[Senate Hearing 112-789]
[From the U.S. Government Publishing Office]
S. Hrg. 112-789
DIVERTING NON-URGENT EMERGENCY ROOM USE:
CAN IT PROVIDE BETTER CARE AND LOWER COSTS?
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HEARING
BEFORE THE
SUBCOMMITTEE ON PRIMARY HEALTH AND AGING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED TWELFTH CONGRESS
FIRST SESSION
ON
EXAMINING DIVERTING NON-URGENT EMERGENCY ROOM USE, FOCUSING ON IF IT
CAN PROVIDE BETTER CARE AND LOWER COSTS, AND HEALTH CENTER STRATEGIES
THAT MAY HELP REDUCE THEIR USE
__________
MAY 11, 2011
__________
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
TOM HARKIN, Iowa, Chairman
BARBARA A. MIKULSKI, Maryland
JEFF BINGAMAN, New Mexico
PATTY MURRAY, Washington
BERNARD SANDERS (I), Vermont
ROBERT P. CASEY, JR., Pennsylvania
KAY R. HAGAN, North Carolina
JEFF MERKLEY, Oregon
AL FRANKEN, Minnesota
MICHAEL F. BENNET, Colorado
SHELDON WHITEHOUSE, Rhode Island
RICHARD BLUMENTHAL, Connecticut
MICHAEL B. ENZI, Wyoming
LAMAR ALEXANDER, Tennessee
RICHARD BURR, North Carolina
JOHNNY ISAKSON, Georgia
RAND PAUL, Kentucky
ORRIN G. HATCH, Utah
JOHN McCAIN, Arizona
PAT ROBERTS, Kansas
LISA MURKOWSKI, Alaska
MARK KIRK, Illinois
Daniel E. Smith, Staff Director
Pamela Smith, Deputy Staff Director
Frank Macchiarola, Republican Staff Director and Chief Counsel
______
Subcommittee on Primary Health and Aging
BERNARD SANDERS (I), Vermont, Chairman
BARBARA A. MIKULSKI, Maryland RAND PAUL, Kentucky
JEFF BINGAMAN, New Mexico RICHARD BURR, North Carolina
ROBERT P. CASEY, Jr., Pennsylvania JOHNNY ISAKSON, Georgia
KAY R. HAGAN, North Carolina ORRIN G. HATCH, Utah
JEFF MERKLEY, Oregon LISA MURKOWSKI, Alaska
SHELDON WHITEHOUSE, Rhode Island MICHAEL B. ENZI, Wyoming
TOM HARKIN, Iowa (ex officio)
Ashley Carson Cottingham, Staff Director
Evan Feinberg, Minority Staff Director
(ii)
C O N T E N T S
__________
STATEMENTS
WEDNESDAY, MAY 11, 2011
Page
Committee Members
Sanders, Hon. Bernard, Chairman, Subcommittee on Primary Health
and Aging, opening statement................................... 1
Paul, Hon. Rand, a U.S. Senator from the State of Kentucky....... 3
Bingaman, Hon. Jeff, a U.S. Senator from the State of New Mexico. 4
Whitehouse, Hon. Sheldon, a U.S. Senator from the State of Rhode
Island......................................................... 51
Merkley, Hon. Jeff, a U.S. Senator from the State of Oregon...... 53
Witness--Panel I
Macrae, James, Associate Administrator, Bureau of Primary Health
Care, Health Resources and Services Administration, U.S.
Department of Health and Human Services, Rockville, MD......... 4
Prepared statement........................................... 6
Witnesses--Panel II
Draper, Debra A., Director, Health Care, Government
Accountability Office (GAO), Washington, DC.................... 15
Prepared statement........................................... 16
Cunningham, Peter, Ph.D., Senior Fellow, Center for Studying
Health Systems Change, Washington, DC.......................... 19
Prepared statement........................................... 20
Eck, Alieta, M.D., Founder and Co-Director, Zarephath Health
Center, Zarephath, NJ.......................................... 30
Prepared statement........................................... 32
Kraus, Dana, M.D., Family Practice Physician, Northern Counties
Health Care, St. Johnsbury, VT................................. 37
Prepared statement........................................... 38
ADDITIONAL MATERIAL
Statements, articles, publications, etc.:
Alliance Defense Fund (ADF), Matthew S. Bowman, Esq., Legal
Counsel.................................................... 63
Letters:
American College of Emergency Physicians................. 64
U.S. Government Accountability Office (GAO).............. 65
New Jersey Primary Care Association, Inc. (NJPCA)........ 75
(iii)
DIVERTING NON-URGENT EMERGENCY ROOM
USE: CAN IT PROVIDE BETTER CARE AND LOWER COSTS?
----------
WEDNESDAY, MAY 11, 2011
U.S. Senate,
Subcommittee on Primary Health and Aging,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The subcommittee met, pursuant to notice, at 10 a.m. in
Room 430, Dirksen Office Building, Hon. Bernard Sanders,
chairman of the subcommittee, presiding.
Present: Senators Sanders, Bingaman, Merkley, Whitehouse,
and Paul.
Opening Statement of Senator Sanders
Senator Sanders. Let me open the very first meeting of the
U.S. Senate Subcommittee on Health, Education, Labor, and
Pensions, Subcommittee on Primary Health and Aging.
Today we have a very important hearing. Senator Paul is
here as well and we expect other members as the hearing
proceeds.
We have some excellent panelists and in a bit we will be
hearing from James Macrae who is the associate administrator
for the Bureau of Primary Health Care, Health Resources and
Services Administration. Our second panel will include Deborah
Draper, the director of Health Care, Government Accountability
Office; Peter Cunningham, senior fellow, Center for Studying
Health Systems Change; Alieta Eck, M.D., founder and co-
director Zarephath Health Center in New Jersey; Dana Kraus,
M.D., Family Practice Physician, Northern Counties Health Care
in St. Johnsbury, VT. We are pleased that you are all here.
Let me begin with an opening statement and say that I think
most of us would agree that our health care system today has
many very, very serious problems. In America today we have some
50 million fellow Americans who lack any health insurance, we
have many more who are under-insured with large copayments and
deductibles and many more even with insurance who are finding
it very hard to locate a primary health care physician who will
treat them and their family.
The United States today is the only Nation in the
industrialized world that does not guarantee health care to all
of its people as a right. Meanwhile, despite 50 million
Americans without any health insurance, we end up spending--and
this will be an important part of what this hearing is about--
we end up spending almost twice as much per person on health
care as any other industrialized Nation. I think it is
important to understand why that is so and how we can go
forward in providing quality health care to all of our people
in a cost-effective way.
Here are just a few facts that should concern every
American. According to a study from Harvard University, some
45,000 Americans will die this year because they do not get to
a doctor on time. They are sick, their sicknesses fester and by
the time they walk into the doctor's office it is often too
late. Further, in terms of cost, we spend an unsustainable 17.6
percent of our GDP on health care in 2009 and that is projected
to go up to 20 percent by 2020. So this is not just an issue of
people who cannot afford health insurance, it is not just an
issue of employers who are forced to pay 10, 20, 30 percent
more a year for health insurance, it is an issue for our entire
economy. This health care cost soaring is just not sustainable.
Yet, despite all of that, we rank approximately 26th among
major developed nations on life expectancy and 31st on infant
mortality. It just seems to me that with those problems facing
us we have to take a hard look at why these problems occur.
One of the major focuses of today's hearing is the use of
emergency rooms in a way that is not appropriate. While there
are differences of opinion, and certainly the figures will vary
in different parts of the country, nobody denies that many,
many hospitals see large numbers of people who are coming into
their emergency rooms, not for emergency care. It is terribly
important, I think we all agree, that our emergency rooms are
there for people who have heart attacks, strokes, accidents,
etc, but there is no debate that many people use the emergency
room as a source of primary health care because there are not
other primary health care facilities available.
The testimony that we will hear today, and that I think
everyone agrees on, is that an emergency room is, in fact, the
most expensive form of primary health care. That, for example,
if one were to go to a federally qualified community health
center or other primary health care facilities, the cost is
substantially lower. So it seems to me one of our goals is to
increase access for primary health care, get people who don't
need the emergency room out of the emergency room and provide
good quality primary health care to those people at a cost that
will be substantially lower than the cost of an emergency room.
Obviously in different parts of the country the figures are
different, but in some cases at least, a visit to an emergency
room for primary health care may be as much as 10 times more
than a visit to a community health center. So my hope is that
we can begin to understand, and we are going to hear some
interesting testimony today, how we can do that. How we can
keep unnecessary visits to the emergency room lower and get
people the quality primary health care that we need.
I very much look forward to hearing the testimony that we
will be hearing in a few minutes.
Senator Sanders. Senator Paul.
Statement of Senator Paul
Senator Paul. Thank you, Senator Sanders.
I do agree, as a physician I have seen it first hand, that
ER visits are much more expensive than primary care visits and
that the emphasis should be trying to figure out how we can get
patients to go to primary care as opposed to clogging up the
emergency rooms.
I would also say though, that private clinics and
charitable clinics are much more efficient than government
clinics. This is true throughout all of the economy, that
private enterprise is always more efficient than government,
just as a matter of fact.
I wholeheartedly agree with Dr. Eck, who will testify
later, that charity should be voluntary. In fact, charity is,
by definition, voluntary. The nobleness of giving is only real
if giving is voluntary. Many on the left wish to experience the
reward of giving by giving other people's money, but it doesn't
work that way. When you use force to transfer money from those
who work to those who don't, that is not charity, that is
redistribution of wealth. When you use government to try to
perform good works, not only is the accolade of charity
undeserved but the effect of the good works is always less than
satisfactory because government rarely does anything well.
I often ask an audience, if you had a hundred dollars to
give who would you rather give it to, the Federal Government or
the Salvation Army. I've yet to meet a thinking adult who would
choose the Federal Government. Government, particularly
government that is distant from the people is inefficient and
wasteful. Our job should not be to expand wasteful government
programs but to get government out of the way of true charity.
Not only is true charity good for the heart, but it is good
for the recipient. It warms the heart to hear of those who
receive charity, giving back with their time and effort to the
charity itself. In fact, many charities that work well require
the recipient to work at the charity. Many charities have come
to the conclusion that cash payments to recipients is
counterproductive and so the charity only pays bills directly.
Charity encourages help in times of need, but does not
encourage the perception of lifelong entitlement. Those who
receive charity typically understand that charity is a
temporary hand-up and not a permanent hand-out.
As a physician, I have seen the difference firsthand. Time
and again patients who I treated through the Lions Eye Clinic,
a charity that I helped set up, were appreciative and courteous
while others who felt entitled to free care were often
disruptive and rude.
Obamacare expands entitlements at a time when entitlements
are already stretched beyond solvency. Because we are living
longer and because of the population boom after World War II,
entitlements are all short of money. Social Security is $6
trillion short. Medicare is short over $30 trillion over the
next several decades. Social Security, for the first time, last
year pays out more than it brings in. Even without Obamacare,
the entitlements are on a collision course to consume the
entire budget within little more than a decade. We have serious
problems, just adding on more programs isn't the answer.
What we should be discussing today is, is it fiscally
responsible to increase funding to taxpayer financed health
centers by 68 percent over the next 5 years? Where will the
money come from? Are we willing to borrow from China to pay for
Obamacare? Are we willing to raise taxes to pay for the
expansion of entitlements? Are we willing to ask the Federal
Reserve to simply print more money to pay for the entitlements?
Will we expand government welfare to such a degree that we
bankrupt the entire system and no entitlements are paid?
I know advocates of increased welfare mean well, but in the
end good intentions must also be paired with fiscal
responsibility and that is the discussion that we as a country
should now be engaged in. Thank you.
Senator Sanders. Thank you, Senator Paul.
Senator Bingaman.
Statement of Senator Bingaman
Senator Bingaman. Mr. Chairman, I am here to hear the
witnesses and focus on this issue. I do think that diverting
folks from emergency rooms to other opportunities to get health
care is a great opportunity for us to save money in the health
care system, both in the public health care system and in the
private health care system.
So I commend you for having the hearing.
Senator Sanders. Thank you very much.
Let's begin with Mr. Macrae. James Macrae is the associate
administrator for the Bureau of Primary Health Care, Health
Resources and Services Administration, usually referred to as
HRSA, the U.S. Department of Health and Human Services.
Mr. Macrae, thanks very much for being with us.
