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

The Link Between Povery, Obesity and Diabetes

Having to pay for a portion of any health care leads to decreased access. Electronic medical records result in increased quality.  Primary care causes lower costs.  The Disease Management Care Blog is responsible for the DMCB spouse's migraines.  While each assertion may be technically true, the real underlying question is "By how much?"

That's why this New England Journal paper "Neighborhoods, Obesity and Diabetes - A Randomized Social Experiment" by Jens Ludwig and colleagues that examines the association between poverty and diabetes is important.  Researchers have known that low income can lead to preference for the "cheap calories" in refined and high fat foods which, in turn, lead to a high rate of obesity among indigent persons.  Now we have a better idea on how much.

Ever hear of the "Moving to Opportunity" demonstration project?  Neither did the Disease Management Care Blog, but this was a demo designed to test the long term impact of housing and poverty on health and well-being.  In the study, females with children who were candidates for public housing assistance were entered into a lottery that randomly assigned participants to one of three groups:

1) a low poverty voucher group that could use their vouchers to rent housing in a census tract with less than a 10% poverty rate (N=1425).  After one year, persons assigned this group could move anywhere they wished;

2) a traditional voucher group that could be used anywhere (N=657);

3) a control group that was SOL (N=1104).

The women were asked questions about their health at baseline, including height, weight and also provided blood samples to check an A1c to assess the presence of diabetes mellitus.  They were then followed for approximately 10 years.

Not all persons completed the follow up, so the authors used an "intention-to treat" analysis.  The rates of poverty are here, while the rates of obesity and diabetes are here.  The low poverty voucher group not only had lower rates of obesity (defined as a BMI greater than 35) but a lower rate of abnormal A1cs (16.3% vs. 20% in the control).  The traditional voucher group had lower numbers vs. the controls but they failed to achieve statistical significance.  It appears, based on this study, that living in a low poverty neighborhood reduces the rate of obesity and diabetes in the absolute range of 3% to 4%.

The authors correctly point out that not all persons in the study completed the follow-up, which could have biased the results.  In addition, the A1c results don't account for the possibility that more persons in the voucher group may have had their diabetes successfully treated.  Last but not least, much of the data were self reported.

The DMCB was surprised that poverty seemed to directly account for a relatively small amount of "new" disease.  On the other hand, an additional 3-4% involving millions of U.S. citizens represents a public health disaster.  Based on these data, we have a better insight on the role of poverty in diabetes and can point to at least one Federal program where taxpayers appear to have gotten their money's worth.