health care is simultaneously both a human right and extraordinarily expensive and that the practice of medicine is both a calling and a source of employment for real people. It is in this context that the article by Mandel and Kotagal12 provides an extremely valuable contribution. The provocative title of the article, “Pay for Performance Alone Cannot Drive Quality,” is somewhat misleading. The use of financial incentives is a strategy by those participants in the health care sector who are separate from providers—employers, government, managed care—to influence the behavior of providers. A simpler case to consider is the prospective payment system. By providing a fixed reimbursement to hospitals for patients with a particular diagnosis, the prospective payment system was designed to improve efficiency through giving an incentive to shorten the length of stay. It is a purely external incentive. The Center for Medicaid and Medicare Services (then the Health Care Financing Administration) provided no resources or technical support for hospitals to achieve efficiencies; it assumed that hospitals, either on their own or with the help of consultants, would develop such mechanisms if it was in their financial interest to do so. As such, it achieved its goal of enhancing efficiency, albeit with some level of gaming the system, in this case by encouraging “upcoding” of diagnostic labels.13,14 In the case of pay for performance, the incentives are meant to influence a more complex process, quality of care, rather than simply promote efficiency. Nonetheless, pay-for-performance programs intend to prompt providers themselves either as individuals or as systems to respond to those incentives through adoption of methods and tools, such as those used by the Cincinnati practice network, that will enable them to improve performance and thus receive the awards. Pay for performance without capacity in the health care system to respond to the incentives cannot—and was never meant to—drive quality. Mandel and Kotagal describe the breathtaking results that they have achieved in their practice network. Using the latest quality improvement methods, including patient registries, engagement of families in cooperative care, and the science of reliability adopted from high-risk industries such as nuclear power, their practice network has achieved unprecedented levels of performance in the delivery of evidence-based care for children with asthma. Through their efforts, more than 98% of children with asthma cared for in their practice network have received all of the 4 evidence-based practices—results that far exceed usual care and similarly exceed the results of previous improvement efforts! Such an approach is the current benchmark for network performance. Mandel and Kotagal attribute much of the success of their efforts to their innovative approach that aligns financial incentives with the desired quality results. Their approach addresses many of the concerns others have raised about pay for performance: they reward participation so that everybody gets credit just for making an effort beyond business as usual; they reward collective performance across the entire network to encourage collaboration and recognition of the network as a delivery system rather than a set of autonomous agents; and they base some of their payments on all-payer information rather than information from a single payer to encourage enhancing overall system performance rather than cherry-picking or differential effort. They reward the creation of infrastructure for measurement and tracking, as they know this is a hidden cost of any improvement effort. They set a high bar through the use of bundled performance measures, assuring that the measures are focused on getting each patient the desired care. They reward absolute performance rather than relative performance because the goal is not the win and lose of business but the betterment of patient outcomes. All of these recommendations are credible. They are all designed to address the weaknesses of most current approaches to pay for performance: they reward system performance rather than individual effort; they build infrastructure; and they encompass the full patient panels rather than a segment. However, from a research perspective, we have no way of knowing, and it may be ultimately too complicated to fully disentangle, the contribution of pay for performance to the success of this overall initiative, much less knowing how important the specific elements of the pay-for-performance package might be. The primary care independent practice association in which this initiative was based is a component of the Physician Hospital Organization of Cincinnati Children's Hospital and Medical Center, a participant in the highly competitive Pursuing Perfection program designed to create “Toyota”-like excellence within health care.15 As 1 indicator of their high level of performance capability, Cincinnati Children's Hospital and Medical Center was the 2006 recipient of the prestigious American Hospital Association–McKesson Quest for Quality award.16 Much of the dramatic improvement undertaken by the hospital has been done without the benefit of immediate financial incentives. The practice network already had access to this extremely strong quality improvement capacity and had launched their efforts. The timing of their improvements was coincident with implementation of the pay-for-performance program, but this may simply have been the duration of time required for the improvement efforts to grab hold. Important and groundbreaking as these results are, we should also acknowledge the limitations of the approach. This network tackled the topic that has the most extensive evidence in pediatrics, the management of children with asthma. Using this approach on other topics about which there is less consensus, such as childhood obesity or behavioral health, may prove more contentious. Their exclusive use of process measures—albeit processes well grounded in evidence—leaves open the possibility that the treatments are not being delivered in a way that leads to better outcomes. Porter and Teisberg17 contend that the consumer should ultimately