WEEK NINE: PRIVATE SECTOR INNOVATION POLICY ADVANCEMENTS
Innovation plays a crucial role in the private sector regarding reducing inappropriate use of emergency department for non-urgent visits. Integrating primary care and hospital care is a potential innovative strategy for private sectors such as primary care practices (Center for Care Innovations, 2017). Patients who don’t have primary care providers (PCP) usually use EDs for their care. Studies showed that individuals who did not receive appropriate primary care usually delay receiving appropriate care which results in an increased use of EDs (Agarwal et al., 2016). Therefore, increase the proportion of people with a regular PCP will improve patient access to care and potentially reduce the inappropriate use of ED (HealthyPeople.gov, 2016). An ED to PCP program is recommended by the literature to reduce ED visits, and increase visits to PCP.
Neighborhood Outreach Access to Health (NOAH) is a not-for-profit organization which has 11 community health centers in low-income areas throughout the valley in Arizona. Each health center offers family medicine, pediatric care, dental services, and behavioral health services. The health center serves everyone in the community whether they have insurance, and their patients are mostly the underserved population. Recognizing the need of integrating primary care and hospital care, this organization partners with a big hospital organization and is currently implementing the Hospital to Primary Care Program. Hospital to Primary care is a program that establishes care with a PCP for patients who visit the ED and do not have a PCP after being discharged. At the hospitals, they have an eligibility specialist in the ED to help patients schedule a follow up with a PCP and try to direct them to receive care from a PCP instead of a hospital.
References
Agarwal, P., Bias, T. K., Madhavan, S., Sambamoorthi, N., Frisbee, S., & Sambamoorthi, U.
(2016). Factors associated with emergency department visits. Health Services Research and Managerial Epidemiology, 3. https://doi.org/10.1177/2333392816648549
Center for Care Innovations. (2017). Integrating primary care and hospital care. Retrieved from https://www.careinnovations.org/resources/facilitating-care-integrationintegrating-primary-care-and-hospital-care/
HealthyPeople.gov. (2016). Access to health services. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services/objectives
Interview with a Policy Maker.
I was honored to interview an Arizona Representative who is also an Emergency Physician about Inappropriate Use of Emergency Department for Non-Urgent Conditions.
“Every year, nearly $1.1 trillion was spent on healthcare and half of the budget is spent on hospital care. According to the CDC (2017), every year there were 145 million visits to the Emergency Department (ED), and it is estimated that one-third to one-half of all ED visits were for non-urgent conditions. Inappropriate use of emergency services increases costs to the healthcare system. Also, using the ED for non-urgent care causes crowding in the ED and negatively impacts the quality of care patients receive as well as the satisfaction of patients.
- As an Emergency Department Physician and a Policy Maker, what are your thoughts about this issue?
“Yeah. Everything you said was true, it would be nice if that didn’t happen. It somehow reflects our system as a whole. There are couple big drivers of why there are many of those. Number one is, they do not have insurance that put them at a place which they can easily access the system. If you don’t have insurance, you can’t get the office visit, but the ER will see you no matter what. So people will just come to the ER. They don’t know how to get a doctor’s office visits or even if they could get a visit, it can be a wait. It’s harder to fit in your schedule. It’s not always easy for people to go and find a doctor to follow up and the ER is just there for them to go. Some of it is that we do have some incentives that are not structure properly. We have doctor visits, depending on insurance plans. Some of the insurance plans have a situation where the ER copay is $0 but the copy to go to the doctor’s visit is actually higher so it may cost less to go to the ER. The next one is the incentive, if you are working really hard and can’t take time off, the ER has the ability to do everything at one visit, whether labs, radiology, and/or specialty consultation. You can get all that done in the ER. Whereas, when you try to do that out there, you have to take multiple day off work, going to multiple appointments. It is slower. Even if somebody waits hours in the ER, but that is only a day off. It could take you several days or weeks when you go to your primary care doctor, to wait for specialty consultation, to have labs, and radiology done. Not everyone can do that because you know it’s economic. So there are quite a lot of reasons why the ER gets you the way it does. Some of it has to do with the level of convenience. Some of it has to do with the economic reason.“
2. Since the implementation of the Affordable Care Act (ACA), have you noticed any changes in emergency department use?
“Yes. We have seen the changes. It used to be a lot more people come to the ER. We wan to see that with the ACA the visits went down. Well, unfortunately they didn’t go down, they actually have gone up. One of the big things Obama care does is increase Medicaid, a lot more people got on Medicaid. When Medicaid expansion (only in some states) went through, what ended up happing is that a lot of those folks cannot get to a primary care doctor easily because, remember, not a lot of doctors take Medicaid. It’s hard for a lot of them to get a regular doctor. And the fact that Medicaid has $0 copay for ER. It then becomes the case where this is inviting to the ER. Now that they have insurance and $0 copays, it’s going to push some people over to the ER. I think that’s part of the issue. If you really wanted to steer people away from the ER you could do it with policy tools, but I think there is some concern about doing that as well.“
3. Due to the high cost of ED treatment, some health insurance companies proposed an “avoidable ER (emergency room) policy,” which denies coverage if the ED discharge diagnosis is non-emergent (Chou, Gondi, & Baker 2018). What’s your opinion about the policy?
