1. Holt, Mark MD


Abstract: Texas has one of the highest rates of uninsured in the United States. In addition, the Medicaid program is one of the poorest programs, in terms of benefits, of any state in the union. This article summarizes how a large pediatric practice responded to this crisis in a large metropolitan area. Key ingredients for success include both physician practice leadership (they have significant resources at their disposal), extensive community involvement (to provide, in particular, monies for the program), and local hospital involvement (for emergency and inpatient services).


PEDIPLACE IS AN outpatient ambulatory pediatric health care center that was born in 1994. PediPlace provides a medical home to the following groups of pediatric patients:


* patients on Medicaid


* patients who have CHIPs, a state program funded by the state and federal funds that extend the coverage and financial limits used to define Medicaid coverage


* uninsured patients



The uninsured families of pediatric patients fall into two basic groups:


* those who are chronically without the means to pay for health care and who do not qualify, for arious reasons, for Medicaid and CHIP


* those who have suffered more acute financial setbacks-primarily the loss of employment-and who have in the past had insurance to cover their health care needs (this group fluctuates by definition according to the local and national economy)



A brief word about the history and design of PediPlace is provided next. PediPlace was conceived and designed by Dr. Darla Kincaid and myself. We are pediatric partners in a private pediatric practice in Lewisville, Texas, the home of PediPlace. PediPlace is a separate, autonomous, community-based health care center that has no financial or other ties to our pediatric practice (i.e., it was designed and built to stand on its own as an autonomous, nonprofit, community-based pediatric health care center). On a critical, strategic note, I should also mention that Dr. Kincaid continues to be involved-on a strictly volunteer basis-as the medical director of PediPlace. She donates her medical leadership and time on an ongoing basis to PediPlace. My role is much more limited, in that I contribute financial and intermittent strategic consults to PediPlace.


Dr. Kincaid and I both worked in the children and youth pediatric health care centers in Dallas, while we were residents at the Children's Medical Center in Dallas. These school-based pediatric health care centers were staffed by pediatric nurse practitioners and other important ancillary pediatric personnel, such as social workers and dentists. The centers were under the direction of a pediatrician who supervised the care provided by the nurse practitioners and also provided some pediatric care themselves. The centers were based near elementary schools in Dallas and served the pediatric population that was either uninsured or on Medicaid. Specialty and hospital care was provided through subspecialty clinics based at the Children's Medical Center or inpatient care at either Children's or the pediatric floor at Parkland Memorial Hospital, which is adjacent to Children's. This model-using pediatric nurse practitioners supervised by a pediatrician medical director-was used in the design and construction of PediPlace.


The primary difference between PediPlace and the children and youth health care centers is that, unlike the centers, PediPlace provides care without a hospital or subspecialty focus, which means a lack of pediatric residents and onsite pediatrician medical directors who provide a system of outpatient and inpatient care. Located 15 miles north of Dallas, Lewisville has a population of approximately 75,000 people; the several surrounding and adjacent communities increase the population served to more than 100,000 people. Lewisville is in Denton County, which has no county hospital whose mission is to provide indigent care. Therefore, the local hospitals in Denton County provide care to the uninsured, with the entry point being the emergency room.


Currently, PediPlace primarily utilizes the Medical Center of Lewisville, which is five minutes away from PediPlace, for emergency room and inpatient care. Subspecialty care is currently provided by a mixture of local physicians, including orthopedic and ENT specialists, as well as pediatric subspecialists from both Children's Medical Center in Dallas and Cooks Children's Hospital in Ft. Worth. Both pediatric hospitals have satellite centers located either in Lewisville or within 20 minutes of Lewisville to serve the growing population north of Dallas.


A number of hurdles that required focused problem solving had to be overcome in the birth, growth, and development of PediPlace.