Value-Based Approaches for Emergency Care in a New Era.

Although emergency departments (EDs) play an integral role in the delivery of acute unscheduled care, they have not been fully integrated into broader health care reform efforts. Communication and coordination with the ambulatory environment remain limited, leaving ED care disconnected from patients' longitudinal care. In a value-based environment focused on improving quality, decreasing costs, enhancing population health, and improving the patient experience, this oversight represents a missed opportunity for emergency care. When integrated with primary and subspecialty care, emergency care might meet the needs of patients, providers, and payers more efficiently than yet realized. This article uses the Merit-Based Incentive Payment System from the Medicare Access and CHIP Reauthorization Act as a framework to outline a strategy for improving the value of emergency care, including integrating quality and resource use measures across health care delivery settings and populations, encouraging care coordination from the ED, and implementing robust health information exchange systems.

Medical cost burdens among nonelderly adults with asthma.

OBJECTIVES: We used the 2003-2009 Medical Expenditure Panel Survey to evaluate average annual total and out-of-pocket expenditures by nonelderly adults with asthma. STUDY DESIGN: We divided patients diagnosed with asthma into 4 groups, based on whether or not they had had an asthma attack in the previous year (a crude marker for disease severity) and whether or not they reported using treatment for their asthma. METHODS: For each group we calculated total and out-of-pocket average annual spending for hospital inpatient, hospital outpatient, emergency department, and physician office care, as well as for prescription drugs. These averages were adjusted to account for differences in respondents' overall health (presence of other co-morbidities, self-reported health status, and self-reported activity limitations), sociodemographic characteristics (age, sex, race/ethnicity, income), and insurance status. RESULTS: We found that among the 4 groups, those who were receiving treatment but continued to experience asthma attacks had the highest total and out-of-pocket expenditures in all categories, consistent with their likely higher illness severity. However, patients who reported receiving treatment and did not experience attacks also reported relatively high adjusted total and out-of-pocket expenditures-most notably $536 per year out of pocket for prescription medications and $231 per year out of pocket for physician office visits. After adjustment, about the same proportion of patients in these 2 groups (13.5% who did not get treated and had attacks, and 13.8% who did get treated and avoided attacks) reported high financial burden. CONCLUSIONS: Patients may experience financial challenges to appropriate self-management of asthma, even when they are able to avoid exacerbations.

Trends in the financial burden of medical care for nonelderly adults with diabetes, 2001 to 2009.

OBJECTIVES: To examine trends in out-of-pocket spending and the financial burden of care for persons with diabetes between 2001 and 2009, and to examine whether these trends are consistent with trends in access to prescription drugs and utilization of hospital services. STUDY DESIGN AND METHODS: Data are from the 2001 to 2009 Medical Expenditure Panel Survey (MEPS). The sample includes persons aged 18 to 64 years with diagnosed diabetes. The primary outcome variable is the percent of people with out-of-pocket spending on insurance premiums and services that exceed 10% of family income. Secondary outcome measures include the percent with diabetes-related prescription drug use, perceived access to prescription drugs, hospital inpatient stays, and emergency department use in the past 12 months. Multiple regression analysis is used to control for changes in comorbid chronic conditions and other characteristics of persons with diabetes. RESULTS: Both out-of-pocket spending and the percent with high financial burden decreased markedly for persons with diabetes between 2001 to 2003 and 2007 to 2009. The decrease in spending was driven primarily by a decrease in spending on prescription drugs, including diabetes-related prescriptions. The shift from brand name drugs to generics accounts for much of this decline, although decreases in out-of-pocket spending for both brand name and generic drugs also contributed. During the same period, utilization of and access to diabetes-related prescriptions increased, and hospital use decreased. CONCLUSIONS: Although the prevalence of diagnosed diabetes continues to increase, treatment is becoming more affordable, especially prescription drugs. This may offset some of the costs to the healthcare system of higher prevalence by reducing complications of uncontrolled diabetes that result in more costly hospital use.

High physician concern about malpractice risk predicts more aggressive diagnostic testing in office-based practice.

Despite widespread agreement that physicians who practice defensive medicine drive up health care costs, the extent to which defensive medicine increases costs is unclear. The differences in findings to date stem in part from the use of two distinct approaches for assessing physicians' perceived malpractice risk. In this study we used an alternative strategy: We linked physicians' responses regarding their levels of malpractice concern as reported in the 2008 Health Tracking Physician Survey to Medicare Parts A and B claims for the patients they treated during the study period, 2007-09. We found that physicians who reported a high level of malpractice concern were most likely to engage in practices that would be considered defensive when diagnosing patients who visited their offices with new complaints of chest pain, headache, or lower back pain. No consistent relationship was seen, however, when state-level indicators of malpractice risk replaced self-rated concern. Reducing defensive medicine may require approaches focused on physicians' perceptions of legal risk and the underlying factors driving those perceptions.

Care coordination agreements: barriers, facilitators, and lessons learned.