be indifferent about processes so long as the desired outcomes are achieved (eg, we do not reward companies for their manufacturing process but rather the reliability and performance of their products). Porter and Teisberg similarly argue that incentives based on process assessment will be increasingly intrusive, leading to continued professional demoralization and excess administrative burden. However, a simple return to outcome-based reimbursement without adjustment for disease complexity, churning enrollment, and population differences leads to the same difficulties we witnessed with managed care in general—the manipulation of risk selection rather than a focus on improvement and emphasis on shorter-term rather than longer-term outcomes. In addition, the condition and measures chosen in this case only reflect care within the walls of the network as opposed to the more challenging context of coordinating care between primary care and subspecialty care and between clinical practice and community resources.18 An enlightened pay-for-performance program such as that described by Mandel and Kotagal, coupled with progressive organizational leadership, a willingness to partner with families and the community, and expert use of quality improvement methods (including performance data and patient registries), provides an outstanding basis for important and substantial incremental improvements that will result in predictably better care for children and families. Quantum changes in system performance, ie, the creation of systems that will continuously improve the health and well-being of children and society and overcome the short-term focus and fragmentation of children's services, will require a broader and more comprehensive change in financial incentives.19 Such a broad change would provide incentives for improving population health rather than the health of those cared for in a single setting, would develop mechanisms that encompass broader goals across multiple systems affecting child well-being (including public health, education, and welfare), and would develop mechanisms to account for the long-term perspective.20,21 But, failing such a radical redesign, Mandel and Kotagal provide a cogent and promising approach to aligning incentives in today's world and offer a compelling set of recommendations that both provider organizations and payer groups would be wise to consider. Even more compelling, they provide an example of what a concerted approach to improvement can produce, providing a benchmark of performance in care. Correspondence: Dr Homer, National Initiative for Children's Healthcare Quality, 20 University Rd, Seventh Floor, Cambridge, MA 02138 (chomer@nichq.org). Financial Disclosure: None reported. References 1. Committee on Quality Health Care in America,Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC National Academy Press2001; 2. Fisher ESWennberg DEStukel TAGottlieb DJLucas FLPinder EL The implications of regional variations in Medicare spending, part 1: the content, quality, and accessibility of care. Ann Intern Med 2003;138 (4) 273- 287PubMedGoogle ScholarCrossref 3. Gauthier ASerber N A Need to Transform the US Health Care System: Improving Access, Quality, and Efficiency. New York, NY Commonwealth Fund2005; 4. Agency for Healthcare Research and Quality, National healthcare quality report, 2006. http://www.ahrq.gov/qual/nhqr06/nhqr06.htmAccessed March 31, 2007 5. Agency for Healthcare Research and Quality, National healthcare disparities report, 2006. http://www.ahrq.gov/qual/nhdr06/nhdr06.htmAccessed March 31, 2007 6. Leatherman SMcCarthy D Quality of Care for Children and Adolescents: A Chartbook. New York, NY Commonwealth Fund2004; 7. Bodenheimer T Primary care: will it survive? N Engl J Med 2006;355 (9) 861- 864PubMedGoogle ScholarCrossref 8. Gertner J From 0 to 60 to world domination. N Y Times Mag February18 2007;Google Scholar 9. Leatherman SBerwick DIles D et al. The business case for quality: case studies and an analysis. Health Aff (Millwood) 2003;22 (2) 17- 30PubMedGoogle ScholarCrossref 10. Petersen LAWoodard LDUrech TDaw CSookanan S Does pay for performance improve the quality of health care? Ann Intern Med 2006;145 (4) 265- 272PubMedGoogle ScholarCrossref 11. Rosenthal MBDudley RA Pay-for-performance: will the latest payment trend improve care? JAMA 2007;297 (7) 740- 744PubMedGoogle ScholarCrossref 12. Mandel KEKotagal UR Pay for performance alone cannot drive quality. Arch Pediatr Adolesc Med 2007;161 (7) 650- 655Google ScholarCrossref 13. Russell LBManning CL The effect of prospective payment on Medicare expenditures. N Engl J Med 1989;320 (7) 439- 444PubMedGoogle ScholarCrossref 14. Chulis GS Assessing Medicare's prospective payment system for hospitals. Med Care Rev 1991;48 (2) 167- 206PubMedGoogle ScholarCrossref 15. Institute for Healthcare Improvement, Pursuing perfection: raising the bar for health care performance. http://www.ihi.org/IHI/Programs/StrategicInitiatives/PursuingPerfection.htm?TabId=4Accessed April 3, 2007 16. Britto MTAnderson JAKent WK et al. Cincinnati Children's Hospital Medical Center: transforming care for children and families. Jt Comm J Qual Patient Saf 2006;32 (10) 541- 548PubMedGoogle Scholar 17. Porter METeisberg EO Redefining competition in health care. Harv Bus Rev 2004;82 (6) 64- 76PubMedGoogle Scholar 18. Homer CJCooley WCSobo EJedKurtin PSed Creating a medical home for children with special health care needs. Optimizing Care for Young Children with Special Health Care Needs. Baltimore, MD Brookes Publishing2007;Google Scholar 19. Homer CChild Health Business Case Working Group, Exploring the business case for improving the quality of health care for children [published correction appears in Health Aff (Millwood). 2004;23(5):283]. Health Aff (Millwood) 2004;23 (4) 159- 166PubMedGoogle ScholarCrossref 20. Kindig DA A pay-for-population health performance system. JAMA 2006;296 (21) 2611- 2613PubMedGoogle ScholarCrossref 21. Halfon NDuPlessis HInkelas M Transforming the US child health system. Health Aff (Millwood) 2007;26 (2) 315- 330PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Pediatrics & Adolescent Medicine American Medical Association