STATEMENT OF JAMES MACRAE, ASSOCIATE ADMINISTRATOR, BUREAU OF
PRIMARY HEALTH CARE, HEALTH RESOURCES AND SERVICES
ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES,
ROCKVILLE, MD
Mr. Macrae. Thank you very much Mr. Chairman, members of
the committee and subcommittee. Thank you for the opportunity
to testify today.
I am Jim Macrae, the associate administrator of the Bureau
of Primary Health Care in the Health Resources and Services
Administration. I am very pleased to join my other colleagues
today in appearing before you.
Our agency, HRSA, helps the most vulnerable Americans
receive quality primary health care, without regard to their
ability to pay. Our agency works to expand access to health
care for millions of Americans, the uninsured, the underserved
and the vulnerable. HRSA recognizes that people need to have
access primary care and through its programs and activities the
agency seeks to meet these needs.
HRSA's vision for the Nation is healthy communities and
healthy people. Our mission is to improve health and achieve
health equity through access to quality services, a skilled
workforce and innovative programs. At HRSA we also believe that
primary care is more than having a place to go when you are
sick. We view primary care as an institute of what medicine
does, providing integrated, accessible health care services
like clinicians who are accountable for addressing a large
majority of personal health care needs, developing a sustained
partnership with patients and practicing in the context of
family and community.
Now I would like to talk more specifically about the health
center program. For more than 40 years health centers have
developed comprehensive, high quality, cost-effective primary
care to patients regardless of their ability to pay. During
that time health centers have become an essential primary care
provider for America's most vulnerable populations, people
living in poverty, the uninsured, the homeless, ethnic and
racial minorities, public housing residents and people who are
geographically isolated. Health centers advance the preventive,
coordinated, comprehensive and patient-centered care model
coordinating a wide range of medical, dental, behavioral and
social services. Today more than 11,000 health centers operate
over 8,000 delivery sites that provide care, in every U.S.
State, the District of Columbia, Puerto Rico, the U.S. Virgin
Islands and the Pacific Basin.
More importantly health centers offer care that is
affordable and accessible. The health center program
requirements include: The provision of care to all patients
regardless of their ability to pay; offering discounts to
patients on a sliding fee scale for all patients at or below
200 percent of the poverty level and the provision of services
at times and locations that assure accessibility and meet the
needs of the populations. Health centers frequently offer
evening and weekend hours and are located in areas convenient
to where the target population lives, including schools,
homeless shelters and through mobile vans.
Health centers are also required to provide professional
coverage for medical emergencies during hours when the center
is closed. This coverage must be clearly defined and include
telephone access to a clinician who can access the patient's
needs and recommend appropriate followup care. This includes
advising the patient of whether a visit to the ER is
appropriate.
The impact of health centers can be seen in other ways as
well. Health centers provide high quality care to rural and
urban populations by focusing attention on improving the
community's health through preventive care and providing direct
patient care.
The health center model also reduces the use of costlier
providers of care such as emergency rooms and hospitals.
Research has shown that Medicaid beneficiaries receiving care
from a health center were less likely to be inappropriately
hospitalized and less likely to visit the emergency room
inappropriately. Rural counties with a community health center
site had fewer than 33 percent emergency room visits than those
without a health center.
Health centers also improve access to care, health outcomes
and reduce health disparities and reduce costs. For example,
studies have demonstrated that uninsured people living within
close proximity to a health center are less likely to have an
unmet medical need, less likely to have postponed or delayed
seeking needed care and more likely to have had a general
medical visit. Health center uninsured patients are more likely
to have a usual source of care than the uninsured nationally.
Likewise, Medicaid beneficiaries receiving care from health
centers are more likely to report having access to care.
The reach of health centers is not limited to just what we
do in HRSA. In the past several years we have been working with
our counterparts in the Center for Medicaid and Medicare
Services on emergency room diversion programs. In 2008 CMS
awarded grants to 20 States with the goal of reducing hospital
emergency rooms by Medicaid beneficiaries, with many health
centers playing a key role in highlighting that health centers
are well positioned to adopt and showcase innovations in care
delivery, their experience with quality improvement and the use
of evidence-based models like the Chronic Care Model.
Finally, I would like to highlight an important finding
referenced in the GAO report, that health centers reduce the
use of hospital emergency rooms for non-urgent care because
health centers have the attributes of the medical home. Several
studies have shown that medical homes reduce emergency room use
significantly, not only for healthy patients but for those who
are sicker and have greater health care needs. HRSA is
dedicated to helping health centers move toward the medical
home model and to date more than 125 health centers have
enrolled in HRSA's recently announced Patient-Centered Medical
Home Initiative.
In closing, we recognize the key role that health centers
do and can play in the reduction of inappropriate emergency
room use and I appreciate the opportunity to testify today.
Thank you.
[The prepared statement of Mr. Macrae follows:]
Prepared Statement of James Macrae
Mr. Chairman, Ranking Member, and members of the committee, thank
you for the opportunity to testify. I am Jim Macrae, associate
administrator of the Bureau of Primary Health Care in the Health
Resources and Services Administration (HRSA). I am pleased to join my
other colleagues in appearing before you today.
hrsa overview
The Health Resources and Services Administration helps the most
vulnerable Americans receive quality primary health care, without
regard to their ability to pay. HRSA works to expand access to health
care for millions of Americans--the uninsured, the underserved and the
vulnerable. HRSA recognizes that people need to have access to primary
health care and, through its programs and activities; the Agency seeks
to meet these needs.
HRSA delivers on its obligation to address primary care access
through the 6 Bureaus and 13 Offices that comprise the Agency. The
Agency collaborates with government at the Federal, State, and local
levels, and also with community-based organizations and non-profit
foundations, to seek solutions to primary health care challenges. HRSA
provides leadership and financial support to health care providers in
every State and U.S. territory.
hrsa's vision, mission and goals
HRSA's vision for the Nation is healthy communities and healthy
people. Our mission is to improve health and achieve health equity
through access to quality services, a skilled health workforce and
innovative programs.
The Agency seeks to further our vision and carry out our mission
through four major goals:
Improve Access to Quality Care and Services;
Strengthen the Health Workforce;
Build Healthy Communities; and
Improve Health Equity.
At HRSA we also believe that primary care is more than having a
place to go when you are sick. We view primary care as the Institute of
Medicine (IOM) does \1\: providing integrated, accessible health care
services by clinicians who are accountable for addressing a large
majority of personal health care needs, developing a sustained
partnership with patients, and practicing in the context of the family
and the community.
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\1\ Donaldson M, Yordy K, Vanselow N, eds. Institute of Medicine.
Defining Primary Care: an Interim Report. Washington, DC: National
Academy Press, 1994:16.
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health center program overview
For more than 40 years, health centers have delivered
comprehensive, high-quality, cost-effective primary health care to
patients regardless of their ability to pay. During that time, health
centers have become an essential primary care provider for America's
most vulnerable populations: people living in poverty, uninsured, or
homeless; minorities; farm workers; public housing residents; people
who are geographically isolated; and people with limited English
proficiency.
Health centers advance preventive, coordinated, comprehensive, and
patient-centered care, coordinating a wide range of medical, dental,
behavioral, and social services. Today, more than 1,100 health centers
operate over 8,000 service delivery sites that provide care in every
U.S. State, the District of Columbia, Puerto Rico, the U.S. Virgin
Islands, and the Pacific Basin.
In fiscal year 2009, these non-profit and public, community-based
and patient-directed health centers served 18.8 million patients,
providing almost 74 million patient visits, at an average cost of $600
per patient. Patient services are supported through a variety of
revenue sources, including but not limited to Medicaid, Medicare, and
State and local grants. The Health Center Program grant funds from HRSA
account on average for 20 percent of total revenues for health centers.
health center research
Research continues to highlight health centers' success in
increasing access to care, improving health outcomes for patients,
reducing health disparities, and containing health care costs.
Health centers increase access to health care through an innovative
model of community-based, comprehensive primary health care that
focuses on outreach, disease prevention, and patient education
activities. For example, studies found:
Uninsured people living within close proximity to a health
center are less likely to have an unmet medical need, less likely to
have postponed or delayed seeking needed care, and more likely to have
had a general medical visit.\2\
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\2\ Hadley J and Cunningham P. Availability of Safety Net Providers
and Access to Care of Uninsured Persons. Health Services Research
2004;39(5):1527-46.
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Health center uninsured patients are more likely to have a
usual source of care than the uninsured nationally (98 percent versus
75 percent).\3\
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\3\ Carlson, BL, et al., ``Primary Care of Patients without Health
Insurance by Community Health Centers.'' April 2001 Journal of
Ambulatory Care Management 24(2):47-59.
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Medicaid beneficiaries receiving care from health centers
are more likely to report having access to care.\4\
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\4\ Shi L, Stevens GD, and Politzer RM. ``Access to care for U.S.
Health center patients and patients nationally: how do the most
vulnerable populations fare?'' 2007 Med Care 45(3):206-13.
Despite serving sicker and more at-risk patients than seen
nationally, health centers continue to demonstrate a strong track
record in delivering high quality care and reducing health disparities.
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For example, studies found:
Health center patient rates of blood pressure control were
better than rates in hospital-affiliated clinics or in commercial-
managed care populations, and racial/ethnic disparities in quality of
care were eliminated after adjusting for insurance status.\5\
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\5\ Hicks LS, et al. The Quality of Chronic Disease Care in U.S.
Community Health Centers. Health Affairs 2006;25(6):1713-23.
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Health center low-birth weight rates continue to be below
the national averages for all infants. In particular, the health center
low-birth weight for African-American patients is below the rate
observed among African-Americans nationally (10.7 percent versus 14.9
percent respectively).\6\
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\6\ Shi, L., et al. America's health centers: Reducing racial and
ethnic disparities in perinatal care and birth outcomes. Health
Services Research, 2004; 39(6):1881-1901.
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Health centers play a critical role in providing health
care services to rural residents who tend to have higher rates of
chronic diseases, such as the 27 percent of rural residents suffering
from obesity \7\ and nearly 10 percent diagnosed with diabetes.\8\
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\7\ Bennett, KJ., Olatosi, B., & Probst, JC. (2008). ``Health
Disparities: A Rural--Urban Chartbook.'' South Carolina Rural Health
Research Center.
\8\ Pleis JR, Lethbridge-Cejku M. Summary health statistics for
U.S. adults: National Health Interview Survey, 2006. National Center
for Health Statistics. Vital Health Stat 10(235). 2007.
Health centers provide high-quality care to rural and urban
populations alike by focusing attention on improving public health
through preventive care in addition to direct patient care. The health
center model of care has been shown to reduce the use of costlier
providers of care, such as emergency departments and hospitals. For
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example, studies found:
Medicaid beneficiaries receiving care from a health center
were less likely to be hospitalized.\9\
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\9\ Falik M., et al. Ambulatory care sensitive hospitalizations and
emergency visits: experiences of Medicaid patients using federally
qualified health centers. Medical Care 2001;39(6):551-61.
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Medicaid beneficiaries receiving care from a health center
were less likely to be inappropriately hospitalized and less likely to
visit the emergency room inappropriately.\10\
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\10\ Falik M., et al. Comparative Effectiveness of Health Centers
as Regular Source of Care. Journal of Ambulatory Care Management
2006;29(1):24-35.
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Rural counties with a community health center site had 33
percent fewer uninsured emergency room/department visits per 10,000
uninsured population than those without a health center.\11\
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\11\ Rust George, et al. ``Presence of a Community Health Center
and Uninsured Emergency Department Visit Rates in Rural Counties.''
Journal of Rural Health Winter 2009 25(1):8-16.
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emergency room diversion program
In the past several years, HRSA has worked with our counterparts in
the Centers for Medicare & Medicaid Services (CMS) on Emergency Room
Diversion programs. In 2008, CMS awarded grants to 20 States with the
goal of reducing the use of hospital emergency rooms by Medicaid
beneficiaries for non-emergent reasons. One community health center
project in Colorado focused on three goals: (1) to educate the Medicaid
population about alternative nonemergency care options; (2) to offer
real time referrals to alternative non-emergency care through the use
of Outreach Case Managers; and (3) to promote the concept of a medical
home for Medicaid patients so that they will have a better
understanding of their healthcare options and appropriately use health
care services. Additionally, Connecticut proposed to utilize a Web-
based application to connect providers in federally qualified health
centers (FQHCs) and hospitals in designated communities throughout the
State to create a common platform to search and schedule appointments
for Medicaid enrollees. This approach was designed to facilitate access
to primary care and enhance linkages between emergency departments and
community-based primary care providers.
patient-centered medical home initiative
As highlighted by GAO, one reason health centers reduce the use of
hospital emergency departments for non-urgent care is because they have
attributes of the medical home model. Studies have shown that having a
``medical care home'' reduces emergency department use significantly,
not only among healthy patients but also among those who are sicker and
have greater health care needs. Patient-centered medical homes (PCMHs)
utilize interdisciplinary teams that re-distribute care
responsibilities to those most capable and most accessible. A PCMH then
coordinates care within this interdisciplinary team and with others in
the community including hospitals and specialists.
