A recent NPR article discussed a study in the Journal of the American Medical Association pointing out that complex problems cannot be solved by simple solutions. The problem to be solved is the high cost of emergency department (ED) utilization. The solution being developed by many states: Don’t pay for non-emergent visits. Sounds logical. But, as the authors point out, patients don’t go to the emergency department with diagnoses, they go with symptoms. A person with chest pain and shortness of breath at 3 a.m. should be evaluated on an emergency basis; if that person is having a heart attack, the visit is justified. If the person actually is having gastroesophageal reflux, is the visit not necessary? How is the person to know? Clearly, some people use the ED for non-emergent conditions, but making payment decisions based on discharge diagnoses has the possibility of discouraging patients from seeking needed care. In this study, only 6.3% of ED visits were classified as “primary care-treatable.”
The article makes an excellent point—“Between 4.5% and 8% of individuals in the ED are frequent users, but they account for 21% to 28% of visits.” In a 2003 Massachusetts study, 3.8% of ED users accounted for 17.6% of all ED visits. Our own data show similar results for these ED 'frequent flyers.' Perhaps a better way to reduce ED costs is to focus on those individuals who are the most frequent users, addressing their medical and socioeconomic problems, rather than penalizing those who genuinely believe they are having a medical emergency. The Centers for Medicare and Medicaid Services (CMS) should consider studying the profiles of frequent users of the ED and designing policies to address their challenges.
In a fee for service environment, ED overutilization is a logistic challenge for hospitals, but in an accountable care organization environment, with hospitals financially responsible for the health of the population it serves, ED overutilization becomes a financial issue. It is time to take a detailed look at this problem.
A recent Kaiser Health News article questions consumers’ ability to navigate insurance exchanges. State-sponsored and federally facilitated insurance exchanges are building their technology platforms, selecting qualified health plans, and setting up their infrastructure. The underlying assumption is that in October 2013, when open enrollment begins, consumers will be prepared.
The consumer’s ability to navigate exchanges is perhaps the most critical component of success. The Federal Government, recognizing that this process might confuse consumers, has funded Exchange Navigators to help consumers understand eligibility, subsidies, enrollment rules and processes, and the specifics of Qualified Health Plan (QHP) design provisions.
Consumers and Navigators need robust information and efficient tools to manage this process. Improved consumer education benefits not only the consumer and the exchange but also the health plans — by ensuring that individuals select the plan that’s right for their situation and have a great customer experience while doing so. Increasing a consumer’s ongoing engagement in their own healthcare management can lower costs and increase their plan loyalty and satisfaction — which is especially important in this new marketplace.
For exchanges to succeed, we must elevate consumer interest and participation in healthcare decision making to the same level as other important life decisions. States, the Federal Government, and health plans all need to share the responsibility to make that happen.