The Primary Care Spectrum:
Emergency Department Care Versus Population Health Management
Most stakeholders in healthcare are in agreement that appropriate primary
care resources for patients must be expanded if high quality and integrated
care which is affordable and accessible is to be achieved. Unfortunately,
much of this care today is being delivered in over-crowded, high cost
emergency departments. Solutions to address these challenges were outlined
in our blog posted two weeks ago, entitled, “What is the Role of
the Emergency Department in Transforming Healthcare?” However, any
optimism about implementing such solutions was tempered by our blog posted
the following week , “The Emergency Department – Part Two”.
Having seen little change in over 30 years, it is clear to us, as the
partners in Royer-Maddox-Herron Advisors, that most providers are not
committed to implementing organized systematic innovation that will create
a different tomorrow. The transformation strategies that we are recommending
to our clients, and believe that they are not only desirable, but are,
in fact, necessary conditions for survival.
One of the most common proposals today for delivering high quality, low
cost and accessible healthcare delivery model is Population Health Management.
Unfortunately, this approach is entirely opposite the primary care delivered
inappropriately in the emergency department. So the question remains:
will we ever make the necessary transformational changes? Will we still
be at the same place 30 years from now? Do we have the will as the stakeholders
to commit to moving away from paying for an episode of sick care to a
transformational model that rewards participants for keeping patients healthy?
In a position paper published by VHA in 2013, the authors defined population
health as “the health outcomes of groups of individuals, including
the distribution of such outcomes within the group.” It goes on
to highlight the seven determinates of health we have talked about by
stating, that “in addition to medical care, a myriad of factors
impact the health of a population – public health resources, the
social environment, cultural beliefs, education, social support systems,
employment, the physical environment (clean water and air), infrastructure
(design, transportation, etc.), individual choices and behaviors, and genetics.
The contrast between primary care delivered in the two models is abundantly
clear. In the Emergency Department, the provider focuses on treating individual
sicknesses. Having practiced there for many years, I know there is a tendency
to support defensive medicine, thereby over-ordering tests and over-utilizing
procedures. Care in an ED is often delivered in silos, with little or
no coordination with the hospital, insurer, specialists, nor with any
other services deemed appropriate. The fee-for-service reimbursement model
incentivizes the practice that more is better, and the idea that occupied
beds are good.
But as a direct opposite, population health management builds a culture
that focuses the provider on prevention and keeping the population well.
A similar group of patients are managed by protocols that drive the appropriate
utilization of services, including acute care diagnosis, treatments, and
post-acute care. The model also fosters collaboration among providers
which drives well-coordinated care, which is always higher in quality
and lower in costs, minimizing the amount of duplication of testing, and
the like. This is the delivery of care seamlessly across an entire episode
of care. Finally, this model has as its ultimate goal keeping people well
and out of the hospital. If population health was fully successful, it
might make the recent statement of a colleague become reality: “In
10 years, a hospital admission will be seen as a failure of the healthcare
delivery system”. What a bold and innovative thought!
Yes, we all agree that primary care expansion will be a critical success
factor going forward. But the cultural changes required to move from the
Emergency Department model to the Population Health Model are mammoth,
with little progress being made in the last 30 years. But before we can
come together and hopefully close the gap, we must pause and realize first
how far apart we are! And that we are!!
Closing Note: This will be the last bog we will post for this year. As
2013 comes to a close, we wish all our readers, and present and future
clients a joyous holiday season, filled with much peace and happiness.
Please keep checking our Web page in the new year for our blogs which
will continue to address important issues for a successful transformation
journey in healthcare,