HRSA is dedicated to assisting health centers move toward the
medical home model, and health centers are well-positioned to adopt and
showcase innovations in care delivery because they are experienced with
quality improvement that uses evidence-based models like the Chronic
Care Model. To date, more than 125 health centers have enrolled in
HRSA's recently announced Patient Centered Medical/Health Home
Initiative. Additionally, through the CMS Center for Medicare and
Medicaid Innovation, a Medicare FQHC Advanced Primary Care Practice
Demonstration project will be implemented soon to engage up to 500 FQHC
sites and up to 195,000 fee-for-service Medicare beneficiaries in a
medical home demonstration. One of the key expected outcomes of this
demonstration is a decrease in ED utilization by those that
participate.
health center support services
Another core component of the comprehensive model of primary care
provided by health centers is the non-clinical services that aim to
increase access, improve health care quality and reduce emergency use.
The provision of these enabling services is a distinguishing feature of
health centers, which recognize that barriers to care take various
forms. Health centers offer a variety of supportive and enabling
services to their patients including:
Case management for chronic conditions, reducing the need
for emergency services;
Eligibility and enrollment assistance for health and
social services;
Outreach and transportation services; and
Education of patients and the community regarding the
availability and appropriate use of health services, including
emergency rooms.
health center care is affordable, accessible and reduces the need for
emergency room care
Health centers offer affordable care to people in need. Health
centers are required to provide care to all patients regardless of
ability to pay, and to offer discounts based on a sliding fee scale for
all patients at or below 200 percent of the Federal poverty level. This
requirement helps ensure that financial concerns do not prevent
patients from accessing the health center's primary and preventive
services offered in a timely manner.
Health Centers offer care that is accessible. Health centers are
required to provide services at times and locations that assure
accessibility and meet the needs of the population to be served. For
example, health centers frequently offer evening and weekend hours to
ensure they are accessible to working adults. They are located in areas
convenient to where the target population lives or works, including
schools, homeless shelters, and/or through mobile van services.
Health centers are also required to provide professional coverage
for medical emergencies during hours when the center is closed. This
coverage must be clearly defined, and include telephone access to a
clinician who can assess the patient's needs and recommend appropriate
followup care. This includes advising the patient on whether a visit to
an ED is appropriate.
conclusion
In closing, we recognize the key role that health centers do and
can play in the reduction of inappropriate emergency room use. I
appreciate the opportunity to testify today, and I would be pleased to
answer any questions at this time.
Senator Sanders. Thank you very much.
Let me begin. Mr. Macrae, as you know, we recently
increased funding for community health centers and the word
went out that more money was available. What kind of response
did you get? In your judgment, is there a need for more
community health centers around this country?
Mr. Macrae. Senator, in terms of our recent announcement,
we had an announcement for what we call community health center
new access points, which is applications for both new community
health centers as well as satellite sites for exciting health
centers, to establish. We put out our application guidance
saying that we could fund approximately 350, we received
applications from over 800 applicants all across the country
for those resources. So there is clearly demand for these
services.
Senator Sanders. All right. I want you to elaborate on a
point that you just made. Common sense would suggest that if
there was good quality primary health care available to people
on a sliding scale basis, that welcomed Medicaid and Medicare,
took private insurance as well, that people were welcomed to
walk in the door, they would go there and they would find a
medical home which could treat them in a general sense. What
has been the experience, and I know we will hear more about
this this morning, about community health centers keeping
people from using an emergency room, what kind of experiences
have we seen?
Mr. Macrae. There have been several studies, as I mentioned
in my testimony, about the impact of even having a health
center in a particular community. The study that was done most
recently looked at rural communities and the impact of having a
health center in that community actually reduced the level of
inappropriate emergency room use by almost a third. In
addition, by expanding the access in terms of evening hours and
weekends and making sure that care is available through a
sliding fee scale, enables people to be able to use the
services of a health center as opposed to going to the
emergency room.
In fact, one of the big initiatives that we have been
working on with our health centers is to actually coordinate
and work with hospitals on working with the triage group there
to educate folks about the appropriate use of the emergency
room and actually create opportunities for followup visits from
emergency room visits, to actually hook them up with the health
center. About 65 percent of ER discharges actually result in a
referral to a clinic or a primary care provider and we are
trying to foster that kind of connection to make sure that
folks are aware that health centers are available.
Senator Sanders. In your judgment, what kind of potential
savings are out there if we can provide quality primary health
care in areas where people are now over-using the emergency
room? Do you see this as an opportunity for both government and
the private sector to be saving significant sums of money?
Mr. Macrae. It is definitely an opportunity and I think you
will definitely hear more from our colleagues in GAO about
this. They estimate that about 8 percent of emergency room use
currently is for non-urgent, nonemergency types of situations.
If we can encourage the use of primary care, in particular
through health centers and other safety net providers or other
primary care providers, that will definitely have an impact in
cost. It has been estimated that the cost at a health center is
roughly six to seven times less than what we would receive in
an emergency room.
Senator Sanders. In general, if one walks into an emergency
room, one gets the care for the problem that one has. That is a
different care than one would get if one had a medical home and
an ongoing primary health care physician. Would you agree that
it makes a lot more sense to try to find a medical home for
people so that physicians can know the family history, be
treating people on an ongoing basis, rather than just episodic
care at an emergency room?
Mr. Macrae. Yes. That is definitely something that we are
promoting at the Health Resources and Services Administration
through our medical home model, to really encourage the
opportunity for folks to have a place to go, a regular source
of care for their primary care needs. And through that actually
preventing illness, preventing emergencies and making sure that
they know they have a place to go or even a person to call when
they are in an emergency situation and determine whether it
makes sense to go to the emergency room or to actually followup
with a visit at the health center.
Senator Sanders. It appears that in many parts of this
country there is a shortage of primary health care physicians.
We increased funding for the National Health Service Corps to
encourage medical school students to work in primary care in
underserved areas. How are we doing in that regard? Are we
finding medical school students interested in moving into
primary health care in underserved areas?
Mr. Macrae. We very much are. As you know, the National
Service Corps has seen an increase in its funding and through
that we have put out application guidance for both what we call
our scholarship program as well as loan repayment program. The
program has received thousands of requests for applications and
we have been able to fulfill many of those. Actually, many of
those providers are providing service in health centers as well
as other clinics all across the country.
Senator Sanders. All right. Say a word about that, because
I am not sure everybody knows what the National Health Service
Corps does.
Mr. Macrae. The National Health Service Corps provides loan
forgiveness, either through a scholarship mechanism to
encourage folks to practice in medically underserved areas and
for medically underserved populations. So in exchange for
either a scholarship encouraging folks to enter medical school
or once they have completed medical school to pay back their
loans, there will be loan forgiveness, depending on the amount
of time that you provide service in that particular community.
Senator Sanders. OK. Thank you very much.
Senator Paul.
Senator Paul. Thank you, Mr. Macrae and thank you for
coming this morning.
Mr. Macrae. Yes.
Senator Paul. At your taxpayer-funded health centers do you
provide screening for sexually transmitted disease?
Mr. Macrae. Yes, we do.
Senator Paul. Birth control?
Mr. Macrae. Yes.
Senator Paul. Family planning and pregnancy testing?
Mr. Macrae. Yes.
Senator Paul. It sounds a lot like some of the things that
Planned Parenthood does. Would you say that maybe you duplicate
or they duplicate some of the things you do?
Mr. Macrae. I can't comment specifically on Planned
Parenthood, but the health center program is required to
provide preventive and primary care services to their
population.
Senator Paul. It sounds to me like you exactly duplicate
what they are doing.
I guess my question here is, as you have heard, we are a
little bit short of money, you are asking for a lot more money
and I think what responsible legislators should do and what
responsible government officials should do should be to own up
and say, ``Look if I think this is good and the government
needs to provide for it, why are we providing for it with three
different entities?''
I see no reason whatsoever, if you are wanting 68 percent
increase in your budget, that you can't own up, stand up and
tell us, ``Yes, we are doing the same thing Planned Parenthood
does. It is a very emotional, political football, but we are
doing the same darn thing they are doing and we should just
eliminate one or the other.'' Are you willing to give up the
money that Planned Parenthood does or do you want them to give
it up? That is the choices, the difficult choices that should
be made and what we should be talking about here.
Do you have a comment on that?
Mr. Macrae. I can't comment specifically on the family
planning piece, but I can say in terms of health centers that
the investment is cost-effective in the sense that, as I think
you will hear from some of the witnesses, that investing in
primary care and in prevention actually reduces overall cost
for patients. There have been many studies that have
demonstrated that the overall reduction in cost for health
center patients is significant, especially for Medicaid
beneficiaries as well as for other patients.
So the investment is actually cost-effective in the sense
of investing on the front end through prevention and primary
care actually results in less hospitalization and less cost to
the system overall.
Senator Sanders. Senator Bingaman.
Senator Bingaman. Thank you very much for being here. One
of the points you made in your testimony is that health centers
frequently offer evening and weekend hours to ensure they are
accessible to working adults. When does the inappropriate use
of emergency rooms occur; how much of that inappropriate use
occurs during the evenings or the weekends because people
really don't have a choice, as they see it?
Mr. Macrae. I think my colleagues will speak to this more
clearly, but clearly that is a huge impact in terms of people
being able to access care. Both what we have heard from
emergency room physicians as well as different studies that our
counterparts in the Centers for Disease Control and Prevention
have indicated is that a significant number of visits are
evenings or on weekends. And that is one of the things that we
have been working with our community health centers--to extend
and expand the number of evening hours as well as hours on the
weekend.
In addition, making sure that there are people that folks
can call and contact before they make that decision to go to
the ER. There are many reasons why it absolutely makes sense
for people to go directly to the ER. But in a lot of
circumstances, as you said, it is the only place that people
feel like they can go.
Senator Bingaman. Yes. My impression is, and this is just
anecdotal, that a lot of the health centers and sites in my
State of New Mexico do not provide services regularly on
weekends and even some evenings. That could substantially
increase access to these community health centers and reduce
cost in the emergency room, by expanding hours of operation. So
I hope you can give that a real priority and as you expand the
services or the delivery system that you folks are in charge
of, I hope you can give priority to expanding the hours of
service in areas where that is justified.
Mr. Macrae. Absolutely. In fact, with the expansion it is
not just, for us, about creating new sites and even expanded
service, it is about redesigning how the care is provided. One
of the key pieces of that actually is expanding the number of
hours that are available on evenings and weekends. Most
recently, through the Recovery Act, we actually provided
additional resources to health centers to expand their capacity
to provide those evening and weekend hours.
Through the Medical Home Initiative we are actually really
working with our health centers to look at how they even
provide care in the clinic today. The whole idea of creating
more open access, same day appointments so that there aren't
wait times for appointments and other things, so that people
can have ready access, whether that is during the day, in the
evening or on the weekends.
Senator Bingaman. Senator Sanders was talking about the
importance of this--of having patients able to go to their so-
called medical home when they need medical care instead of just
episodic visits at emergency rooms. I would think that anything
that could be done to expand the availability of those services
in the evenings and weekends would be a big factor.
My recollection is, when we were raising our son, that he
only got sick on weekends.
[Laughter.]
At times when it was very difficult to find a physician
other than taking him to some emergency room, which clearly was
not the ideal case. I commend you on what you are trying to do
with expanding these services. They are extremely valuable to
my State and they are really a lifeline for a lot of folks.
I agree with the points you made that this is a cost-
effective way to spend taxpayer dollars. I mean if we are going
to have taxpayer dollars spent to try to assist people in
getting health care, one of the most cost-effective
expenditures we make is through these community health centers.
I will stop with that, Mr. Chairman.
Senator Sanders. Thank you. If I might just open it up to
all of the Senators here, to respond a little bit to Senator
Paul's statement.
Of course there is quote/unquote duplication of services.
In my view Planned Parenthood does an excellent job and I
strongly support it. Obviously some of the services that
Planned Parenthood provides are also provided in community
health centers and probably provided at almost every primary
health care office in the United States of America.
