Will Medical Homes Eliminate Unnecessary Emergency Department Utilization?

Vol. 10 No. 5

AuthorAuthorWhat is a Medical Home?1
In 1967, the American Academy of Pediatrics ("AAP") first introduced the concept of a "medical home."2  Although the medical home was envisioned at that time as little more than a central source of a (pediatric) patient's medical records, the concept has evolved considerably over time, and has gained enormous traction in recent years.  By 2007, four leading organizations representing physicians involved in primary care had released a document titled "Joint Principles of the Patient-Centered Medical Home."3

Today, as defined by the Agency for Healthcare Research and Quality ("AHRQ"),4 "a medical home [is recognized as] not [being] simply…a place."5  Instead, it is "a model of the organization of primary care that delivers the core functions of primary health care."6  As defined by the Patient Protection and Affordable Care Act (“PPACA”), "patient-centered medical homes" have the following attributes:

"(A) personal physicians; (B) whole person orientation; (C) coordinated and integrated care; (D) safe and high-quality care through evidence-informed medicine, appropriate use of health information technology, and continuous quality improvements; (E) expanded access to care; and (F) payment that recognizes added value from additional components of patient-centered care."7

Key Medical Home Provisions in the Patient Protection and Affordable Care Act
As a result of the increased interest in the medical home model, legislators inserted several provisions into PPACA supporting further development of the concept.  Although the following examples are not exclusive of all of the provisions in PPACA that may further the development of the medical home model, they are some of the more significant. 

Section 2703 of PPACA provided state Medicaid programs with the option of providing coordinated care through the provision of a "health home" to Medicaid recipients with chronic conditions.8  A "health home" is defined as "a designated provider (including a provider that operates in coordination with a team of healthcare professionals) or a health team selected by an eligible individual with chronic conditions to provide health home services."9 "Health home services" specifically named include:

"(i) comprehensive care management; (ii) care coordination and health promotion; (iii) comprehensive transitional care, including appropriate follow-up, from inpatient to other settings; (iv) patient and family support (including authorized representatives); (v) referral to community and social support services, if relevant; and (vi) use of health information technology to link services, as feasible and appropriate."10

Also of particular note is Section 3021 of PPACA, which established the Center for Medicare and Medicaid Innovation ("CMI").  The CMI was created "to test innovative payment and service delivery models to reduce program expenditures" while at the same time "preserving or enhancing the quality of care furnished to individuals…."11 The models that may be tested by the CMI include models "[p]romoting broad payment and practice reform in primary care, including patient-centered medical home models for high-need applicable individuals, [and] medical homes that address women’s unique health care needs…."12

Similarly, Section 3502 of PPACA established "community health teams" to support the patient-centered medical home.  Specifically, funds were authorized to be paid to "eligible entities to establish community-based interdisciplinary, interprofessional teams.…"13  Grants or contracts are to be used to "establish health teams to provide support services to primary care providers," and "provide capitated payments to primary care providers…."14

The Promise of Medical Homes
Proponents claim that there are multiple benefits associated with adopting the medical home model.  Some of these purported benefits include improved quality of care, improved patient health, and reduced healthcare costs.  Additionally, it is claimed that the adoption of the medical home model will significantly reduce unnecessary emergency department ("ED") visits. 

In general, studies examining the impact of medical homes have demonstrated that these benefits can be realized.15  However, the claim that medical homes will solve the problem of unnecessary ED visits deserves closer examination. 

Unnecessary Emergency Department Visits: The Magnitude of the Problem
Many patients go to the ED for issues that could be treated by a primary care provider ("PCP").  These visits occur despite the increase in cost of an ED visit, as well as the often long wait that patients may experience there. 

A 2008 report from the Centers for Disease Control and Prevention classified eight percent of ED visits as "nonurgent."16  However, when combining "semiurgent"17 visits with "nonurgent" patients, that number increases to 29.2 percent.18  Many of these "semiurgent" visits could also easily be treated by a PCP.19  Thus, a significant proportion of patient visits to EDs are unnecessary.    

Reducing Unnecessary Emergency Department Visits
While ensuring that patients establish ongoing care with a PCP would seem to be a clear starting point to prevent unnecessary ED visits, it may not be sufficient.  Proponents of the medical home model argue that primary care practices adopting such a model may be more successful at preventing unnecessary ED visits.

Unfortunately, even a patient who has a relationship with a PCP may not be able to see his or her PCP in a timely manner due to a lack of available appointment times.  For example, a 2007 study found that 64.7 percent of ED visits occurred during times when primary care offices were usually not open - either in the evenings, or on the weekends.20  Patient work schedules may also cause patients to have difficulty in obtaining an appointment with a PCP.  Ideally, further adoption of the medical home model would address some of these issues.21

Although studies evaluating the results of medical home projects have often demonstrated some decrease in ED utilization, others have not.22  Even where medical home projects have managed to decrease ED utilization, there are often still many unnecessary ED visits occurring.  The medical home model is not, in and of itself, likely to be the panacea for eliminating all unnecessary ED visits. 