“Well that I don’t favor. What we’ve had for a very long time is what we call prudent layperson standard and what that means is that if a reasonable person thought that when you came into the ER with whatever your situation was, if a prudent person thought that that is a reasonable thing to come to the ER for then it should get paid for. For instance, if a patient came in with chest pain and gets diagnosed with the flu then the insurance company would say, “Well based on your diagnosis you thought it was the flu” but when the patient went in there the patient didn’t know it was the flu. A prudent person would say if you have chest pain you should go to the ED. The key difference here is the patient didn’t know it was the flu. That’s why I don’t agree with that policy. It has always been and should remain what we call prudent layperson.
4. What are we doing in Arizona to tackle the issue of inappropriate use of emergency services?
“Well, That’s a great question. I don’t know if anyone has tried to tackle this unless you’re aware of any legislation. I’m not aware of any legislation specifically to try to tackle this. I think AHCCCS as a whole, which is what the legislation mostly controls, does a pretty good job at keeping costs down. However, they keep things down they keep it down. It’s one of those things that I think people say, “look if AHCCCS is doing a good enough job we won’t worry about it.” Yes, people going to the ER but also not the worst thing in the world. It’s not overwhelming. It’s not anything people are making a big over. Also, the economy is improved overall. One of the things, AZ legislators always wanna do is helping the economy. When the economy goes up, the number of people on Medicaid will drop, people will get on regular insurance. This will prevent people going to the ER because regular insurance has copay and Medicaid is not.”
DNP 711 Blog 
Ha,
As a former Emergency Room (ER) Registered Nurse (RN), I feel strongly against the Avoidable ER Policy. I will admit there were times the ER seemed overly crowded with patients presenting with non-life-threatening chief complaints; however, I do not believe the answer is penalizing them for seeking care. A 2013 study found that there is nearly 90 percent overlap in symptoms between non-emergencies and emergencies (Raven, Lower, Maselli, & Hsia, 2013). If this is the case, it would ultimately be the patient’s experience of the symptoms dictating whether or not they believe it is a true emergency. Perhaps the issue goes beyond overabundance of the ER visits, but the lack of access patients have to quality primary care. Policymakers should instead focus on improving preventive care, including the expansion of health coverage for it.
Reference
Raven, M.C., Lowe, R.A., Maselli, J., & Hsia, R.Y. (2013). Comparison of presenting complaint vs discharge diagnosis for identifying “nonemergency” emergency department visits. The Journal of the American Medical Association, 309(11), 1145-1153. doi: 10.1001/jama.2013/1948
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According to the Centers for Disease Control and Prevention (CDC), an annual sample survey completed in 2016 by the National Hospital Ambulatory Medical Care (NHAMC) found that out of 145.6 million emergency department (ED) visits in the United States, only 7.8% resulted in hospital admissions (2017).
The overuse of Emergency Department (ED) for non-urgent medical care has significantly impacted health care spending in the United States. Not only is health care in the United States expensive, but the cost of care in an emergency setting is significantly higher than care in other medical settings (Adams, 2013). While Americans are living longer and the population in the United States continues to grow, access to healthcare will be increasingly difficult unless something changes. In order to increase access to care and reduce spending, it is important for policy makers to focus on promoting alternative approaches to primary care services (Adams, 2017). For example, the development of more free-standing hospital-based care clinics, accessible walk-in clinics, and additional specialized services for the undeserved and vulnerable populations. Options such as these can help decrease ED utilization for non-emergent conditions and reduce spending while providing more options for care. Policy for reducing over use of ED services should also include incentives for offering extended hours, walk-ins, and telehealth so that access to healthcare is attainable for both the insured and uninsured. However, for this to happen, policy makers must work together with not only the health care system but also providers, patients, and advocates to create more effective ways to receive healthcare in America.
References
Adams, J. G. (2013). Emergency department overuse. JAMA, 309(11), 1173. doi:10.1001/jama.2013.2476
Centers for disease control and prevention. (2017, January). Emergency department visits. Retrieved February 8, 2020, from https://www.cdc.gov
Centers for disease control and prevention. (2017, January). Emergency department visits. Retrieved February 8, 2020, from https://www.cdc.gov
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The “Avoidable ER Policy ” is very interesting to me for several reasons, one very personal. I completely understand the burden non-emergent visits place on the department, staff and consumers. I worked in the ER for a short period and during that time I was surprised how many patients felt like 80% or more of conditions and signs and symptoms that would have been better suited for an urgent care facility or making an appointment with a primary care provider. The ER began to feel like an urgent care, but a very expensive one that did full panel labs on all admissions and standard tests. According to an article by Nicole Cohen (2019) a small number of patients, less than 10% are admitted to the hospital after being assessed in the ER.