For Love, for Money, or for Both?: Which Way Will We Choose to Transform Children's Health Care?

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References (21)

Publisher
American Medical Association
Copyright
Copyright © 2007 American Medical Association. All Rights Reserved.
ISSN
1072-4710
DOI
10.1001/archpedi.161.7.715
pmid
17606838
Publisher site
See Article on Publisher Site

Abstract

Both the American people and the physician community hold internally conflicting views about health care and the medical profession, respectively. We are uncertain as a people whether access to high-quality health care is a fundamental right, such as freedom of speech, or a commercial service, such as hotel accommodations. We are uncertain as a medical profession whether our work is a calling or a job. These ambivalences are reflected in the current policy emphasis on and the public and professional queasiness about pay for performance. The goal of the health care system is to continuously improve the health and well-being of the American public; the needs of our economy dictate that this effort be done in such a way as to achieve the greatest benefit at the lowest cost.1 Countless studies document the shortcomings of the health care system: the dramatic variability across regions independent of patient need; the failure to deliver services well established to produce better results; the insensitivity of those services to patient and family needs and desires; the frequent errors resulting in unnecessary harm; the differences in care owing to patient race, ethnicity, or economic well-being; and the use of services known to be ineffective.2-5 These failings of our system, documented in pediatrics as well as in adult care, persist despite innumerable reports and a variety of strategies such as capitation and public accountability to promote reform.6 These latter efforts have led to a professional workforce that is demoralized by the high administrative burdens and increasing external oversight of clinical practice.7 These widespread defects in quality of care cry out for the application of quality improvement methods. In industries as varied as automobile manufacturing, telecommunications, and banking, use of quality improvement methods results in more reliable, higher-performing products, often at lower cost. Industries adopt these approaches not out of an abstract desire for quality but because they lead to dramatic financial benefits.8 Businesses are able to translate greater reliability and efficiency to increased market share, higher prices, and greater profits. In health care, in contrast, there is no consistent business case for such a focus on quality.9 This logic has led to widespread efforts to realign the incentives in health care so that quality and financial well-being are better aligned. These approaches are broadly encompassed under the rubric of pay for performance. Numerous studies and review articles are now seeking to assess these approaches and answer the question of whether pay for performance works as an approach to improving quality of care.10,11 This is a naïve question, as simplistic as the question of whether managed care works. A better question is what incentives in which settings are most likely to lead to desirable results—improved quality, reduced costs, and better health outcomes—while minimizing undesirable outcomes such as gaming rather than improving, competing rather than sharing, selecting healthy patients rather than managing a population, and adding even greater administrative burden to the most administratively complex health care system in the world. This nuanced question acknowledges that health care is simultaneously both a human right and extraordinarily expensive and that the practice of medicine is both a calling and a source of employment for real people. It is in this context that the article by Mandel and Kotagal12 provides an extremely valuable contribution. The provocative title of the article, “Pay for Performance Alone Cannot Drive Quality,” is somewhat misleading. The use of financial incentives is a strategy by those participants in the health care sector who are separate from providers—employers, government, managed care—to influence the behavior of providers. A simpler case to consider is the prospective payment system. By providing a fixed reimbursement to hospitals for patients with a particular diagnosis, the prospective payment system was designed to improve efficiency through giving an incentive to shorten the length of stay. It is a purely external incentive. The Center for Medicaid and Medicare Services (then the Health Care Financing Administration) provided no resources or technical support for hospitals to achieve efficiencies; it assumed that hospitals, either on their own or with the help of consultants, would develop such mechanisms if it was in their financial interest to do so. As such, it achieved its goal of enhancing efficiency, albeit with some level of gaming the system, in this case by encouraging “upcoding” of diagnostic labels.13,14 In the case of pay for performance, the incentives are meant to influence a more complex process, quality of care, rather than simply promote efficiency. Nonetheless, pay-for-performance programs intend to prompt providers themselves either as individuals or as systems to respond to those incentives through