The issue is, it seems to me, is there a need for more
primary health care access in the United States of America? The
question also is, if we provide that access, do we, (a) not
only keep people healthier, because the doors are now opened to
walk into a primary health care physician when you are sick,
but equally important, do we save money.
Now you may be familiar, Mr. Macrae, with the study done by
George Washington University, and they said, in fact, that if
we expand community health centers and enable people to walk in
the door, so that they don't have to go to the emergency room
as much as 10 times the cost per visit, so that they don't get
sicker and then when they walk in the doctor's office they end
up in the hospital at what could be more than 50 times the cost
of what it might have been to treat them initially, then in
fact investing in primary health care access and community
health centers saves substantial sums of money, both for the
government, in terms of Medicaid and Medicare and for the
private sector as well. Is that your understanding?
Mr. Macrae. Yes. I would say there are several studies that
point out that by investing on the front end, in terms of
preventive and primary care, the services that health centers
provide, it does, again, reduce the use of emergency rooms,
hospitalizations and overall reduces the costs for the patients
and for the government, in terms of care.
Senator Sanders. Senator Paul.
Senator Paul. So one followup on this, on the idea of
whether Planned Parenthood is duplicate service, as obviously
it is, and I know you don't want to comment because it is very
emotional, political football, but they obviously do. You
duplicate every one of their services. The real difference
between you and Planned Parenthood is you are a civil servant,
correct?
Mr. Macrae. Yes.
Senator Paul. You can be fired by the taxpayers, someone in
the executive branch can replace you, if you don't do your job.
Planned Parenthood is not responsive to the taxpayer or to the
government and we give them money.
The other question is, and this is in the scheme of the
large picture, we are nearly $2 trillion short every year.
Should we not, at the very least, even if I accept all of your
arguments that the government should be doing this, if we stick
our head in the sand and just say every program is going to
always get money, we have 42 different programs doing Federal
workplace training; we have 82 different programs judging
teachers. Every year we just add on one more program.
You are here and Obamacare is going to give you 68 percent
increase in funding. We are throwing tons of money at community
health centers and yet we are still throwing at it because
Planned Parenthood is supported by the left, they give
contributions, they lobby and they are a big organ for the
other side. But the thing is, why don't we try to--I don't see
you as a partisan, you are trying very hard not to be a
partisan, but Planned Parenthood is a partisan, politically and
otherwise. You are not. At the very least, if you want
government to do it, if you want taxpayers to fund it, let's do
it through a government agency and not be giving it to a
private agency. Thank you.
Senator Sanders. Let me just say I wasn't quite aware,
maybe at some point we can do a hearing on Planned Parenthood.
I am strongly supportive of what they do.
Does the government have a serious deficit problem? It sure
does. You are absolutely right. But some of us think maybe the
cause of that are two wars that were unpaid for, huge tax
breaks for the rich and a Wall Street bailout, we could talk
about that also, Senator Paul, at some point.
But, Mr. Macrae, that is probably not your area of
involvement.
[Laughter.]
So why don't we thank you, if that is OK with Senator Paul,
thank you very much for being here and thank you very much for
the excellent work you and your agency do.
Now let us bring up all of our other panelists.
Mr. Macrae. Thank you.
Senator Sanders. Thank you.
Mr. Macrae. Thank you very much.
Senator Sanders. We have a great panel and I want to, on
behalf of the committee, thank you all very much for being with
us today to discuss this very important issue. My request is
that you limit your initial remarks to 5 minutes. Senator Paul
and I and any others, we are going to ask you questions and we
can go on from there in a kind of an informal way.
Let's begin with Debra Draper. Am I pronouncing your name,
last name correct?
Ms. Draper. It is Draper.
Senator Sanders. Draper. Sorry. All right.
Dr. Draper is a director on the health care team at the
U.S. Government Accountability Office. She received her
doctorate in health services organizations and research from
the Medical College of Virginia, Virginia Commonwealth
University.
Dr. Draper, thanks very much for being with us.
STATEMENT OF DEBRA A. DRAPER, DIRECTOR, HEALTH CARE, GOVERNMENT
ACCOUNTABILITY OFFICE, WASHINGTON, DC
Ms. Draper. Chairman Sanders, Ranking Member Paul, thank
you for the opportunity to be here today as you discuss the
diversion of non-urgent use of hospital emergency departments
in the implications for care and costs.
Hospital emergency departments are a major component of the
Nation's health care safety net. They are open 24 hours a day,
7 days a week and generally are required to medically screen
all individuals, regardless of their ability to pay. Emergency
department use has increased over time and in 2007 there were
approximately 117 million visits, of which 8 percent were
classified as non-urgent.
Like hospital emergency departments, the national network
of health centers, which includes approximately 8,000 delivery
sites, is an important component of the health care safety net,
particularly for those who may have difficulty obtaining access
to health care because of financial or other limitations.
Health centers are funded, in part, through Section 330 grants
and provide comprehensive health care services without regard
to a patient's ability to pay. They also provide enabling
services, such as case management and transportation which help
patients to access care.
Some emergency department visits, include those for non-
urgent conditions, may be treated in other, more cost-effective
settings such as health centers. According to 2008 national
survey data, the average amount paid for a nonemergency visit
to the emergency department was seven times more than that for
a health center visit. Individual's decisions to go to the
emergency department vary, but often include the lack of timely
access to care in other settings.
In my statement today I will discuss key findings from a
report that we are publicly releasing today that describe
strategies that health centers have implemented that may reduce
emergency department use. I will also highlight challenges that
health centers may face in implementing and evaluating these
strategies.
Health center officials that we spoke with described three
types of strategies they have implemented that may reduce
emergency department use. One type of strategy focus on
emergency department diversion, which is often implemented in
collaboration with the hospital, and includes educating
emergency department patients on appropriate use. Diversion
strategies often target patients whose visits are non-urgent,
lack a regular source of care, are uninsured or have Medicaid
or are frequent users.
The second type of strategy that health centers have
implemented focuses on care coordination. Health center
officials describe two types of care coordination strategies,
the first is the medical home model, which uses a physician-led
team to provide ongoing and comprehensive care to patients to
improve outcomes. The second is chronic care management which
aims to reduce, if not prevent, disease-related emergencies. It
emphasizes the monitoring and management of conditions such as
diabetes, asthma and heart disease through preventative care,
screening and patient education on healthy lifestyles.
The third type of strategy that health centers have
implemented focuses on increasing awareness of and access to
services and includes expanding health center hours to include
evenings and weekends, making available same day or walk-in
appointments and locating service delivery sites in or near
hospitals, schools and homeless shelters. Health center
officials also discuss the use of strategies that reach out to
patients, including tele-medicine, home visits and mobile
clinics.
Health center officials identified a number of challenges
implementing the strategies that I have discussed today. For
example, they talked about the difficulty of changing the care
seeking behaviors of some patients who are frequent emergency
department users, including those who are homeless or have
substance abuse and mental health issues. Health center
officials also told us that they have mostly anecdotal evidence
on the effectiveness of the strategies they have implemented.
However, one health center that had participated in a diversion
program with a formal evaluation reported a 63 percent decrease
in emergency department visits 1 year after patients enrolled
in the program.
To conclude, as more people obtain health care coverage
through the Affordable Care Act, the demands on hospital
emergency departments are likely to increase. Health centers
may provide a more effective alternative for some emergency
department visits, including those for non-urgent conditions.
The Affordable Care Act provides health centers with an
additional $11 billion in funding over the next 5 years, which
is expected to increase capacity, positioning these providers
to serve more people, including those who may have sought care
from hospital emergency departments.
Mr. Chairman, this concludes my opening remarks. I am happy
to answer any questions.
[The prepared statement of Dr. Draper follows:]
Prepared Statement of Debra A. Draper
summary
Our work found that health centers have implemented three types of
strategies that may help reduce emergency department use. These
strategies focus on (1) emergency department diversion, (2) care
coordination, and (3) accessibility of services. For example, some
health centers have collaborated with hospitals to divert emergency
department patients by educating them on the appropriate use of the
emergency department and the services offered at the health center.
Additionally, by improving care coordination for their patients, health
centers may help reduce emergency department visits by encouraging
patients to first seek care at the health center and by reducing, if
not preventing, disease-related emergencies from occurring. Finally,
health centers employed various strategies to increase the
accessibility of their services, such as offering evening and weekend
hours and providing same-day or walk-in appointments--which help
position the health center as a convenient and viable alternative to
the emergency department. Health center officials told us that they
have limited data about the effectiveness of these strategies, but some
officials provided anecdotal reports that the strategies have reduced
emergency department use. These officials also described several
challenges in implementing strategies that may help reduce emergency
department use. For example, health center officials indicated that
some services, such as those provided by case managers who may help
coordinate care, are generally not reimbursed by third-party payers.
Additionally, some officials noted that it is difficult to change the
behaviors of patients who frequent the emergency department and some
noted challenges with recruiting the necessary health providers to
serve their patients.
______
Chairman Sanders, Ranking Member Paul, and members of the
subcommittee, I am pleased to be here today to discuss strategies that
health centers--facilities that provide primary care and other services
to individuals in communities they serve regardless of ability to pay--
employ that may help reduce hospital emergency department use. Hospital
emergency departments are a major component of the Nation's health care
safety net as they are open 24 hours a day, 7 days a week, and
generally are required to medically screen all people regardless of
ability to pay.\1\ From 1997 through 2007, U.S. emergency department
per capita use increased 11 percent.\2\ In 2007, there were
approximately 117 million visits to emergency departments; of these
visits, approximately 8 percent were classified as nonurgent.\3\ The
use of emergency departments, including use for nonurgent conditions,
may increase as more people obtain health insurance coverage as the
provisions of the Patient Protection and Affordable Care Act (PPACA)
are implemented.\4\
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\1\ In order to participate in Medicare, hospitals are required to
provide a medical screening examination to any person who comes to the
emergency department and requests an examination or treatment for a
medical condition, regardless of the individual's ability to pay.
Social Security Act 1866(a)(1)(I), 1867 (codified at 42 U.S.C
1395cc(a)(1)(I), 1395dd). Medicare is the Federal health program that
covers seniors aged 65 and older, certain disabled persons, and
individuals with end-stage renal disease.
\2\ In 1997, there were an estimated 35.6 emergency department
visits per 100 people compared to 39.4 visits in 2007. See P. Nourjah,
``National Hospital Ambulatory Medical Care Survey: 1997 Emergency
Department Summary,'' Advance Data, no. 304 (1999), and R. Niska, F.
Bhuiya, and J. Xu, ``National Hospital Ambulatory Medical Care Survey:
2007 Emergency Department Summary,'' National Health Statistics
Reports, no. 26 (2010).
\3\ The National Center for Health Statistics developed time-based
acuity levels based on a five-level emergency severity index
recommended by the Emergency Nurses Association. The acuity levels
describe the recommended timeframe for being seen by a physician. The
recommended timeframes to be seen by a physician are less than 1 minute
for immediate patients, between 1 and 14 minutes for emergent patients,
between 15 minutes and 1 hour for urgent patients, greater than 1 hour
to 2 hours for semiurgent patients, and greater than 2 hours to 24
hours for nonurgent patients.
\4\ We refer to the Patient Protection and Affordable Care Act,
Pub. L. No. 111-148, 124 Stat. 119, as amended by the Health Care and
Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat
1029, as PPACA. According to estimates from the Congressional Budget
Office (CBO), an additional 32 million individuals are projected to
obtain health insurance coverage by 2019; CBO also estimates that
gaining insurance increases an individual's demand for health care
services by about 40 percent. See D. Elmendorf, Director, CBO,
``Economic Effects of the March Health Legislation'' (presentation at
the Leonard D. Schaeffer Center for Health Policy and Economics,
University of Southern California, Los Angeles, CA, Oct. 22, 2010).
---------------------------------------------------------------------------
Some nonurgent visits are for conditions that likely could be
treated in other, more cost-effective settings, such as health centers.
In 2008, the average amount paid for a nonemergency visit to the
emergency department was seven times more than that for a health center
visit, according to national survey data.\5\ While there are many
reasons individuals may go to the emergency department for conditions
that could also be treated elsewhere, one reason may be the lack of
timely access to care in other settings, possibly due to the shortage
of primary care providers in some areas of the country.