I can understand and sympathize for the situation as the ER being utilized as a walk-in clinic, but it also brings up concern for patients who should seek treatment from the ER and may be concerned regarding if the patient’s illness is ER suitable. On a personal note my mother passed away the first semester of this school from a tooth infection. Yes, tooth infection. She had been battling gingivitis for several years and was scheduled to have several teeth extracted as well as her gums cared for. She became sick several months prior to her scheduled surgery and made over 4 visits to a local urgent care, each time sent home on an antibiotic and diagnosed with respiratory infections. Although we urged my mother several times to seek care at an ER she did not feel she was ill enough to require emergent care. My mother unfortunately did not live long enough for her surgery. She passed within 4 days of going to the ER of sepsis. I assume if she would have gone to the ER earlier, instead of the urgent care facility, her labs would have been drawn and maybe the development of the infection could have been caught and cured.
Reference
Cohen, N. (2019). Urgent care centers and virtual visits help avoid unnecessary trips to the ER.
Fairfield County Business Journal, 55(24), 13. Retrieved from
http://login.ezproxy1.lib.asu.edu/login?url=https://search-proquest-.ezproxy1.lib.asu.edu/docview/2261152877?accountid=4485
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This topic is so important to address. Thank you for sharing this information. As I was reading your blog, I found myself thinking about the three strategies that CMS has identified to reduce inappropriate emergency department use and how all three may be intertwined. Behavioral health patients tend to be a large portion of frequent utilizers of emergency departments (numbers 2 and 3 of the strategies). If these patients, perhaps, had more urgent care facilities across the valley (number 1 of the strategies) for mental health services that included immediate intake assessments, ability to prescribe bridge prescriptions, ensure appropriate follow up appointments are in place and transportation and funds are available, and follow up services this may positively impact the inappropriate utilization of the emergency departments. With the shortage of psychiatric providers, sometimes appointments for evaluations are months out and an urgent care mental health setting can get services and medications started sooner with the hopes for stabilization. I look forward to learning more about your topic in future blogs.
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Ha,
I would agree with you that electronic health record systems are a very important technological advancement when it comes to healthcare. As you mentioned electronic health records have been breached and it is important to consider adopting electronic health record systems with strong barriers to protect patient information. Because of the sensitive nature of the information stored within electronic health record systems, it is important to understand that several security safeguards have been introduced through the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act (Kruse, Smith & Nealand, 2017). Firewalls and cryptography are important security techniques, as well as cloud computing, antivirus software and initial risk assessment programs along with a chief information security (Kruse, Smith & Nealand, 2017). Cloud computing appears to be a promising platform and according to a cyber-security checklist created by the Office of the National Coordinator for Health Information Technology, antivirus software is in the top ten listed methods for avoiding security breaches (Kruse, Smith & Nealand, 2017). Definitely something to consider when making decisions to protect private data stored in electronic health record systems.
References
Kruse, C. S., Smith, B., Vanderlinden, H., & Nealand, A. (2017). Security techniques for the electronic health records. Journal of medical systems, 41(8), 127. https://doi.org/10.1007/s10916-017-0778-4
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Hi Ha,
I had a remarkable experience last week, which was to learn a new way of framing the value of the profession I care about deeply: cancer rehabilitation therapists. I am not a therapist, but I continue to experience negative side-effects from my treatment. Most of these issues could have been avoided completely if had seen a cancer rehabilitation specialist during my treatment.
As you point out in your blogs, reducing unnecessary ED visits is a great way to generate significant cost savings for the healthcare system. But there is a second way to reduce avoidable trips to the ER, and that is to reduce trips to the ER that are justified, but that could have been avoided in the first place.
Treating conditions early in their development can be the difference between a needed trip to the ER and far less expense, and more effective therapy provided by a skilled provider. That is the role that can be played by a cancer rehabilitation therapist who addresses symptoms of fatigue and lymphedema as soon as they develop in the trajectory of cancer treatment.
What you might find equally interesting is that this solution, like so many of the solutions that you describe, depends on the EMR. Cancer rehabilitation therapists know cancers, they know treatments, and they know when impairments are likely to occur. If the EMR were used to trigger periodic assessments at crucial milestones in the treatment trajectory, cancer rehabilitation specialists could catch and address problems as they are developing, before they accumulate and worsen over the course of treatment.
I learned about this role of cancer rehabilitation specialists, which can be framed as a significant cost saving to healthcare providers from a webinar by Dr. Michael Stubblefield, the leading expert in the field. If you have interest in pursuing this line of thought, here is a link to his March 26 webinar, sponsored by the National Coalition of Cancer Survivors:
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