adoption of methods and tools, such as those used by the Cincinnati practice network, that will enable them to improve performance and thus receive the awards. Pay for performance without capacity in the health care system to respond to the incentives cannot—and was never meant to—drive quality. Mandel and Kotagal describe the breathtaking results that they have achieved in their practice network. Using the latest quality improvement methods, including patient registries, engagement of families in cooperative care, and the science of reliability adopted from high-risk industries such as nuclear power, their practice network has achieved unprecedented levels of performance in the delivery of evidence-based care for children with asthma. Through their efforts, more than 98% of children with asthma cared for in their practice network have received all of the 4 evidence-based practices—results that far exceed usual care and similarly exceed the results of previous improvement efforts! Such an approach is the current benchmark for network performance. Mandel and Kotagal attribute much of the success of their efforts to their innovative approach that aligns financial incentives with the desired quality results. Their approach addresses many of the concerns others have raised about pay for performance: they reward participation so that everybody gets credit just for making an effort beyond business as usual; they reward collective performance across the entire network to encourage collaboration and recognition of the network as a delivery system rather than a set of autonomous agents; and they base some of their payments on all-payer information rather than information from a single payer to encourage enhancing overall system performance rather than cherry-picking or differential effort. They reward the creation of infrastructure for measurement and tracking, as they know this is a hidden cost of any improvement effort. They set a high bar through the use of bundled performance measures, assuring that the measures are focused on getting each patient the desired care. They reward absolute performance rather than relative performance because the goal is not the win and lose of business but the betterment of patient outcomes. All of these recommendations are credible. They are all designed to address the weaknesses of most current approaches to pay for performance: they reward system performance rather than individual effort; they build infrastructure; and they encompass the full patient panels rather than a segment. However, from a research perspective, we have no way of knowing, and it may be ultimately too complicated to fully disentangle, the contribution of pay for performance to the success of this overall initiative, much less knowing how important the specific elements of the pay-for-performance package might be. The primary care independent practice association in which this initiative was based is a component of the Physician Hospital Organization of Cincinnati Children's Hospital and Medical Center, a participant in the highly competitive Pursuing Perfection program designed to create “Toyota”-like excellence within health care.15 As 1 indicator of their high level of performance capability, Cincinnati Children's Hospital and Medical Center was the 2006 recipient of the prestigious American Hospital Association–McKesson Quest for Quality award.16 Much of the dramatic improvement undertaken by the hospital has been done without the benefit of immediate financial incentives. The practice network already had access to this extremely strong quality improvement capacity and had launched their efforts. The timing of their improvements was coincident with implementation of the pay-for-performance program, but this may simply have been the duration of time required for the improvement efforts to grab hold. Important and groundbreaking as these results are, we should also acknowledge the limitations of the approach. This network tackled the topic that has the most extensive evidence in pediatrics, the management of children with asthma. Using this approach on other topics about which there is less consensus, such as childhood obesity or behavioral health, may prove more contentious. Their exclusive use of process measures—albeit processes well grounded in evidence—leaves open the possibility that the treatments are not being delivered in a way that leads to better outcomes. Porter and Teisberg17 contend that the consumer should ultimately be indifferent about processes so long as the desired outcomes are achieved (eg, we do not reward companies for their manufacturing process but rather the reliability and performance of their products). Porter and Teisberg similarly argue that incentives based on process assessment will be increasingly intrusive, leading to continued professional demoralization and excess administrative burden. However, a simple return to outcome-based reimbursement without adjustment for disease complexity, churning enrollment, and population differences leads to the same difficulties we witnessed with managed care in general—the manipulation of risk selection rather than a focus on improvement and emphasis on shorter-term rather than longer-term outcomes. In addition, the condition and measures chosen in this case only reflect care within the walls of the network as opposed to the more challenging