Tuesday, September 7, 2010

Reducing ER Utilization? More Likely With Disease Management

Even though this literature says otherwise, the Disease Management Care Blog always thought emergency room (ER) physicians were a cranky lot. Thanks to being largely salaried, buffeted by ER overcrowding and serving on the front lines of a system in crisis, who can blame them for feeling as if they're being taken advantage of? To hospital administrators, ERs and their docs are a large fixed cost to be mitigated by high patient throughput and mining it for remunerative hospital admissions. No wonder they're advertising wait times.

Which is why the DMCB thinks it can always count on ER physicians to point out reasons why ERs are being overused. Case in point is this hot-off-the-presses study that was discussed at a recent Health Affairs Briefing attended by the DMCB. Drawing on yearly Federal survey data from 2001-2004, the authors calculated that Americans currently experience 321 outpatient visits per 1000 people per month - a considerable increase compared to 1961, when were about 250 visits per thousand. About one third - or about 107 visits per 1000 per month - were for "acute care," defined as also including chronic disease flare-ups. Nationwide, ER docs, who account for only 4% of the nation's physician workforce, handled 11% of all ambulatory acute care visits. Two thirds of these visits occurred on weekends or after office hours.

Quoting literature that shows that most primary care practice is underfinanced and filled with chronic care follow-up visits that take up the entire day, the authors reviewed the possibility that Patient Centered Medical Homes, Accountable Care Organizations, urgent care clinics and retail clinics will reduce ER utilization.

That's a big maybe, says the DMCB. It's difficult to define just what constitutes an emergency, and the HMO backlash resulted in the open access to ERs with a prudent layperson legal standard. Smart managed care organizations have been working on this problem for years and haven't made much progress. In the meantime, enterprising hospitals know ERs can be a cash cow. Last but not least, the finding that 4% of the physician workforce can handle 11% of all ambulatory acute care visits suggests they're giving the U.S. a great deal. The likelihood that this mix of policy, reform, financing and politics will have any impact on current ER utilization rates in the near future is nil.

But, the DMCB would like to point out one area of research that, strangely enough, went unexamined by Health Affairs' authors, reviewers and editors. There are a group of interventions that have been shown to reduce unnecessary ER utilization for acute exacerbations of disease that were included in the analysis above. They're collectively called disease a.k.a. care population-based management. Not hard-to-find examples can be found here for diabetes, here in heart failure (where ER visits typically lead to hospitalizations), here for COPD and here for asthma. '

Sure, the literature isn't perfect, but the DMCB says it's better than the current science supporting PCMHs or ACOs when it comes to ER utilization. As noted previously, modern Ver. 2.0 disease management promises to be part of the right interlocking mix of services that will include ACOs, medical homes, health information technology, physician payment reform and value-based insurance designs. The DMCB is very optimistic that the Feds, States, policy makers, Departments of Insurance will eventually discover that, especially if they don't limit their reading to the traditional print media dominated by an academic perspective.

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