A study
published in July’s Health Affairs adds yet another wrinkle to the quandary of
reducing ED usage. The report entitled
“Understanding Why Patients of Low Socioeconomic Status Prefer Hospitals over
Ambulatory Care” offers what many will consider a surprising conclusion – poor
people who decide to use the emergency department make that decision
rationally. What does this mean? According to the study, it means several
things. First, that poor people are able
to “articulate clear, logical reasons for preferring hospital to ambulatory
care.” Second, it means that decisions
to use the ED cannot be blamed on cultural tendencies. And, third, it means that use of the ED
cannot be fixed with more education. The
icing on the cake is a paradox uncovered by the study, which is that as
hospitals improve in the quality of the care that they provide, it makes it
more likely that ED usage by poor people will remain high.
Let’s look a little deeper into the study to explore how it
came to these conclusions. This qualitative
study is based on open-ended interviews of forty low socio-economic status
patients who presented to an inner-city Philadelphia hospital. The interview results were then discussed in
the communities where the participants lived to see if the responses were
consistent with how other members of the low income community viewed hospital
usage.
Two themes developed in the responses as to why the ED was
preferred over other settings: access
and quality. With respect to access, both
uninsured and Medicaid participants believed that hospital care was less
expensive. The uninsured couldn’t afford
ambulatory care fees, relying on a hospital’s charity care. Those with Medicaid agreed that ambulatory
care cost about the same for them as ED care, but overall cost was more with
ambulatory care because of the additional time taken and co-pays for specialist
visits and testing ordered by primary care physicians – respondents said they
would rather get the comprehensive care they needed at the “one-stop shop”
ED. Other access issues included the
commonly noted problems with after-hours access, transportation to ambulatory
care facilities, and inability to reach physicians with questions on the phone
(with the response on the phone typically to go straight to the ED). On the quality front, low income interviewees
believed that hospitals provided better technical diagnostic care, and when
they were displeased with their physician believed that trying a different
physician would be fruitless.
Social determinants also played a role in ED use, with the
most socially disadvantaged subset of the interviewees providing additional
reasons for ED use like a “rare source of demonstrable support” from hospital
employees in a world filled with isolation and difficulty. For these frequent users, the ED almost
becomes a “home” for them since outside the hospital living conditions are less
than desirable.
So what are the implications of the study? First, it brings out the inherent conflict
between patients who believe hospitals are the best place to receive care and a
system-wide policy belief that the best care needs to be provided in the lowest
cost settings that still provide a quality experience. Second, it shows that improving hospital
quality to reduce readmissions may backfire to some extent, since the increased
quality will only confirm low income beliefs about the lack of quality in
ambulatory care. The study suggests that
efforts should be made to equalize both the quality and its perception in the
ambulatory care context. Third, the
study posits that Accountable Care Organizations can restructure the delivery
of care in the ambulatory setting to mimic the “one-stop” shop that the ED can
provide. Finally, the study recommends
that community health workers be used outside of the hospital to provide
“respite” care that the most disadvantaged patients sought in the ED.
The complex problem of ED overuse is not going away anytime
soon, and this Health Affairs study reveals that there are even more layers to
the issue than we would like to think.
Physicians must be the leaders in coming up with creative and innovative
ways to address the lowest income patients in South Carolina. Many of these new solutions will likely involve
the delivery of care in ways that have not been done in the past. For example, a physician-led team involving a
combination of primary care physicians, specialists, community health workers,
substance abuse counselors, and local church support to provide a comprehensive
approach to a clinical problem exacerbated by social determinants. Payers will need to step up to the plate,
too, and reimburse for innovative care models in a way that allows the
physician-led team to do what they do best without undue interference – heal
the sickest of our patients.
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