The demand for the Emergency Department (ED) is likely to climb and surge even further with the population gaining insurance under the Affordable Care Act. With more than 65 percent of current ED visits presenting as urgent (not emergent) visits, the anticipated demand surge from newly insured individuals will exacerbate the existing problem of patients using one of the most expensive care sites in our system.
What an opportunity! An opportunity to engage ED super-users and redirect them to better sites for their care. An opportunity to engage consumers pre-ED visit and integrate them to other sites of care. An opportunity to introduce Emerging Care to non-emergent sites of care. To find out how big the opportunity might be, we priced out a proposal made in a Health Affairs article to redirect 20 percent of ED visits to other sites of care — it created a national savings of $4B annually. How much could we save locally and how would we go about it? The following lists some of the solutions I’ve seen — which I offer for consideration to the healthcare community, in the call for redirecting consumers to the right care site, at the right time, for the right reason:
- Redirect Super-Users: Direct personalized messaging about the right sites to use for any individuals with 5+ visits/year.
- Let ‘em come — on a schedule: Face it. Some consumers love the ED. Love the assurance of the best trained doctors taking care of the scary stuff. Let them book appointments at the ED clinic.
- Learn to Self Manage: For those with risk factors — send them personalized ED-prevention care messages to remind them to take care of themselves.
- Call v. Show Up for the Curiously Considering: Nurse- or extender-staffed call /live chat lines to discuss impulse driven reasons for the ED to take preventive steps.
- Next time — to the Doctor: Employ a discharge patient coach who schedules patients into physician practices or the federally qualified community health center.
- Open Door to the Fast Track: Provide mobile applications showing wait times and a way to reserve time for the walk-in patients.
- Send Them to the Store: Since 85 percent of retail users have primary care providers (PCPs), I wonder how many of them split their time in EDs? Optimize the experience between PCP and ED for primary care, planned, urgent, and emergent care.
In his February 23, 2013 article in the New York Times, Richard Thaler, noted professor of Economics at the Booth School of Business at the University of Chicago, makes several suggestions on how to improve US health care.
Among them are:
- Paying doctors and hospitals for health, not illness treatment
- Using evidence-based medicine approaches
- Making more efficient use of nurse practitioners, pharmacists, physician assistants and other medical professionals
- Opening opportunities for all patients to have end of life discussions
- Implementing safe harbor from medical liability under certain situations
- Incremental changes and experiments with innovation to improve the US health care approach
These are all good ideas that have been under discussion, some for many years. I agree with the ideas, but I would argue in favor of reaching further, reaching for transformational changes. To amplify this thought:
- The Affordable Care Act opens the door for Accountable Care Organizations (ACOs). Well designed ACOs have the potential to transform US healthcare in many ways:
- End of Life discussions and planning are not “death panels,” and we cannot, and must not, get tangled up in arguments based on inaccurate assumptions as a way to avoid these needed discussions.
A healthcare system implies a uniform, defined approach to problem—something the US does not have. We have a fragmented, expensive sector not designed with the goal of improved health, but organized around principles where the main benefactor is the entire healthcare industry, not the patient. I don’t think we need more experiments; we need transformational change with the goal of achieving the Triple Aim of improving healthcare quality and satisfaction, improving population health, and reducing the cost of healthcare.
Dr Michael L Taylor
Chief Medical Officer
Your great-grandchildren will laugh when someone tells them that, not so long ago, all patients with the same diagnosis received the same treatment. They will say that would be similar to all people getting the same shoe regardless of the size of their feet.
The era of personalized medicine is emerging. Patients are beginning to receive different diagnostic tests and treatments based on their genetic makeup and metabolism. Expanding this to all patients will require the manipulation and study of big volumes of data, including genomic and proteomic mapping as well as the integration of near real time electronic medical information.
I celebrate that the National Institutes of Health are putting a fresh emphasis on health informatics. Biomedical computing will foster collaboration across medical disciplines, and there is little doubt that such efforts will bring forth unique insights and generate novel analytical tools. Truven Health Treatment Pathways is a first generation product of this movement. With it, we have the capability to conduct comparative effectiveness research in a real world setting using large populations in a matter of weeks instead of years.
As a treating physician, I have been struck by the nearly complete absence of information comparing treatment alternatives - most are approved against doing nothing rather than each other. By comparing treatment regimens and outcomes, not only will doctors and patients be better informed but health plans will be able to markedly advance the field of evidence based benefit design. For all of these reasons both public and private investment into medical big data should be endorsed and promoted.
Ray Fabius MD
Chief Medical Officer