Coordination of Care Offers Opportunities for Providers
Watching the Olympic opening ceremonies, it would be difficult to miss the fact that the UK chose this very public stage to celebrate, of all things, their healthcare system. It is hard to imagine such a thing happening on US soil where if we aren’t fighting over how the system should work, we are complaining about why it doesn’t.
A large part of why it doesn’t is structural, financial, and political – all better left for discussion on another day. Yet another large piece of our current system’s inefficiency lies in the shortfalls in coordination and information exchange among the various components of the continuum of care. These gaps are more readily addressed by the private sector and represent huge opportunities for providers who manage to crack the code.
An excellent example of this coordination crisis is a recent study that shows that emergency department (ED) utilization by nonelderly Medicaid recipients is up to 3 times higher than for private pay patients. This ED utilization rate difference was not a surprise, but the reason for increased utilization was. Standard wisdom is, that facing access challenges for primary care, Medicaid patients turn to EDs for care of non-emergency conditions. Not so. The study showed that only about 10% of ED visits among the non-elderly Medicaid population were for non-emergent conditions, higher than the 7% rate for private pay patients, but representing only a small minority of visits.
Now, while the Medicaid population is not turning to Emergency Departments as a replacement for primary care, the likely reason for higher utilization of the ED is that these patients are not receiving the preventative and on-going care that would help them avoid urgent crises in the first place. Emergency visits aren’t replacing primary care per se, but they are frequently the only care that these patients can access.
The challenge here is not to convince patients to see their primary care physician instead of rushing off to the emergency room. The challenge is to make sure they are receiving sufficient care across the full array of non-emergency providers so that they don’t experience the true emergencies.
It sounds like semantics, but presents an entirely different challenge. Raising ED copays or turning patients away at the ED door are not the answer. By the time these patients arrive on at the triage desk there is a 90% chance they are experiencing a true medical emergency.
Better overall primary care access is an obvious first step to shift care out of the ED. The Medicaid study found that in 2008 only about half of specialists were accepting Medicaid patients. If patients can’t get in to see a doctor, it is unlikely that chronic conditions can be managed well enough to prevent an emergency. This places a challenge before short-term acute care providers, doctors and hospitals to find ways to coordinate care to keep chronic conditions from becoming acute.
Even patients with reasonable access to care face offices with limited hours, no after-hours coverage, and a lack of in-office resources. Companies that can offer cost-effective solutions – rental equipment, after hours support, or the EMR systems to allow seamless transfer of critical information gathered by overtaxed primary care physicians – can find a place at the table to ensure that patients manage their health in a way that keeps them out of emergency mode. Home care agencies, clinics, and case managers can all play a role here.
There is a financial opportunity to be captured, for sure. And systems that manage the flow of patient care and associated data bring value far beyond the scope of Medicaid. In an age when every managed care organization seeks to optimize utilization and spending, solutions that keep patients out of the hospital will have scores of interested parties knocking on their door. And while the dollars are intriguing, the potential to keep people healthier and emergency departments emptier is also a compelling outcome.
I still can’t imagine anyone doing a song and dance about our healthcare system, but maybe someday if we can get all of the pieces in place it could happen.