Jammed access: Thinking beyond universal coverage
July 21, 2009 – 9:49 am by Gina Monari
Many Americans do not feel that access to health coverage will result in access to actual medical care and are willing to adopt new models of care, which may have the potential to expand access without increasing costs. A PricewaterhouseCoopers study titled, “Jammed Access: Widening the Front Door to Healthcare” identifies where the bottlenecks are in the health system and finds that the American public and the healthcare industry are open to new ways of receiving and delivering care through innovative and cost-effective delivery models.
More than half of the 1,000 consumers surveyed, about 55%, believe that if universal health insurance coverage is passed by Congress it will not ensure equal access to care because of capacity constraints, particularly in hospital emergency rooms. A significant number of people would be open to the idea of shared doctor appointments, online physician consultations, worksite clinics, and other alternative ways of receiving medical care.
PricewaterhouseCoopers’ research reveals that universal coverage could swamp the health system unless simultaneous steps are taken to create innovative, new ‘care delivery’ models that will expand access to care without adding costs to the system.
Alternative models in care delivery
Americans are willing to participate in alternative ways to access healthcare, many of which bring access to the patient. Some of these solutions are in use today and include electronic interaction with providers and payers, retail and worksite clinics for patients, the use of telehealth technologies, and shared medical appointments.
About one half, or 50%, of consumers surveyed say they are willing to seek healthcare through the Internet or other computer technology as a substitute for a face-to-face, non-emergent visit. Of those, e-mail consultations was the preferred method of interaction at about 76%, followed by telehealth, question/answer fee-based consults, and an online forum/chat room monitored by a doctor.
Of consumers surveyed, 37% say they would be likely to use a worksite clinic, and 36% would use a retail clinic. Ten percent of large employers surveyed in PricewaterhouseCoopers’ 2009 Annual Employer Barometer Survey said they are now providing worksite clinics, up from 1% in 2008.
In Bob Laszewski’s Health Care Policy and Marketplace Review blog in March 2008, a post by Brian Klepper claims that:
“Unlike retail clinics, worksite clinics are medical homes. Although most early worksite clinic ventures have focused on jumbo employers, properly configured they work even for small employers.”
He points out that:
“Because they’re built from scratch, these clinics can take advantage of incentives, IT, analytics and care management programs that in turn help the practice identify and manage health problems and costs. In the WeCare clinics, employees and their family members come to the clinic for free, without co-pays and without paying for drugs and labs. This approach brings in low-income employees and their families who often don’t see doctors because they might have to pay something for the visit or for their prescriptions, and it dramatically reduces the costs of care that is needed when people avoid primary care.
Telehealth, which is the use of medical information exchanged from one site to another via electronic communications, such as video conferencing or bio-metric remote monitoring, is expanding access — particularly to specialty physicians for patients in remote and underserved areas. About three-quarters, or 73%, of consumers say they would use biometric electronic remote monitoring services to track their condition and vital signs.
According to the Health Resources and Services Administration, U.S. Department of Health and Human Services, technologies used in telehealth typically are videoconferencing, the Internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications. Although new applications are increasingly found for using these technologies, significant barriers remain to making these technologies an integral part of daily health care practice.
PricewaterhouseCoopers says about 28%, of consumers surveyed say they would be willing to participate in a shared medical appointment. This would typically be a 60- to 90-minute session that includes a private or personal exam integrated with patient education and discussion with a group of 10 to 15 people. Providers offering shared medical appointments have found increased patient and physician satisfaction. Instituting one shared medical appointment can increase patient access and a physician’s productivity by an additional six patients during a four-hour clinic session.
According to the American Academy of Family Physicians, group visits or shared medical appointments can be satisfying to physicians and patients. They can offer an increase in the productivity and efficiency of the healthcare team and can enhance the patient’s visit by offering a holistic and therapeutic approach. Group visits are generally most appropriate for patients needing routine follow-up care; stable, chronically ill patients requiring total mind/body care; patients who typically require more time with their physician; patients who come for frequent return visits; patients with extensive emotional, informational, or psychosocial needs; and the “worried well.”
The AAFP believes there are a number of factors that can contribute to the success of group visits, such as instilling hope in patients by allowing them to see examples of success in managing a health issue; add universality by disconfirming the uniqueness felt by patients regarding their conditions and/or health issues; impart information and allay patient anxiety; encourage an unselfish regard for the welfare of others; promote imitative behavior and allow for positive role modeling among patient peers; offer interpersonal and cognitive learning within the group setting; and provide group cohesiveness where peers can offer support among themselves.
Three general models for the shared medical appointment exist, which are the cooperative health care clinic, created for older patients requiring frequent, broad-spectrum care; the disease-specific cooperative health care clinic, a diagnostically exclusive group that aids patients with chronic-disease management; and the drop-in group medical appointment, intended for established patients needing a more comprehensive approach to their follow-up care. These three types of shared medical appointments have some common features. These group visits are voluntary interactive, care delivery systems rather than classes, intended to enlist and validate patients as their own caregivers, and efficient and effective.
Physicians who fall into the following categories should carefully consider whether the group-visit model makes sense for their practice, such as physicians lacking adequate resources needed to run the program, physicians with small practices, physicians with few or no access problems, and physicians who practice half-time or less.
Hospital factors in rising costs
Americans in general, not just the uninsured, are increasingly using costly hospital emergency rooms as the first point of entry into the health system, according to the PwC report.
“It’s clear that access to insurance coverage does not translate into access to care,” says David Chin, M.D., principal, PricewaterhouseCoopers and leader of the PricewaterhouseCoopers Health Research Institute. “The quick fix is to build bigger emergency rooms, but increasing supply will only drive up healthcare costs. We must find solutions that expand access without adding costs, and we believe the answer lies in new flexible models to care that use the right technologies and incentives and behavior changes to unclog jammed access points.”
Per capita visits to hospital emergency departments already are at an all-time high, reflected in overcrowded emergency rooms, ambulance diversions and long waits. Jammed access points have been created by shortage of physicians, lack of access to specialists, Medicaid reimbursement disincentives, high costs for the under-insured, poor coordination among practitioners, growing consumer demand, and inefficiencies throughout the system.
PricewaterhouseCoopers’ research finds that patients covered by Medicaid use hospital emergency rooms at twice the rate of the uninsured even though the uninsured are most often blamed. About 44% of Medicaid respondents visited an emergency department in the past year compared to 20% of uninsured respondents. More than half of people who went to a hospital emergency department in the past year said they went for a reason other than an emergency, for example, their doctor’s office was closed or they couldn’t get an appointment in an acceptable time.
Hospital emergency rooms have become holding tanks for mental health patients because of a shortage of mental health providers and beds. The average length of stay in the emergency department for patients in need of mental health services is double that of other patients. In addition, one in four consumers and one-third of Medicaid patients said it takes more than 30 days to see a doctor. One in 10 said they’ve had to wait three months or longer.
PricewaterhouseCoopers’ analysis found an inverse relationship between insurance status and emergency department usage. States with higher uninsured populations generally have lower emergency room use than states with lower uninsured populations. For example, Massachusetts, which has one of the lowest rates of uninsured residents, at about 3%, has one of the highest per-capita usage rates of hospital emergency rooms in the country. In addition, Massachusetts has the highest number of physicians per capita but has been plagued by a severe physician shortage since introducing near-universal coverage in 2006.
