My stubbornness is well-known in my family, to the point that I’m told my theme song should be “Hard-Headed Woman.” Sometimes I get so invested in an idea or belief that I have to see it all the way through, even if it is clearly wrong from the start. While I do credit my tenacity with getting me far in life, other times it has been embarrassing to find that I’m wrong after I’ve dug my heels in deeply. Over the years, I’ve finally begun to learn that course corrections along the way don’t indicate failure, but are a necessary part of achieving long-term success.
This holds true in our health care work, as well. Lately, there has been a lot of conversation about how to solve inappropriate emergency department utilization, especially when it comes to Medicaid patients. High rates of ED utilization are typically associated with worse access to the health care system, delayed or fragmented care, and higher costs. In one attempt to address this issue, the state has been continuously enrolling the majority of Medicaid patients into the Accountable Care Collaborative (ACC) program in order to make solid connections of patients with a primary care provider and care coordination services. As a hypothesis, it seemed to be solid—by improving patients’ access to primary care, inappropriate ED utilization should decrease.
The ACC has proven to be a big success in its two other goal areas, reducing hospital admissions and decreasing the use of high-cost imaging; however, ED utilization has been increasing steadily over the last 6 months, resulting in a lot of head-scratching and hand-wringing. So now the question is, do we dig in our heels or make a course correction?
It seems to me that it’s time to re-examine our process and our assumptions and build on the success of the ACC with some adjustments that will help us reach our third goal. And to start with, we need a better understanding of why patients go to the ED. The connection to a primary care provider is certainly crucial, but what if patients preferred the emergency department over primary care? A study published in the July issue of Health Affairs revealed that many patients of low-socioeconomic status appreciated that hospitals provided the convenience of having all the services to meet their complex needs in one location, the 24/7 hours of operation, the availability of ambulances as transportation, and the access despite ability to pay. Additionally, a CDC survey of non-admitted ED patients (or, patients who weren’t sick enough to require in-patient care) found that over 20% had sought emergency care because their primary care provider had told them to. Clearly these issues aren’t being addressed by the ACC model, which could explain why we haven’t seen a decrease in ED visits.
Nationally, avoidable visits to the ED result in $31 billion every year in preventable costs. If we are going to be successful in our work to reduce that number, then patients, providers, and the delivery system must change together. The solutions we pursue must be rooted in how the system meets the needs of patients and how our communities engender easier access to care. We must move beyond bemoaning poor choices and seek out new approaches, grounded in the real-life experiences of patients. Being needlessly stubborn as we do such critical reform work with the health care system will cost us; balancing perseverance with flexibility will be our key to success.