A Possible Solution
A multifaceted approach is likely to be necessary to truly eliminate unnecessary ED visits.  For example, public education campaigns are an underutilized method for reduction of unnecessary ED visits.  Whether through the provision of written materials, public service announcements, or one-on-one verbal education with patients, education regarding the proper locale for work-up of one's medical problem would likely prevent some unnecessary visits.  As one example of such an approach, emergency medical services in Louisville, Kentucky have been referring non-emergent calls to a nursing help line to help patients decide on the proper place to go for their particular medical issue.23 

The Emergency Medical Treatment and Active Labor Act (“EMTALA”), which requires hospitals that participate in Medicare to provide “an appropriate medical screening examination”24  for all those who present to an ED likely encourages unnecessary ED utilization.    Members of the public are well aware of the fact that one will at least be examined when presenting to an ED.  Evidence for this is the fact that many EDs now even provide preventive health services as a matter of policy (e.g., vaccinations, screening for infectious disease)25  although some of the services provided to patients may actually not be required by EMTALA.  The expanded services provided likely contribute to the perception of the ED as an appropriate location to receive nonurgent care.  Thus, policy changes may need to be made to further reduce unnecessary ED visits.26 

Ultimately, unnecessary ED use may be a result of the fact that it is simply more convenient for the patient than seeking care in another location - i.e., the ED is available when one's PCP is not.  It is also a culturally acceptable practice to seek nonurgent care in an ED, in part because patients may believe that better care is available in an ED than is provided by a PCP.27  Unfortunately, changing this situation is likely to be very difficult.  Cultural change, whereby patients no longer view the ED as a main source of primary care services, will be necessary to further reduce unnecessary ED utilization.  This cultural change can take place over time, but will likely require more than simple policy changes or education, and will require involvement by a range of societal stakeholders.28

Future Outlook
The medical home model is likely to gain in popularity over the coming years.  The provisions in PPACA will ensure continuing development in this area, leading to an expansion of the model.  Although studies of the medical home model have already shown that the model provides benefits, it is unlikely that the model by itself will completely eliminate unnecessary ED visits.  Rather, a multifaceted approach, involving education, policy changes, and cultural changes is needed to further reduce unnecessary ED utilization. 

 

1The terms "medical home," "patient-centered medical home," and "health home" are used by different organizations, at times interchangeably.  Thus, varying terminology is found throughout this article. 
2Calvin Sia, Thomas F. Tonniges, Elizabeth Osterhus and Sharon Taba, History of the Medical Home Concept, 113 Pediatrics 5 (2004). 
3American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians and American Osteopathic Association, Joint Principles of the Patient-Centered Medical Home, available at http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf (last visited December 16, 2013).
4"The Agency for Healthcare Research and Quality, as part of the Public Health Service, is responsible for supporting research designed to improve the quality of healthcare, reduce its costs, address patient safety and medical errors, and broaden access to essential services."  U.S. Department of Health and Human Services, Operating Divisions, available at http://www.hhs.gov/about/foa/opdivs/index.html (last visited December 23, 2013).
5Agency for Healthcare Research and Quality, Patient Centered Medical Home Resource Center: Defining the PCMH, available at http://pcmh.ahrq.gov/page/defining-pcmh (last visited December 16, 2013).
6Id.
742 U.S.C. § 256a-1(c)(2). 
8"Chronic conditions" include, but are not limited to mental health conditions, substance use disorders, asthma, diabetes, heart disease, and overweight.  42 U.S.C. § 1396w-4(h)(2). 
942 U.S.C. § 1396w-4(h)(3).
1042 U.S.C. § 1396w-4(h)(4)(B).
11

42 U.S.C. § 1315a(a)(1).

1242 U.S.C. § 1315a(b)(2)(B)(1). 
1342 U.S.C. § 256a-1(a).
14

Id.

15See, e.g., Patient-Centered Primary Care Collaborative, Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012, available at http://www.pcpcc.org/sites/default/files/media/benefits_of_implementing_the_primary_care_pcmh.pdf (last visited December 16, 2013).
16Defined as a visit where the patient should be seen between 121 minutes and 24 hours.
17Defined as a visit where the patient should be seen between 61 and 120 minutes.
18Centers for Disease Control and Prevention, National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary Tables, available at http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2008_ed_web_tables.pdf (last visited December 16, 2013).
19Many of these patients have viral upper respiratory illnesses, bladder infections, or ear infections.
20Richard Niska, Farida Bhuiya & Jianmin Xu, National Hospital Ambulatory Medical Care Survey: 2007 Emergency Department Summary, National Health Statistics Report, No. 26, available at http://www.cdc.gov/nchs/data/nhsr/nhsr026.pdf (last visited December 16, 2013).
21For example, the AHRQ notes that one of the attributes of the medical home model is "Accessible Services."  Specifically, "[t]he primary care medical home delivers accessible services with shorter waiting times for urgent needs, enhanced in-person hours, around-the-clock telephone or electronic access to a member of the care team, and alternative methods of communication such as email and telephone care.  The medical home practice is responsive to patients’ preferences regarding access."  Agency for Healthcare Research and Quality, supra note 5.
22Patient-Centered Primary Care Collaborative, supra note 15.
23Washington State Hospital Association, Potentially Avoidable Emergency Room Use, available at http://www.wsha.org/files/62/ERReport2.pdf (last visited December 16, 2013).
2442 U.S.C. § 1395dd(a).
25M. Kit Delgado, Colleen D. Acosta, Adit A. Ginde, N. Ewen Wang, Matthew C. Strehlow, Yash S. Khandwala and Carlos A. Camargo, Jr., National Survey of Preventive Health Services in US Emergency Departments, 57 Annals of Emergency Medicine 2 (2011).
26However, even in the absence of EMTALA, providers may arguably have an ethical obligation to screen (and, depending on the circumstances, treat) individuals presenting to the ED. 
27See, e.g., William E. Northington, Jane H. Brice and Bin Zou, Use of an Emergency Department by Nonurgent Patients, 23 The American Journal of Emergency Medicine 2 (2005).
28For example, social marketing techniques (which emphasize product, price, place, and promotion) have been successful in effecting various cultural changes that have an impact on the public's health.  Such techniques could be used by hospitals, government agencies, and nonprofit organizations.  See, e.g., Sonya Grier and Carol A Bryant, Social Marketing in Public Health, 26 Annual Review of Public Health (2005).

 

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