---------------------------------------------------------------------------
\5\ According to estimates from 2008 Medical Expenditures Panel
Survey (MEPS), the average amount paid for a nonemergency visit to an
emergency department was $792, while the average amount paid for a
health center visit was $108. Similarly, the average charge for a
nonemergency visit to an emergency department was 10 times higher than
the charge for a visit to a health center--$2,101 compared to $203.
MEPS is a set of large-scale surveys of families and individuals, their
medical providers, and their employers across the United States.
---------------------------------------------------------------------------
Like emergency departments, the nationwide network of health
centers is an important component of the health care safety net for
vulnerable populations, including those who may have difficulty
obtaining access to health care because of financial limitations or
other factors. Health centers, funded in part through grants from the
Department of Health and Human Services' Health Resources and Services
Administration (HRSA), provide comprehensive primary health care
services--preventive, diagnostic, treatment, and emergency services, as
well as referrals to specialty care--without regard to a patient's
ability to pay. They also provide enabling services, such as case
management and transportation, which help patients access care. In
2009, more than 1,100 health center grantees operated more than 7,900
delivery sites and served nearly 19 million people. With funding from
PPACA--projected to be $11 billion over 5 years for the operation,
expansion, and construction of health centers \6\--health center
capacity is expected to expand.
---------------------------------------------------------------------------
\6\ Specifically, PPACA appropriated $9.5 billion for fiscal years
2011 through 2015 to a new Community Health Centers Fund to enhance
funding for HRSA's community health center program. It also provided
$1.5 billion over that same time period for the construction and
renovation of community health centers. Pub. L. No. 111-148, 10503,
124 Stat. 119, 1004 (2010); Pub. L. No. 111-152, 2303, 124 Stat. 1029,
1083.
---------------------------------------------------------------------------
My statement will highlight key findings from a report we are
publicly releasing today that describes strategies that health centers
have implemented that may help reduce the use of hospital emergency
departments.\7\ For that report, we interviewed officials from nine
health centers, and conducted group interviews with officials from
multiple health centers operating in three States, about strategies
they have implemented that may help reduce emergency department use. We
selected these health centers and States, based on our review of
relevant literature and interviews with HRSA officials and experts, to
provide geographic variation and to ensure that health centers serving
rural and urban areas were represented. We also e-mailed all State and
regional primary care associations--private, nonprofit membership
organizations of health centers and other providers--to identify
specific health centers in their jurisdictions that had implemented
strategies that may have reduced emergency department use.\8\ In
addition, we collected information about health centers' strategies
from the literature and our interviews with agency officials and
experts. Our work was performed from November 2010 through April 2011
in accordance with generally accepted government auditing standards.
---------------------------------------------------------------------------
\7\ GAO, Hospital Emergency Departments: Health Center Strategies
That May Help Reduce Their Use, GAO-11-414R (Washington, DC: Apr. 11,
2011).
\8\ We received responses from 21 of 52 regional and State primary
care associations we contacted.
---------------------------------------------------------------------------
In brief, our work found that health centers have implemented three
types of strategies that may help reduce emergency department use.
These strategies focus on (1) emergency department diversion, (2) care
coordination, and (3) accessibility of services. For example, some
health centers have collaborated with hospitals to divert emergency
department patients by educating them on the appropriate use of the
emergency department and the services offered at the health center.
Additionally, by improving care coordination for their patients, health
centers may help reduce emergency department visits by encouraging
patients to first seek care at the health center and by reducing, if
not preventing, disease-related emergencies from occurring. Finally,
health centers employed various strategies to increase the
accessibility of their services, such as offering evening and weekend
hours and providing same-day or walk-in appointments--which help
position the health center as a convenient and viable alternative to
the emergency department. Health center officials told us that they
have limited data about the effectiveness of these strategies, but some
officials provided anecdotal reports that the strategies have reduced
emergency department use. These officials also described several
challenges in implementing strategies that may help reduce emergency
department use. For example, health center officials indicated that
some services, such as those provided by case managers who may help
coordinate care, are generally not reimbursed by third-party payers.
Additionally, some officials noted that it is difficult to change the
behaviors of patients who frequent the emergency department and some
noted challenges with recruiting the necessary health providers to
serve their patients.
Chairman Sanders, Ranking Member Paul, this concludes my prepared
remarks. I would be pleased to respond to any questions you or other
members of the subcommittee may have at this time.
Senator Sanders. Thank you very much, Dr. Draper.
Our next panelist is Dr. Peter Cunningham who is a senior
fellow and director of quantitative research at the Center for
Studying Health System Change here in Washington. His research
focuses on a number of crucial health care topics that have
long been of interest to policymakers, including trends in
health care access, utilization and expenditures.
Dr. Cunningham, thanks very much for being with us.
STATEMENT OF PETER CUNNINGHAM, Ph.D., SENIOR FELLOW, CENTER FOR
STUDYING HEALTH SYSTEMS CHANGE, WASHINGTON, DC
Mr. Cunningham. Chairman Sanders, Senator Paul and members
of the subcommittee, thank you for the invitation to testify
about the use of hospital emergency departments for non-urgent
health problems.
My name is Peter Cunningham and I am a researcher and
director of quantitative research at the Center for Studying
Health System Change here in Washington. We are an independent,
nonpartisan health policy research organization. Our goal is to
inform policymakers with objective and timely research on
developments in the health care system and the impact on
people. We do not make specific policy recommendations.
Since 1996 we have been following trends in the use of
hospital emergency departments and how it is related to other
developments in the health care system through analyses of
survey data as well as intensive study of the health systems in
12 communities.
My written testimony concurs with many of the points made
in the GAO report in that there has been a substantial increase
in the use of hospital emergency departments over the past 15
to 20 years. This has certainly contributed to crowding at many
emergency departments which has generated concern about the
impact on the quality of patient care, the costs of care and
the ability of hospitals to respond to mass casualty events and
public health emergencies.
To alleviate crowding and to improve the quality of primary
care for patients, we have seen a number of efforts across the
country to shift some of the excess demand for emergency
department care, especially for non-urgent health problems, to
other primary care providers in the community, including
community challenge centers.
My written testimony also notes that it is important that
efforts to shift care out of the emergency department take the
following into account. First, people with private insurance
account for most of the increase in emergency department use.
It is true that the uninsured depend on emergency departments
for their care a lot more than people with insurance coverage.
But the uninsured are generally not responsible for the problem
of crowding, at least at a national level. There is compelling
evidence that insufficient capacity with the primary care
system is resulting in some spillover into hospital emergency
departments.
But it is not just a lack of primary care providers but
also the lack of after hours care at other primary care
providers in the availability of 24/7 at the emergency
department that leads many people to go there for minor
ailments.
Also, identifying visits that should be moved out of the
emergency department must be done very carefully and with
consideration of other primary care resources in the community.
It is not just the acuity level of the health problem or the
immediacy in which the patient should be seen, but also the
availability of after hours care, other facilities such as
freestanding urgent care centers and community health centers
and how easy it is for patients to get same day appointments at
other providers in the community. This differs across
communities as well as by patient characteristics, especially
their insurance coverage.
Despite concerns about crowding at the emergency
department, hospitals are not always onboard with efforts to
shift care out of their emergency departments or at least they
want to do so selectively by shifting their uninsured patients
to community health centers but retaining their paying
patients. We have observed that lack of cooperation by
hospitals can severely limit the effectiveness of any program
to shift care out of the emergency department.
I do agree that visits to emergency departments are more
expensive than at other primary care providers. I am a little
bit more skeptical about the overall amount of cost savings to
the health care system that could be generating by shifting
more of these visits outside, but I think probably more notable
is that it would reduce the financial burden of medical care
for the uninsured and I think it would generate a higher level
of cost savings for the Medicaid program.
Whatever the issue of cost, there is widespread agreement
among medical care providers that shifting non-urgent care out
of the emergency department and into primary care settings has
important benefits for the quality of patient care, the
continuity of care and reducing unnecessary or redundant
utilization. It is also consistent with recent developments in
health care that emphasize a more integrated health care
delivery system and having a medical home where all of the
patient's care, including care by specialists and
pharmaceuticals is coordinated and managed.
That concludes my testimony. Thank you.
[The prepared statement of Dr. Cunningham follows:]
Prepared Statement of Peter Cunningham, Ph.D.
summary
There has been much concern over the past decade about crowded and
overloaded hospital emergency departments (EDs). Contributing to the
problem of ED crowding is a substantial increase in emergency
department utilization among the U.S. population--often attributed to
growing use for nonurgent health problems. As a result, many
policymakers and health care providers believe it is essential to shift
some of this use to community-based primary care providers to relieve
crowded EDs, lower the costs of care to both the health system and
patients, and improve the quality of care. The following points are
key:
Emergency department use has increased substantially over
the past 15 years, but most of this is the result of increased use by
people with private insurance and other health insurance coverage. The
uninsured account for only a small share of the overall increase in
emergency ED volumes. Thus, the problem of ED crowding will not be
resolved by reducing utilization among the uninsured.
Few emergency department visits are truly nonurgent, but a
much larger number could potentially be treated in primary care
settings depending on the circumstances of the visit, such as the time
of day and day of the week when care is needed, the availability of
other providers in the community such as freestanding urgent care
centers, and the ability to get same-day appointments with primary care
physicians.
Capacity constraints in the ambulatory medical care system
have likely contributed to an increase in ED use for nonurgent health
problems, and at the same time, these capacity constraints inhibit the
ability to shift patients from EDs to primary care settings.
Some patients prefer going to the ED--even when they have
a primary care physician--in large part because of the greater
convenience of emergency departments, which are open 24 hours a day, 7
days a week. Thus, increasing the availability of after-hours care and
same-day appointments is critical to shifting care from EDs to primary
care settings.
Many hospital EDs are expanding capacity to accommodate
the increased demand as well as to increase revenues from resulting
inpatient admissions and procedures. Most hospitals have little
financial incentive to discourage ED use, except for uninsured
patients. Gaining cooperation of some hospitals to shift nonurgent ED
visits to primary care settings could be a major obstacle to the
success of any such program.
Reducing the use of EDs for nonurgent health problems may
generate much lower cost savings to the health care system than is
commonly assumed. However, shifting more of this care to community
health centers is likely to generate more substantial cost savings for
both uninsured patients as well as State Medicaid programs.
______
Chairman Sanders, Senator Paul and members of the subcommittee,
thank you for the invitation to testify about use of hospital emergency
departments for nonurgent health problems. My name is Peter Cunningham,
and I am a researcher and director of Quantitative Research at the
Center for Studying Health System Change (HSC).
HSC is an independent, nonpartisan health policy research
organization affiliated with Mathematica Policy Research. HSC also is
the research arm of the nonpartisan, nonprofit National Institute for
Health Care Reform, a 501(c)(3) organization established by the
International Union, UAW; Chrysler Group LLC; Ford Motor Company; and
General Motors to conduct health policy research and analysis to
improve the organization, financing and delivery of health care in the
United States (NIHCR.org).
I and other HSC researchers have conducted a number of studies
documenting the increase in the use of hospital emergency departments,
including for nonurgent health problems, and the problems of crowding
at some emergency departments (EDs). We have examined how these trends
affect and are affected by larger developments in the health care
system, the reasons why people use emergency departments for minor
ailments, and the potential for hospitals to shift some of their
emergency department visits to primary care providers in the community.
Our goal at HSC is to inform policymakers with objective and timely
research on developments in the health care system and the impact on
people. We do not make specific policy recommendations. Our various
research and communication activities may be found on our Web site at
www.hschange.org.
There has been much concern over the past decade about what many
believe is a national crisis of crowded and overloaded hospital
emergency departments and the consequences for patient care and the
ability of EDs to respond to both individual and mass-casualty
emergencies. Contributing to the problem of ED crowding is a
substantial increase in emergency department utilization among the U.S.
population, which is often attributed to growing use of emergency
departments for nonurgent health problems. As a result, many
policymakers and health care providers believe that it is essential to
shift emergency department use for nonurgent health problems to primary
care providers in the community to relieve crowded emergency
departments, lower the costs of care and improve the quality of care.
My testimony today will make the following key points:
Emergency department use has increased substantially over
the past 15 years, mostly because of increased use by people with
private insurance and other health coverage. While emergency department
crowding is often attributed to the uninsured, their use of emergency
departments is considerably less than privately insured people.
Increases in emergency department visits by the uninsured account for
only a small share of the overall increase in emergency department
volumes.
