Wednesday, July 10, 2013

Just Because You Build It They Won't Come: What ACOs, PCMHs and Population Health Advocates Need to Know About Poverty and Emergency Room Use

Thinking about an ER visit.....
As part of a research requirement that it had to fulfill prior to medical school graduation, the young Disease Management Care Blog conducted a patient satisfaction survey. To its surprise, the DMCB discovered patients cared less about high touch primary care and more about access to high tech specialists.

It naturally ignored the income implications and became a general internist.

Fast forward to its job as a Medical Director in a not-for-profit physician-led managed care insurance plan.  No matter how much we "polished" the primary care network, emergency room utilization remained persistently high.

The CEO naturally ignored the DMCB's conclusion that there was little that could be done and assigned another medical director to the task.

Fast forward to Uncle Sam's Healthcare Fantasy Land, where ACOs and medical homes caring for patients with universal insurance will, thanks to the enlightened efficiencies of primary care, save gazillions of dollars by steering patients away from emergency rooms and hospitals.

All three scenarios came together when the DMCB read some research by group of Philadelphia docs who wanted to better understand why patients with low socioeconomic status kept ending up in emergency rooms and hospitals.

Best of all, to do this, they used a novel methodology: they found some patients and.... asked!

Their report appears in the latest issue of Health Affairs.

64 hospitalized patients with low socioeconomic status were approached to participate in a "qualitative" research interview (here's one example of how it's done). The patients were selected because they had been hospitalized via the ER multiple times, were between the ages of 18-64 years, were uninsured or on Medicaid, lived in a poor ZIP-code region of the city. 24 said no, leaving 40 subjects who agreed to have their interviews recorded. A rigorous analysis followed, with two "coders" who listened to the recordings and independently developed themes or ideas. They then circled back to the patients for confirmation.

Two themes emerged:

1) Convenience/Access: Even if they have access to primary care, the emergency room and inpatient setting remains the more convenient option.  That's because walk-in is available 24/7 and all testing as well as specialty care is available during a one-time visit.  Zero dollar primary care co-pays don't make up for the hassle, time and expense of calling ahead for appointments, arranging transportation (even if vouchers through Medicaid are available) or being referred for separate testing as well as specialty consultation.

2) Technology: Based on personal experience with their primary care docs, the emergency rooms and hospitals were perceived to have more technically proficient providers who were better able to achieve the correct diagnosis and render the correct treatment in a timely fashion.

A subset of patients seemed to come from chaotic life circumstances. Those patients found hospitals offered what the researchers described as "respite" and social "support."

The presence of Medicaid insurance had little to do with the attitudes described above.

The DMCB's take:

While subjective qualitative research is viewed with disdain by researchers, policymakers and journal editors, occasionally, good studies like this comes along.  This article sheds important light on a potential Achilles heel of accountable care organizations (ACOs) as well as the patient centered medical home (PCMH).

That Achilles heel? Just because you build it, these 40 patients - and millions who live in poverty like them - won't come.

What's more, they are making rational decisions.

The authors point out that system solutions include co-locating multiple services (primary care, labs, x-rays and specialists), improving the quality of primary care and, when possible, mitigating any social challenges. The DMCB agrees, but is unaware of any ACOs or medical home initiatives that, outside of the usual process measures, specifically address these patients' special concerns.

The DMCB's suggestions:

Advocates for ACOs and the PCMH need to get real, lower expectations and recognize that a key solution to the problem of health care overutilization by persons in poverty is to stop politicians and health care leaders from medicalizing poverty. 

That being said, one possible solution for ACOs and PCMHs serving fragile patients with poverty is high intensity biopsychosocial intervention.  It sounds expensive but full time community-based care management with low case loads and lots of physician support may help ameliorate some of the dysfunction.  It's probably less expensive than all those hospitalizations.

Finally, this may be an opportunity for nimble population health management service providers.  If any are already out there serving this population, the DMCB would like to know about it.

Image from Wikipedia


Dr, Pullen said...

I believe you the findings of this study are right on. It's not just low socioeconomic patients overusing the ER either. Middle income patients who could come to the office on Monday morning, go to the ER on Sunday because they won't need to use a partial or full day off work, saving a paid-time-off day for vacation or not missing a day of paid work. Others find the convenience of getting the "whole evaluation" done in one long visit, i.e. imaging, labs, etc rather than an office visit, a referral for imaging and lab results the next day. Others yet just don't care at all about OPM (other people's money). Until patients have financial skin in the game, the ER is an attractive alternative. I almost never see patients who are spending their own money go to the ER when a much less expensive alternatitve is available.

Anonymous said...

As an ED doc, I would like to ask why we are even talking about "ED use"? Only 2% of all healthcare dollars are spent on ED care. (and treat 136 million of the nations sickest patients with that 2%) Its the inpatient care, not the ED care that is expensive. Why don't we talk about "hospital use" or "ICU use" or, god forbid, "end of life care" all of which represent a lot more dollars?

So what is the solution for primary care? Be more like the ED. Be open 24/7, be legally required to see everyone who comes through the door, be accessible in a reasonable timeframe, and continue to take great care of your patients.

I am not super optimistic that will ever happen, though. In the meantime, your local ED is taking care of anything and everything.