BACKGROUND: With growing pressure to improve the quality and coordination of care, physicians feel a need to streamline their relationships with other practitioners around shared care for patients. Some physicians have developed written agreements that articulate the respective responsibilities of 2 or more parties for coordination of patient care, ie, care coordination agreements (CCAs). OBJECTIVES: To describe how CCAs are formed and explore facilitators and barriers to adoption of effective CCAs, the extent to which CCAs may be replicable in different market contexts, and the implications for policies and programs that aim to improve the coordination of care. STUDY DESIGN: Qualitative study of primary care physicians participating in CCAs and representatives of their specialist, hospital, or community-based partners. METHODS: Semi-structured interviews with participating providers and national thought leaders in care coordination were reviewed to develop key themes. RESULTS: Agreements that address referral and access processes were considered useful by all practices that had implemented them. Practices that implemented agreements including guidance on shared management of specific clinical conditions (comanagement) also found them useful. CCAs were most successful in settings where both parties to the agreement already had stable communication pathways (such as an electronic health record [EHR], designated staff) and strong working relationships. CONCLUSIONS: Policy changes (such as shifts in reimbursement to favor collaborative care or clarification of laws governing such collaborations) can help to support the development and implementation of CCAs, and can address factors that currently make some markets less supportive of coordination.

Emergency preparedness and community coalitions: opportunities and challenges.

Being prepared for a natural disaster, infectious disease outbreak or other emergency where many injured or ill people need medical care while maintaining ongoing operations is a significant challenge for local health systems. Emergency preparedness requires coordination of diverse entities at the local, regional and national levels. Given the diversity of stakeholders, fragmentation of local health care systems and limited resources, developing and sustaining broad community coalitions focused on emergency preparedness is difficult. While some stakeholders, such as hospitals and local emergency medical services, consistently work together, other important groups--for example, primary care clinicians and nursing homes--typically do not participate in emergency-preparedness coalitions, according to a new qualitative study of 10 U.S. communities by the Center for Studying Health System Change (HSC). Challenges to developing and sustaining community coalitions may reflect the structure of preparedness activities, which are typically administered by designated staff in hospitals or large medical practices. There are two general approaches policy makers could consider to broaden participation in emergency-preparedness coalitions: providing incentives for more stakeholders to join existing coalitions or building preparedness into activities providers already are pursuing. Moreover, rather than defining and measuring processes associated with collaboration--such as coalition membership or development of certain planning documents--policy makers might consider defining the outcomes expected of a successful collaboration in the event of a disaster, without regard to the specific form that collaboration takes.

Dispelling myths about emergency department use: majority of Medicaid visits are for urgent or more serious symptoms.

Contrary to conventional wisdom that Medicaid patients often use hospital emergency departments (EDs) for routine care, the majority of ED visits by nonelderly Medicaid patients are for symptoms suggesting urgent or more serious medical problems, according to a new national study by the Center for Studying Health System Change (HSC). About 10 percent of nonelderly Medicaid patient ED visits are for nonurgent symptoms, compared with about 7 percent for privately insured nonelderly people. Nonetheless, there are clearly opportunities to develop less-costly care options than emergency departments for both nonelderly Medicaid and privately insured patients. To reduce ED use, policy makers might consider how to encourage development of care settings that can quickly handle a high volume of potentially urgent medical problems. Policy makers may want to focus initially on conditions that account for high ED volume that could likely be treated in less resource-intensive settings. For example, diagnoses of acute respiratory and other common infections in children and injuries together account for about 53 percent of ED visits by children aged 0 to 12 covered by Medicaid and almost 60 percent of ED visits by privately insured children aged 0 to 12. While some infections and injuries will be too serious to treat elsewhere, lower-cost settings that can provide a moderate intensity of care and urgent response time likely could reduce emergency department use.

After-hours care and its coordination with primary care in the U.S.

BACKGROUND: Despite expectations that medical homes provide "24 × 7 coverage" there is little to guide primary care practices in developing sustainable models for accessible and coordinated after-hours care. OBJECTIVE: To identify and describe models of after-hours care in the U.S. that are delivered in primary care sites or coordinated with a patient's usual primary care provider. DESIGN: Qualitative analysis of data from in-depth telephone interviews. SETTING: Primary care practices in 16 states and the organizations they partner with to provide after-hours coverage. PARTICIPANTS: Forty-four primary care physicians, practice managers, nurses and health plan representatives from 28 organizations. APPROACH: Analyses examined after-hours care models, facilitators, barriers and lessons learned. RESULTS: Based on 28 organizations interviewed, five broad models of after-hours care were identified, ranging in the extent to which they provide continuity and patient access. Key themes included: 1) The feasibility of a model varies for many reasons, including patient preferences and needs, the local health care market supply, and financial compensation; 2) A shared electronic health record and systematic notification procedures were extremely helpful in maintaining information continuity between providers; and 3) after-hours care is best implemented as part of a larger practice approach to access and continuity. CONCLUSION: After-hours care coordinated with a patient's usual primary care provider is facilitated by consideration of patient demand, provider capacity, a shared electronic health record, systematic notification procedures and a broader practice approach to improving primary care access and continuity. Payer support is important to increasing patients' access to after-hours care.