Few emergency department visits are truly nonurgent,
according to the most credible national data. Most ED visits are
neither clearly nonurgent nor truly emergencies. Determining whether
these visits could be shifted to primary care settings in the community
is difficult because the appropriate use of the emergency department
for health problems often depends on factors other than their urgency,
including the time of day and day of the week when care is needed, the
availability of other providers in the community such as freestanding
urgent care centers, and the ability to get same-day appointments with
primary care physicians.
Increases in emergency department visits reflect a more
general increase in the demand for ambulatory care, and it should be
emphasized that physician office visits have increased at an even
higher rate than emergency department visits. As office-based
physicians struggle with growing practice capacity constraints, some of
the excess demand is spilling over into hospital EDs. For their part,
some patients prefer going to the emergency department--even when they
have a primary care physician--because emergency departments are open
24 hours a day, 7 days a week.
Many hospital emergency departments are expanding capacity
to accommodate the increased demand, as well as to increase revenues
from resulting inpatient admissions and procedures, particularly for
privately insured and Medicare patients. Far from perceiving emergency
departments as money losers, most hospitals have little financial
incentive to discourage emergency department use by privately insured
and Medicare patients--including for nonurgent health problems--which
could complicate efforts to shift some nonurgent visits to more-
appropriate community settings.
Despite recent increases in utilization, hospital
emergency departments represent a relatively small part of the U.S.
health care system in terms of both utilization and costs. Reducing the
use of EDs for nonurgent health problems may generate much lower cost
savings than is commonly assumed. However, because Medicaid enrollees
have by far the highest per person use of hospital emergency
departments, the potential cost savings to the Medicaid program could
be more substantial.
the evolving role of hospital emergency departments
Hospital emergency departments are a critical and indispensable
component of the U.S. health care system. While their traditional
mission is to provide trauma and emergency services for people in
imminent danger of losing their life or suffering permanent damage to
their health, the role of emergency departments has evolved over the
past several decades. EDs are on the front lines of communities'
preparedness efforts and responses to natural disasters, other mass-
casualty events, and public health emergencies arising from outbreaks
of influenza and other communicable diseases.
Emergency departments have become the true provider of ``last
resort'' for uninsured people and other patients who are unable to
afford other medical providers in the community, largely as a result of
the 1986 Federal Emergency Medical Treatment and Labor Act (EMTALA)
that requires hospitals to provide emergency screening and
stabilization services regardless of patients' ability to pay. Along
with the fact that emergency departments are often the only medical
facilities in a community that are open 24 hours a day, 7 days a week,
true emergencies comprise only a relatively small share of visits to
emergency departments. Today, hospital emergency departments are a
major source of primary health care in the community, treating a broad
range of health problems that include many visits for minor ailments
and other ``nonurgent'' conditions.
use of emergency departments still relatively rare
Americans made a total of 124 million visits to hospital emergency
departments in 2008, the latest year for which data are available from
the National Hospital Ambulatory Medical Care Survey (NHAMCS)--the most
authoritative and cited source of information on emergency department
utilization (see Table 1).\1\ Compared with other forms of ambulatory
care use, however, use of hospital emergency departments is relatively
rare, accounting for only 10 percent of all ambulatory care visits to
medical providers. By contrast, Americans made 956 million visits to
physician offices in 2008--representing 80 percent of all ambulatory
care visits--and 110 million visits to hospital outpatient departments.
---------------------------------------------------------------------------
\1\ National Center for Health Statistics. Health, United States:
With Special Feature on Death and Dying. Hyattsville, MD (2011).
---------------------------------------------------------------------------
Emergency department use is also much less frequent than physician
office visits on a per capita basis. There were 41 emergency department
visits for every 100 Americans in 2008, compared to 320 physician
office visits for every 100 Americans. About 84 percent of Americans
visited a physician's office in 2007, compared to 23 percent who
visited a hospital emergency department.
Table 1.--Use of Ambulatory Medical Care Services by the U.S.
population, 1995-2008
------------------------------------------------------------------------
Percent
1995 2000 2008 change
1995-2008
------------------------------------------------------------------------
Number of visits in
thousands:
Emergency departments..... 96,545 108,017 123,761 28
Physician offices......... 697,082 823,542 955,969 37
Hospital outpatient 67,232 83,289 109,889 63
departments..............
Number of visits per 100
persons:
Emergency departments..... 37 40 42 14
Physician offices......... 271 304 315 16
Hospital outpatient 26 31 36 38
departments..............
------------------------------------------------------------------------
Source: CDC/NCHS, National Ambulatory Medical Care Survey and National
Hospital Ambulatory Medical Care Survey, as reported in Health, United
States, 2010.
but increases in utilization contribute to crowding
Concern about the use of hospital emergency departments increased
substantially over the past decade because of widespread reports of
growing demand by patients and crowding at many emergency departments.
Indeed, in a 2007 report, the Institute of Medicine described a growing
national crisis of crowded emergency departments leading to delays in
care for patients, ambulance diversions to other hospitals, and
inadequate capacity to handle a large influx of patients from a public
health crisis or mass-casualty event.\2\
---------------------------------------------------------------------------
\2\ Institute of Medicine, Hospital-Based Emergency Care: At the
Breaking Point, The National Academies Press, Washington, DC (2007).
---------------------------------------------------------------------------
Increased crowding at emergency departments has a number of causes,
and a 2003 U.S. Government Accountability Office report concluded that
insufficient inpatient capacity--the inability of hospitals to move
patients from the emergency department into inpatient beds--was a major
factor.\3\ As a result of problems with ``throughput,'' emergency
department patients are (1) waiting longer to be seen in the emergency
department; (2) waiting longer to be admitted as an inpatient if
necessary, and; (3) increasingly leaving the emergency department
without being seen. Also, there has been an increase in hospitals
diverting ambulances to other hospitals because of emergency department
crowding.
---------------------------------------------------------------------------
\3\ U.S. Government Accountability Office, Hospital Emergency
Departments: Crowded Conditions Vary Among Hospitals and Communities,
No. GAO-03-460. Washington, DC (March 2003).
---------------------------------------------------------------------------
Increased demand for emergency departments has exacerbated these
problems. Between 1995 and 2008, visits to hospital emergency
departments increased 28 percent, with much of the increase because of
increased per person use--from 37 visits per 100 persons in 1995 to 41
visits in 2008 (see Table 1). However, physician office visits
increased by an even greater amount between 1995 and 2008--37 percent--
with per person use increasing from 266 visits per 100 persons in 1995
to 320 visits in 2008. Thus, increases in emergency department use over
the past decade and a half reflect a more general increase in the
demand for ambulatory care and must be understood in the broader
context of changes in the health care system. As physician practices
have become busier and patients have greater difficulty getting timely
appointments with their physicians, some of the excess demand for
ambulatory care is no doubt spilling over into emergency
departments.\4\
---------------------------------------------------------------------------
\4\ Cunningham, Peter, and Jessica May, Insured Americans Drive
Surge in Emergency Department Visits, Issue Brief No. 70, Center for
Studying Health System Change, Washington, DC (October 2003).
---------------------------------------------------------------------------
privately insured patients account for most of the increase in ed
volume
Also, while there is a common perception that emergency department
crowding is driven primarily by increases in utilization by the
uninsured, most of the growth in emergency department volume during
this period was driven by insured people. For example, the share of
emergency department visits classified as ``self-pay'' or ``no
charge''--mostly uninsured patients--actually decreased from 17 percent
of visits in 1995 to 15 percent in 2008, despite the fact that the
number of uninsured increased by 23 percent during this period.\5\ \6\
\7\ In contrast, the share of emergency department visits made by
privately insured people increased from 37 percent of all visits in
1995 to 42 percent of visits in 2008. Privately insured people
accounted for about 60 percent of the overall increase in ED use
between 1995 and 2008, while the uninsured accounted for only 9 percent
of the increase.
---------------------------------------------------------------------------
\5\ National Center for Health Statistics, National Hospital
Ambulatory Medical Care Survey: 2008 Emergency Department Summary
Tables, Hyattsville, MD. (2011).
\6\ Stussman, Barbara J., ``National Hospital Ambulatory Medical
Care Survey: 1995 Emergency Department Summary,'' National Center for
Health Statistics Advance Data From Vital and Health Statistics; No.
285, Hyattsville, MD (1997).
\7\ Fronstin, Paul, The Impact of the 2007-09 Recession on Workers'
Health Coverage, Employee Benefit Research Institute Issue Brief No.
356, Washington, DC (April 2011).
---------------------------------------------------------------------------
The perception that the uninsured are responsible for the problems
of emergency department crowding may be because uninsured people depend
more on emergency departments for access to care. For example, more
than one-fourth of all ambulatory care visits by the uninsured are in
emergency departments, compared to only 7 percent for the privately
insured and 17 percent for Medicaid enrollees.\8\ Even more striking is
that uninsured people's dependence on EDs for care has grown
dramatically since 1995 when 16 percent of ambulatory care visits by
the uninsured were in hospital emergency departments.
---------------------------------------------------------------------------
\8\ The estimates in this paragraph are computed from published
reports by the National Center for Health Statistics based on the 1995
and 2008 National Hospital Ambulatory Medical Care Survey and the 1995
and 2008 National Ambulatory Medical Survey.
---------------------------------------------------------------------------
The increasing dependence on hospital emergency departments by the
uninsured reflects an erosion in access to office-based physicians, as
evidenced by declines in the percent of physicians providing any
charity care during this period.\9\ Some physicians believe they are no
longer able to afford to provide charity care because of financial
pressures from payers, while others have much less time for charitable
and volunteer activities because of the increased demand for care by
privately insured patients.
---------------------------------------------------------------------------
\9\ Cunningham, Peter, and Jessica May, A Growing Hole in the
Safety Net: Physician Charity Care Declines Again, Tracking Report No.
13, Center for Studying Health System Change, Washington, DC (March
2006).
---------------------------------------------------------------------------
what are ``nonurgent'' health problems?
Many observers have attributed increases in ``nonurgent'' use of
emergency departments as a key driver of crowding at some EDs. However,
defining a ``nonurgent'' ED visit is not straightforward and has been
the subject of much debate and controversy. Estimates of the percent of
emergency department visits that are for nonurgent health problems vary
widely, from about half of all visits to less than 10 percent.\10\ The
wide differences in estimates largely reflect differences in the
assumptions made about the feasibility of shifting certain types of
visits to a primary care physician's office or clinic without harm to
the patient.
---------------------------------------------------------------------------
\10\ Simonet, Daniel, ``Cost Reduction Strategies for Emergency
Services: Insurance Role, Practice Changes and Patient
Accountability,'' Health Care Analysis, Vol. 17, pp. 1-19 (February
2009).
---------------------------------------------------------------------------
One major problem is that it is difficult to determine the
``urgency'' of a visit based solely on a physician's diagnosis after
examination of a patient, which may be quite different from the
patient's perception of symptoms when deciding to seek emergency care.
An example often used to highlight the difficulty is a patient arriving
at an emergency department complaining of chest pains and concerns of a
possible heart attack, only to learn after a medical examination, the
problem is severe indigestion.
Thus, from the patient's perspective, the visit is certainly urgent
or emergent, but it is unlikely to be classified as such based only on
the physician's diagnosis.
For this reason, the ``urgency'' of a hospital emergency department
visit is best determined by the level of immediacy (in minutes)
assigned upon arrival at the emergency department by triage staff. The
National Hospital Ambulatory Medical Care Survey uses this information
to determine the urgency of a visit, which includes five categories:
(1) Immediate (patient needs to be seen immediately; (2) emergent
(needs to be seen within 15 minutes upon arrival); (3) urgent (between
15-60 minutes); (4) semiurgent (1-2 hours) and nonurgent (2-24 hours).
It is important to note that the immediacy with which a patient should
be seen is unknown for about 16 percent of emergency department visits
in the NHAMCS data for 2008, in part because some emergency departments
either do not triage patients in this way or do not keep records of
their triage decisions.
Based on this classification system, 4 percent of emergency
department visits in 2008 (a total of 4.6 million visits) were visits
in which the patient needed to be seen immediately; 12 percent were
considered emergent; 39 percent were considered urgent; and 21 percent
were semi-urgent (see Table 2). Only 8 percent of visits--a total of
9.9 million--were classified as nonurgent. Trends in the relative
number of nonurgent visits have actually decreased slightly since 2000,
when 10.7 percent of visits were classified as nonurgent.\11\ In sum,
most visits to hospital emergency departments are neither true
emergencies requiring that patients be seen almost immediately nor are
they clearly nonurgent problems that could be addressed in other
primary care settings.