context of coordinating care between primary care and subspecialty care and between clinical practice and community resources.18 An enlightened pay-for-performance program such as that described by Mandel and Kotagal, coupled with progressive organizational leadership, a willingness to partner with families and the community, and expert use of quality improvement methods (including performance data and patient registries), provides an outstanding basis for important and substantial incremental improvements that will result in predictably better care for children and families. Quantum changes in system performance, ie, the creation of systems that will continuously improve the health and well-being of children and society and overcome the short-term focus and fragmentation of children's services, will require a broader and more comprehensive change in financial incentives.19 Such a broad change would provide incentives for improving population health rather than the health of those cared for in a single setting, would develop mechanisms that encompass broader goals across multiple systems affecting child well-being (including public health, education, and welfare), and would develop mechanisms to account for the long-term perspective.20,21 But, failing such a radical redesign, Mandel and Kotagal provide a cogent and promising approach to aligning incentives in today's world and offer a compelling set of recommendations that both provider organizations and payer groups would be wise to consider. Even more compelling, they provide an example of what a concerted approach to improvement can produce, providing a benchmark of performance in care. Correspondence: Dr Homer, National Initiative for Children's Healthcare Quality, 20 University Rd, Seventh Floor, Cambridge, MA 02138 (chomer@nichq.org). Financial Disclosure: None reported. References 1. Committee on Quality Health Care in America,Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC National Academy Press2001; 2. Fisher ESWennberg DEStukel TAGottlieb DJLucas FLPinder EL The implications of regional variations in Medicare spending, part 1: the content, quality, and accessibility of care. Ann Intern Med 2003;138 (4) 273- 287PubMedGoogle ScholarCrossref 3. Gauthier ASerber N A Need to Transform the US Health Care System: Improving Access, Quality, and Efficiency. New York, NY Commonwealth Fund2005; 4. Agency for Healthcare Research and Quality, National healthcare quality report, 2006. http://www.ahrq.gov/qual/nhqr06/nhqr06.htmAccessed March 31, 2007 5. Agency for Healthcare Research and Quality, National healthcare disparities report, 2006. http://www.ahrq.gov/qual/nhdr06/nhdr06.htmAccessed March 31, 2007 6. Leatherman SMcCarthy D Quality of Care for Children and Adolescents: A Chartbook. New York, NY Commonwealth Fund2004; 7. Bodenheimer T Primary care: will it survive? N Engl J Med 2006;355 (9) 861- 864PubMedGoogle ScholarCrossref 8. Gertner J From 0 to 60 to world domination. N Y Times Mag February18 2007;Google Scholar 9. Leatherman SBerwick DIles D et al. The business case for quality: case studies and an analysis. Health Aff (Millwood) 2003;22 (2) 17- 30PubMedGoogle ScholarCrossref 10. Petersen LAWoodard LDUrech TDaw CSookanan S Does pay for performance improve the quality of health care? Ann Intern Med 2006;145 (4) 265- 272PubMedGoogle ScholarCrossref 11. Rosenthal MBDudley RA Pay-for-performance: will the latest payment trend improve care? JAMA 2007;297 (7) 740- 744PubMedGoogle ScholarCrossref 12. Mandel KEKotagal UR Pay for performance alone cannot drive quality. Arch Pediatr Adolesc Med 2007;161 (7) 650- 655Google ScholarCrossref 13. Russell LBManning CL The effect of prospective payment on Medicare expenditures. N Engl J Med 1989;320 (7) 439- 444PubMedGoogle ScholarCrossref 14. Chulis GS Assessing Medicare's prospective payment system for hospitals. Med Care Rev 1991;48 (2) 167- 206PubMedGoogle ScholarCrossref 15. Institute for Healthcare Improvement, Pursuing perfection: raising the bar for health care performance. http://www.ihi.org/IHI/Programs/StrategicInitiatives/PursuingPerfection.htm?TabId=4Accessed April 3, 2007 16. Britto MTAnderson JAKent WK et al. Cincinnati Children's Hospital Medical Center: transforming care for children and families. Jt Comm J Qual Patient Saf 2006;32 (10) 541- 548PubMedGoogle Scholar 17. Porter METeisberg EO Redefining competition in health care. Harv Bus Rev 2004;82 (6) 64- 76PubMedGoogle Scholar 18. Homer CJCooley WCSobo EJedKurtin PSed Creating a medical home for children with special health care needs. Optimizing Care for Young Children with Special Health Care Needs. Baltimore, MD Brookes Publishing2007;Google Scholar 19. Homer CChild Health Business Case Working Group, Exploring the business case for improving the quality of health care for children [published correction appears in Health Aff (Millwood). 2004;23(5):283]. Health Aff (Millwood) 2004;23 (4) 159- 166PubMedGoogle ScholarCrossref 20. Kindig DA A pay-for-population health performance system. JAMA 2006;296 (21) 2611- 2613PubMedGoogle ScholarCrossref 21. Halfon NDuPlessis HInkelas M Transforming the US child health system. Health Aff (Millwood) 2007;26 (2) 315- 330PubMedGoogle ScholarCrossref

Journal

Archives of Pediatrics & Adolescent MedicineAmerican Medical Association

Published: Jul 1, 2007

There are no references for this article.