Do you agree with this discussion post? Social determinants of health (SDOH) can act as barriers to healthcare, potentially increasing a country’s overall burden to affect people’
1. Costs of Care in the Emergency Department
A Colorado woman took her daughters to what she thought was an urgent care clinic in a shopping mall (Olinger, 2015). Both were treated for respiratory problems, and the visit went well. “I thought it was a fine experience”, she commented, “until I got the bill”. She had gotten care from a freestanding emergency department, not an urgent care clinic, and her out-of-pocket obligations for the visit was nearly $5,000.
This represents an unusually high price, but care is expensive in emergency departments. Ho and colleagues (2017) found that treating respiratory infections in a hospital emergency department averaged $1,074 and treating respiratory infections in a freestanding emergency department averaged $1,351. In contrast, treating respiratory infections in an urgent care center averaged $165. (These are average prices paid, not charges). Prices in emergency departments are typically more than 10 times those in urgent care clinics.
These high prices explain why many care reform plans seek to steer patients away from using emergency department. For example, Oregon moved most Medicaid enrollees into coordinated care organizations, with the explicit goal of reducing emergency department use (McConnell 2016). (Because they have difficulty accessing other sources of outpatient care and because they face low out-of-pocket costs, Medicaid enrollees tend to use emergency departments at high rates.) In Oregon, the use of emergency departments fell by 8 percent (McConnell 2016).
About a third of emergency department visits are not emergencies, and there is an ongoing controversy about how much such a visit cost (Galarraga and Pines 2016). Perspective differences cause part of the controversy. Insurers and patients talk about prices that they pay, and the providers talk about how much it cost to produce such visits. Yet another perspective notes that patients who use emergency departments as usual sources of care at high rates of preventable hospitalizations. Galarraga and Pines (2016) estimate that the average payment for a visit that is not an emergency is $883, but the average payment for preventative hospitalization is $9,515.
Discussion questions
Why do patients who are not critically ill go to emergency departments?
Why are the prices so high in emergency department?
Are production costs also high in emergency departments?
What is an example of a fixed cost of emergency department? A variable cost?
If an emergency department’s volumes fell, how would it cost change?
Should insurers try to reduce emergency department use?
How might insurers reduce emergency department use?
2. Can Patient-Centered Medical Homes Help Realize the Triple Aim?
A PCMH emphasizes a team approach to care, typically including physicians, advanced
practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators,
and care coordinators. This team cooperates to improve access (e.g., after-hours care and same-
day visits), patient engagement (e.g., teaching patients how to manage their care and contribute
to decision making), care coordination (e.g., trackint care plans among providers and improving
transitions from hospitals to home), quality (e.g., improving patient satisfaction and tracking
compliance with practice protocols), and safety (e.g., decision support for prescribing and
tracking abnormal test results). Despite broad similarities, PCMHs vary in their emphases
and implementation strategies. Not surprisingly, reviews find weak, variable evidence that
PCMHs save money, although the evidence is stronger and less variable for high-risk patients
(Sinaiko et al. 2017). Similarly, some studies find improvements in patients’ experiences
in PCMH practices, whereas others do not (Sarinopoulos et al. 2017). How much PCMHs
improve quality and safety also remains unclear (Green et al. 2018).
An analysis of Geisinger Health System’s implementation of PCMHs offers some strong
evidence that they can reduce costs (Maeng et al. 2015). An integrated health system that offers
PPOs and HMOs for Medicare, Medicaid, and the ACA marketplace, Geisinger’s PCMH
approach differs from most others in a number of ways:
HM 525 HM# 3 – 3
Geisinger used a standardized model.
Geisinger had clear incentives to reduce cost and improve quality because it offered an
HMO.
Geisinger had a long history of experimenting with PCMH models.
Geisinger focused on high-risk patients.
Geisinger used a mix of volume-based and quality-based payments.
The Geisinger study found that implementation of a PCMH significantly reduced costs
(primarily by reducing hospitalization), and the size of the reduction grew with experience as a
PCMH practice. An earlier Geisinger study found that patients perceived that some aspects of
care had improved and some had not (Maeng et al. 2013). Only modest evidence about quality
and safety has been analyzed. For this highly integrated system, PCMHs appear to contribute to
realizing the Triple Aim.
Can becoming a PCMH help other practices realize the Triple Aim? Green and
colleagues (2018) suggest that the evidence is clearer than it seems. Their analysis focused on
conditions that were targeted by Blue Cross Blue Shield of Michigan and measured how many
PCMH components each practice had implemented (which had seldom been done before). Their
analysis found that emergency department costs and hospitalization costs fell for all conditions
but fell by much more for targeted conditions and for practices with more complete PCMH
implementation. An earlier study that analyzed data for only two years of PCMH implementation
(Paustian et al. 2014) found that full implementation was associated with higher quality and
significant cost reductions for adults. Partial PCMH implementation was associated with higher
quality but not with cost reductions. A separate study found that the patient experience was rated
more highly in PCMH practices (Sarinopoulos et al. 2017).
Discussion Questions
1. Why does offering HMO plans affect incentives?
2. How could improving access reduce costs?
3. How could improving care coordination reduce costs?
4. Why is the evidence about effects on cost so varied?
5. Why is the evidence about effects on quality so varied?
6. Why is the evidence about effects on the patient experience so varied?
7. How would a successful PCMH program affect patients? Hospitals? Participating practices?
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.