---------------------------------------------------------------------------
\11\ McCaig, Linda F., and Nghi, Ly, ``National Hospital Ambulatory
Medical Care Survey: 2000 Emergency Department Summary,'' National
Center for Health Statistics Advance Data From Vita and Health
Statistics, No. 326, Hyattsville, MD (April 2002).
---------------------------------------------------------------------------
The majority of visits that are considered urgent or semi-urgent
reside in a gray area as to whether they could potentially be shifted
to other primary care settings, such as freestanding urgent care
centers or through same-day appointments with private practice
physicians. While many conditions associated with these visits could
likely be treated in other outpatient settings, it is not necessarily
inappropriate for the patient to use the emergency department depending
on the circumstances, such as the availability of other health care
providers in the area, the time of day and day of the week when
services are needed, and the affordability of these other providers
based on a patient's insurance status and ability to pay.
Two-thirds of all emergency department visits occur outside normal
business hours--8 a.m. to 5 p.m., Monday through Friday, compared to
only 5 percent of visits to office-based physicians and 11 percent of
visits to hospital outpatient departments.\12\ Thus, increasing the
number of primary care providers in the community who are available
after normal business hours (i.e., in the evenings and on weekends) is
essential for any effort to shift visits from the ED to other primary
care providers in the community.
---------------------------------------------------------------------------
\12\ Pitts, Stephen R., et al., ``Where Americans Get Acute Care:
Increasingly, It's Not at Their Doctor's Office,'' Health Affairs, Vol.
9, No. 1, pp. 1-10 (September 2010).
Table 2.--Triage Status of Emergency Department Visits, by Expected Source of Payment, 2008
----------------------------------------------------------------------------------------------------------------
Percent distribution of visits
-------------------------------------------------------------------
Number of
visits in Immediate/ Urgent Semiurgent Nonurgent Unknown
thousands Emergent
----------------------------------------------------------------------------------------------------------------
All visits.................................. 123,761 16 39 21 8 16
Expected Source of Payment:
Private insurance......................... 51,887 17 41 21 6 15
Medicaid/SCHIP............................ 29,701 14 40 22 10 15
Medicare.................................. 22,827 25 41 14 6 14
Uninsured................................. 19,094 12 34 24 12 19
Worker's compensation..................... 1,561 8 32 37 8 13
Other..................................... 5,706 17 43 22 8 11
Unknown................................... 7,492 11 33 19 7 30
----------------------------------------------------------------------------------------------------------------
Triage status is based on the following classification:
Immediate/emergent--Patient should be seen immediately or within 15 minutes.
Urgent--Patient should be seen within 15-60 minutes.
Semiurgent--Patient should be seen within 61-120 minutes.
Nonurgent--Patient should be seen between 121 minutes and 24 hours.
Unknown--No mention of immediacy in the medical record; hospital does not perform triage; or the patient was
dead on arrival.
Source: CDC/NCHS. National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary Tables
(Table 7).
most nonurgent visits made by persons with insurance coverage
As with emergency department visits overall, people with insurance
coverage account for most nonurgent ED visits, with privately insured
persons alone accounting for about one-third of nonurgent visits
(computed from Table 2). Uninsured persons account for slightly less
than one-fourth of all nonurgent emergency department visits, while
Medicaid enrollees account for 29 percent. Nevertheless, the uninsured
are more likely to use emergency departments for nonurgent health
problems compared to the privately insured: visits for nonurgent health
problems account for 12 percent of ED visits by the uninsured compared
to 6 percent for the privately insured. Similarly, the uninsured are
less likely to use emergency departments for true emergencies compared
to privately insured persons: emergencies accounted for 12 percent of
visits for uninsured persons compared to 17 percent for privately
insured persons (see Table 2).
immigrants infrequent users of emergency departments
Another common perception is that immigrants--particularly
undocumented immigrants--are responsible for much of the crowding in
emergency departments. Although the National Hospital Ambulatory
Medical Care Survey has limited information on race/ethnicity and
immigration status, other studies call into question the extent of the
problem that emergency departments have treating undocumented
immigrants. Recent immigrants--in the United States for 5 years or
less--are less likely to use emergency departments (9 percent),
compared both to immigrants who have been in the United States for 20
years or more (19 percent), as well as native-born Americans (22
percent).\13\ In addition, an analysis of variation in emergency
department use across communities showed that communities with high
levels of emergency department use had fewer Hispanic noncitizens
compared to communities with low levels of emergency department
use.\14\
---------------------------------------------------------------------------
\13\ Cunningham, Peter, and Samantha Artiga, ``How Does Health
Coverage and Access to Care for Immigrants Vary by Length of Time in
the U.S.,'' Kaiser Commission on Medicaid and the Uninsured,
Washington, DC (June 2009).
\14\ Cunningham, Peter, ``What Accounts For Differences In The Use
Of Hospital Emergency Departments Across U.S. Communities?'' Health
Affairs, Web Exclusive (July 2006).
---------------------------------------------------------------------------
Low ED use by recent immigrants reflects the fact that they are
much less likely to use health care of any type, including physician
office visits, primarily as a result of high uninsured rates and a lack
of access to care.\15\ As with the uninsured, recent immigrants tend to
rely on emergency departments to a much greater extent when they do use
health care compared to native-born Americans, which may contribute to
the perception that they are ``flooding'' local hospital emergency
departments. Crowding of emergency departments by immigrants may occur
in some isolated circumstances, such as in communities along the border
with Mexico or areas that have seen a recent surge in immigration, but
it is not a major contributor to hospital emergency department crowding
nationally.
---------------------------------------------------------------------------
\15\ Cunningham and Artiga (June 2009).
---------------------------------------------------------------------------
lack of primary care access not the reason for emergency department use
It is not the case that people who use emergency departments for
nonurgent health problems have no source of primary care they could use
instead. One study found that among all people visiting the emergency
department for nonurgent health problems, two-thirds reported they had
a regular source of medical care at a physician's office.\16\ Only 3
percent reported that the ED was their usual source of care, while 15
percent reported they did not have any usual source of care. In
addition, people who use the ED for nonurgent health problems tend to
have greater use of physicians in other ambulatory care settings over a
1-year period. This strongly suggests that use of emergency departments
for nonurgent problems does not reflect lack of access to other primary
care providers for most patients, although it is a much more important
reason for uninsured patients.
---------------------------------------------------------------------------
\16\ Cunningham, Peter, ``The Use of Hospital Emergency Departments
for Nonurgent Health Problems: A National Perspective,'' Medical Care
Research and Review, Vol. 52, No. 4, pp. 453-74 (1995).
---------------------------------------------------------------------------
capacity constraints contribute to higher emergency department use
As noted previously, it is possible that greater capacity
constraints in the ambulatory care system are shifting some of the
excess demand for ambulatory care from physician offices to emergency
departments. Many experts and policymakers have been concerned about
physician shortages--particularly of primary care physicians--resulting
in some patients having greater difficulty finding physicians that are
close to their home or work, scheduling same-day appointments with
their primary care physician, and physicians being able to spend
adequate time with patients.\17\
---------------------------------------------------------------------------
\17\ O'Malley, Ann S., et al., Rising Pressure: Hospital Emergency
Departments as Barometers of the Health Care System, Issue Brief No.
101, Center for Studying Health System Change, Washington, DC (November
2005).
---------------------------------------------------------------------------
In examining differences between communities with low levels of ED
use and communities with high levels of ED use, I have observed that
communities with high levels of ED use tend to have greater capacity
constraints among office-based physicians, as reflected in longer
average appointment waiting times for patients and a greater number of
visits per physician in the community.\18\ This suggests that as demand
for medical care increases over time and the capacity of office-based
physicians is squeezed, some of the excess demand for ambulatory care
will spill over to hospital emergency departments.
---------------------------------------------------------------------------
\18\ Cunningham (July 2006).
---------------------------------------------------------------------------
At the same time, many patients prefer to use hospital emergency
departments even if they believe that their health problem could have
been handled by a primary care physician outside of the emergency
department.\19\ The greater convenience of hospital emergency
departments relative to primary care providers is among the most
important reasons for using EDs, especially the fact that they are open
24 hours a day and 7 days a week, and that they can ``walk-in'' to the
emergency department at their own convenience rather than scheduling an
appointment. The greater convenience of emergency departments is
especially important for people who are unable or unwilling to take
time off from work to see a physician.
---------------------------------------------------------------------------
\19\ California HealthCare Foundation, Overuse of Emergency
Departments Among Insured Californians, Oakland, CA (October 2006).
---------------------------------------------------------------------------
What is less clear is whether patient preferences for the emergency
department will continue given the increased crowding at many
facilities and the longer wait times. The total amount of time that
patients spend in the emergency department--including time spent
waiting as well as for examination and treatment--has increased from 45
percent of visits lasting 2 or more hours in 2001 to 60 percent of
visits in 2008.\20\ Other research has shown that patients'
satisfaction with their visit to an emergency department decreases
rapidly the longer they wait to be seen. For example, two-thirds of
patients who waited 15 minutes or less to be seen by a medical provider
in the emergency department reported that the thoroughness of their
exam was very good or excellent.\21\ However, positive ratings of their
visit dropped to 46 percent for patients who waited between 30 and 60
minutes, and 28 percent for patients who waited more than an hour.
---------------------------------------------------------------------------
\20\ National Center for Health Statistics (2011); and McCaig and
Ly (April 2002).
\21\ Cunningham and May (October 2003).
---------------------------------------------------------------------------
hospitals expanding emergency department capacity
At the same time, many emergency departments have been expanding
capacity to meet increased demand. More than one-fourth of emergency
departments in 2008 had expanded their capacity in the previous 2
years, and 28 percent had plans to expand their capacity in the next 2
years.\22\ Emergency departments serving a large volume of patients
(50,000 or more per year) were much more likely to be expanding
capacity compared to emergency departments serving smaller volumes of
patients.
---------------------------------------------------------------------------
\22\ National Center for Health Statistics (2011).
---------------------------------------------------------------------------
Expanding the capacity of hospital emergency departments appears to
conflict with a widely held view that emergency departments are money
losers for hospitals--i.e., they generate insufficient revenue from
billings to cover the costs. In this view, hospitals should be
reluctant to expand emergency department capacity and be eager to look
for ways to decrease their volumes by shifting patients to other
sources of primary care when appropriate.
However, when the overall financial status of many hospitals is
considered, emergency departments generate more revenue for the
hospital than they lose, mainly by serving as a conduit for inpatient
admissions. Researchers at the University of Southern California
estimated that by closing the emergency department, a hospital would
lose one-third or more of its inpatient admissions, which would cost
the hospital much more than the savings generated by closing the
emergency department.\23\ Seen in that context, it is not surprising
that many hospitals are expanding their emergency departments, not only
to relieve crowding because of increased demand, but also as a way to
generate more revenue from inpatient admissions.
---------------------------------------------------------------------------
\23\ Melnick, Glenn A., et al., California Emergency Departments:
Do They Contribute to Hospital Profitability? California HealthCare
Foundation, Oakland, CA (July 2003).
---------------------------------------------------------------------------
Efforts to expand emergency department capacity and volume also
suggest that many hospitals perceive few incentives or benefits to
shift nonurgent care from their emergency department to primary care
settings. Even if an emergency department visit does not result in an
inpatient admission, nonurgent emergency department patients may
require inpatient care or other hospital services in the future, in
which case the assumption is that the patient would continue to use the
same hospital to receive these more ``profitable'' services. Hospitals
will especially encourage privately insured, Medicare and sometimes
even Medicaid patients to use their emergency departments, as these
patients generate revenue for the hospital. Many hospitals are likely
to be much more selective about the patients they are willing to shift
to primary care settings, focusing especially on their uninsured
patients to decrease their uncompensated care costs.
cost savings from reducing nonurgent ed use likely to be modest
About $47.3 billion was spent on emergency department visits in
2008, accounting for 4 percent of all health care expenditures received
by the U.S. population during that year, according to the Medical
Expenditure Panel Survey.\24\ Total spending on emergency department
visits doubled between 2000 and 2008, even after accounting for general
inflation, and has been rising at a faster rate than overall health
care spending.\25\ The cost of emergency department use for nonurgent
health problems is more difficult to estimate since expenditures are
not collected in the National Hospital Ambulatory Medical Survey.
Moreover, the wide range of estimates of the number of emergency
department visits that could potentially be shifted to primary care
settings also means that the potential cost savings from these shifts
will also vary widely.
