Over The River and … To the ER We Go?
Remove barriers to health care to influence behavior positively
By George Martin, MD – Senior Medical Director for Health Integrated
Generally, the response to health care issues is that the system is broken. Out-of-control costs are often cited as the issue and short term solutions typically are proposed. Previously, we discussed end of life issues. Now, here is the other extreme. More than 50% of all children born in the United States are eligible for government assistance to meet their health care needs. Medicaid is the largest of the programs. It also includes programs for “Healthy Children” and for those with specific disabilities.
One common complaint from both governments and payors is that this population accesses the system through the hospital emergency departments. The response is often to establish programs that are forms of demand control. Nurse call lines, increased co-payments and “education” are all attempts to modify behavior by inhibiting use of the “inappropriate” resource.
What should be well known is that placing barriers in front of people only causes reaction. Push me and I will push back. This is normal human behavior. Certainly, it’s possible to place barriers before people that are increasingly difficult to surmount but this runs the risk of unintended consequences including inhibiting children from receiving appropriate care in a timely fashion and thereby increasing the ultimate cost of care.
The issue is access to appropriate care. Or rather lack of same. High volume and long waits for office visits, lack of preventive care and no access at all at the time the public desires/needs it all contribute to use of the emergency department as a source of acute care that might better be delivered elsewhere.
At 2:00 AM, if the only source of support for a parent with a febrile child is the emergency department, then that is where parent and child will go. It’s possible that the only service needed might be to have a grandmother available to reassure the mother that the child would be alright but granny was not available. Given the potential for additional lifestyle issues and the not being able to get into the child’s physician in the morning, why not go to the emergency room?
A more effective way to approach change in human behavior is to remove barriers. Access to health care is the main barrier. Lack of access for children is driven by many issues. Not the least is that the system has long treated payment for the care of children at a lesser level than that of adults. Medicaid state rules often limit the reimbursement for level four (4) and five (5) evaluation and management (E&M) CPT codes to no more than one every six months. State health departments administer vaccines at no charge in direct competition with the medical home concept. Free vaccines are a good thing, but getting to a state health department is a challenge for many families.
So what should we do? How do we remove barriers and positively influence behavior to ensure that care and treatment are provided by the appropriate provider at the appropriate location?
1. Support the Pediatric PCMH concept.
2. Recognize that access is an issue.
3. Enhance access at the times that the patient or family desires.
4. Shift payments from procedures to primary and preventive care.
5. Support coordination of care.
6. Anticipate the upcoming needs of individual patients and educate the caregivers.
What else would you do to remove barriers? Do tell!
You can reach me directly at healthexecforum@healthintegrated.com, or comment directly in the blog.
As always, thanks for reading and for your input.
George Martin, MD