---------------------------------------------------------------------------
\24\ Agency for Healthcare Quality and Research, ``Emergency Room
Services--Median and Mean Expense Per Person with Expense and
Distribution by Source of Payment, 2008,'' Summary Data Table From the
Medical Expenditure Panel Survey--Household Component.
\25\ Ibid. and Agency for Healthcare Quality and Research,
``Emergency Room Services--Median and Mean Expense Per Person With
Expense and Distribution by Source of Payment, 2000,'' Summary Data
Table From the Medical Expenditure Panel Survey--Household Component.
---------------------------------------------------------------------------
The GAO report, Hospital Emergency Departments: Health Center
Strategies That May Help Reduce Their Use, included an estimate based
on the 2008 MEPS that the average amount for a nonemergency visit to an
emergency department was $792, less than the $1,265 per visit for all
emergency department visits and more than seven times higher than a
visit to a community health center.\26\ However, other research
suggests that the potential cost-savings associated with shifting
nonurgent emergency department visits to office-based practices may be
much lower. An earlier study using data from the 1987 National Medical
Expenditure Survey (the predecessor to the MEPS) compared the costs of
nonurgent visits to the emergency department with the potential costs
of these same visits had they occurred in office-based physician
practices.\27\ The results showed that the cost of nonurgent visits to
emergency departments was only three times higher compared to what they
would have cost in an office-based practice, which is considerably less
than the estimate in the GAO report. Also, a study based on hospitals
in Michigan during the early 1990s found that the average cost of an
urgent emergency department visit was five to six times higher than for
a nonurgent visit, indicating that cost savings to the health care
system from shifting nonurgent emergency department visits to primary
care settings may be less than is commonly assumed.\28\
---------------------------------------------------------------------------
\26\ U.S. Government Accountability Office, Hospital Emergency
Departments: Health Center Strategies That May Help Reduce Their Use,
No. GAO-11-414R, Washington, DC (May 2011).
\27\ Baker, Laurence C., and Linda Schuurman Baker, ``Excess Cost
of Emergency Department Visits for Nonurgent Care.'' Health Affairs,
Vol. 13, No. 5, pp. 162-71 (1994).
\28\ Williams, Robert M., ``The Costs of Visits to Emergency
Departments,'' The New England Journal of Medicine, Vol. 334, No. 10,
pp. 642-46 (March 1996).
---------------------------------------------------------------------------
It is possible that shifting nonurgent emergency department visits
to community health centers (CHCs) could result in greater savings than
comparable visits to private office-based physicians. Research has
shown that the availability of CHCs in an area is associated with lower
rates of hospital emergency department use, particularly among the
uninsured.\29\ There is some evidence that CHCs provide care more
efficiently and at lower cost compared to private physician practices,
perhaps because the large volumes of patients CHCs see permit greater
economies of scale in the cost of patient care.\30\ Also, the typically
tight budgets and low margins with which they operate may compel CHCs
to identify efficiencies and cost savings in their operations. In
addition, many CHCs provide after-hours care in the evening and on
weekends, an important consideration for those who use emergency
departments because of the convenience of after-hours care.\31\
---------------------------------------------------------------------------
\29\ Rust, George, et al., ``Presence of a Community Health Center
and Uninsured Emergency Department Visit Rates in Rural Counties,''
Journal of Rural Health, Vol. 25, No. 1, pp. 8-16 (2009).
\30\ McRae, Thomas, and Robert D. Stampfly, An Evaluation of the
Cost-Effectiveness of Federally Qualified Health Centers Operating in
Michigan, Institute for Healthcare Studies at Michigan State University
(October 2006).
\31\ Michelle M. Doty, et al., Enhancing the Capacity of Community
Health Centers to Achieve High Performance: Findings From the 2009
Commonwealth Fund National Survey of Federally Qualified Health
Centers, The Commonwealth Fund, New York (May 2010).
---------------------------------------------------------------------------
Nevertheless, community health centers comprise only a small share
of total ambulatory care volume in the United States--70 million visits
to CHCs in 2008 compared to a total of 956 million physician office
visits. CHCs are not present or convenient in all areas, and many do
not provide after-hours care. Even with the increased funding for CHCs
included in the Patient Protection and Affordable Care Act, CHCs would
likely be able to accommodate only a relatively small share of the
nonurgent emergency department visits that could potentially be shifted
to primary care providers, and most of these would likely be people who
are uninsured or enrolled in Medicaid who already comprise the majority
of CHC patients. Privately insured people with nonurgent visits to
emergency departments are unlikely to switch to CHCs both because of
negative perceptions that more affluent patients may have of community
health centers and because CHCs are generally not located in areas
where more affluent privately insured persons tend to live.
cost savings for the uninsured and medicaid likely to be greater
While the cost savings to the health care system of shifting care
out of the emergency department to Community Health Centers may be
minimal, the cost savings to uninsured patients could be considerable.
The average cost of an emergency department visit for uninsured persons
was $1,203 in 2008, of which half is paid out-of-pocket.\32\ Nonurgent
visits are likely to be less costly for the uninsured--as they are with
the general population--but they may still be responsible for a bill of
several hundred dollars or more. By contrast, community health centers
typically charge patients on a sliding scale--the fee amount increases
along with their incomes--and typically ranges from $20 to $60 per
visit.
---------------------------------------------------------------------------
\32\ Agency for Healthcare Quality and Research, ``Emergency Room
Services--Median and Mean Expense Per Person with Expense and
Distribution by Source of Payment, 2008,'' Summary Data Table From the
Medical Expenditure Panel Survey--Household Component.
---------------------------------------------------------------------------
It should also be noted that most hospitals have policies that
allow their charges to be waived or reduced based on the patient's
ability to pay, including for visits to hospital emergency departments.
For poor or low-income patients, hospitals often use a sliding-scale
method similar to that used by community health centers to determine
the patient's responsibility, and charges are often waived for the
poorest uninsured patients.\33\ Thus, depending on the hospital's
charity care policies and the patient's income, an uninsured person
could pay little or none of the charge, or they could be responsible
for most or all of the charge of the emergency department visit.
However, hospitals sometimes limit the effectiveness of their charity
care policies by failing to advertise them or making them known to
patients, as well as by rigorous eligibility determination process that
includes verification of sources of income.
---------------------------------------------------------------------------
\33\ Staiti, Andrea, et al., Balancing Margin and Mission:
Hospitals Alter Billing and Collection Practices for Uninsured
Patients, Issue Brief No. 99, Center for Studying Health System Change,
Washington, DC (October, 2005).
---------------------------------------------------------------------------
Shifting nonurgent emergency department visits to community health
centers and other sources of primary care could generate greater cost
savings for the Medicaid program. Medicaid enrollees have the highest
rates of emergency department use compared to persons with private
insurance, Medicare or who are uninsured, and Medicaid enrollees
account for more than one-fourth of nonurgent visits to the emergency
department.\34\ Because Medicaid patients already comprise a large
proportion of patients at community health centers--and they tend to
live in areas where CHCs are located--programs designed to shift
nonurgent care from EDs to CHCs may have greater potential to generate
cost savings in the Medicaid program than for private payers, Medicare
or even hospital uncompensated care costs from caring for the
uninsured.
---------------------------------------------------------------------------
\34\ Cunningham, Peter, ``Medicaid/SCHIP Cuts and Hospital
Emergency Department Use,'' Health Affairs, Vol. 25, No. 1, pp. 237-47
(January/February 2006).
---------------------------------------------------------------------------
Finally, improvements in continuity of care, patient satisfaction
and care coordination between primary care providers and specialists
that can be facilitated by community health centers and other primary
care providers can also increase cost savings to the Medicaid program,
primarily by reducing redundant and unnecessary use of health services.
gains in quality of care may be greater than cost savings
Shifting ED use for nonurgent problems to primary care providers in
the community is likely to have even more important implications for
the quality of care. ED use for nonurgent health problems is associated
with greater fragmentation and discontinuity of care with the patients'
primary care physicians and other medical providers they use. Studies
have found that communication and coordination of care between EDs and
primary care physicians tends to be haphazard and generally poor, which
is exacerbated by a lack of shared information systems that could
facilitate communication.\35\ The lack of coordination and continuity
between EDs and other providers in the community often leads to
duplicative testing and other redundant utilization, complicates
appropriate followup care, and increases the risk of medical
errors.\36\
---------------------------------------------------------------------------
\35\ Carrier, Emily, et al., ``Coordination Between Emergency and
Primary Care Physicians,'' National Institute for Health Care Reform,
Research Brief No. 3, Washington, DC (February 2011).
\36\ Pitts (September 2010).
---------------------------------------------------------------------------
Shifting ED use to primary care physicians may also increase
patient satisfaction with care. According to one survey, more than
three-fourths of patients with scheduled appointments at a doctor's
office gave positive ratings about the thoroughness of the exam and the
physician's willingness to listen.\37\ By contrast, only about half of
ED patients gave such positive assessments. Thus, patients may be
motivated to go to the ED because of greater convenience and the
availability of after-hours care but not necessarily because they
believe the ED provides better quality of care.
---------------------------------------------------------------------------
\37\ Cunningham and May (October 2003).
---------------------------------------------------------------------------
Shifting ED visits for nonurgent health problems to primary care
providers in the community is a necessary step for broader efforts in
the health care system to create ``patient-centered medical homes.''
This would not only improve the quality of care by ensuring that
patients have a primary care physician to see for their nonurgent
health problems and coordinating care with specialists and other
providers, but it is also likely to generate additional cost savings by
reducing unnecessary or redundant utilization.
Senator Sanders. Thank you very much, Doctor. Yes.
Dr. Alieta Eck, do I have your first name right?
Dr. Eck. Alieta.
Senator Sanders. Alieta, I am sorry. Dr. Alieta Eck, M.D.,
graduated from Rutgers College of Pharmacy in New Jersey and
the St. Louis School of Medicine in St. Louis. She studied
internal medicine at Robert Wood Johnson University Hospital in
New Brunswick and has been in private practice with her
husband, Dr. John Eck, M.D., in Piscataway, NJ since 1988.
Thanks very much for being with us, Dr. Eck.
STATEMENT OF ALIETA ECK, M.D., FOUNDER & CO-DIRECTOR, ZAREPHATH
HEALTH CENTER, ZAREPHATH, NJ
Dr. Eck. Thank you very much. I appreciate being able to
come here and tell of my experience. I think I can give some
really good advice as to what we could do to reduce the
emergency room costs and reduce the overall costs of medicine
in the entire United States.
I have been in private practice for 23 years. I was
involved in the Medicaid program early on but then got out when
I realized that I was losing money with every Medicaid patient.
That wouldn't have lasted very long if I kept going.
So my husband and I started a free clinic 10 miles away on
a church ground. A little building had been flooded and it got
renovated by volunteers, we started, it was debt free. We have
volunteer physicians, nurses, support staff, everybody
volunteers, nobody gets paid and they love to be there. We see
about 3 to 400 people per month, we only are open 12 hours a
week. So it is a huge, efficient way to take care of people who
just come in. They see smiling faces, everybody is happy to see
them. They are there because they are volunteered and we
provide good primary care.
I looked at the little script in the beginning where it
says that it is a thousand dollars to take care of a patient in
an emergency room and it is about $140 to take care of a
patient in a federally qualified clinic, and that is by the
testimony of somebody who works in one or who runs one in the
next town over. It costs us $13 to take care of a visitor.
With all the volunteers there people come for very, very
different reasons. People are poor for very different reasons
and a lot of them have made social decisions that are not in
their best interest, they have gotten involved with drugs or
alcohol, there are single parents, just things are difficult.
So to have somebody along side that can come and help them with
those type of issues, which is the case in a church
environment, is huge. Our church has gone from 150 to 2,000
members in the 7 years since we have had our free clinic,
because people really want to be in a community that cares.
People want to give in a community that cares, the receivers
and the recipients--and the givers of the care ennobled by true
charity.
I was looking at the Form 990, I was trying to figure out
what it is with these federally qualified clinics that makes
them different than us and why it costs so much to take care of
people there. It seems like it should be a lot cheaper. I
looked at one Form 990, they pay $113,000 for travel, $650,000
for provision for bad debts, personnel recruitment, $265,000 a
year. They get money from Medicaid, they get money from the
Federal Government, grants, they get uncompensated care
payments. Their miscellaneous income is twice the income of our
little clinic--which $58,000 a year is all it costs for us to
take care of these people and do a very good job.
All of that got me thinking, and I said, Medicaid is $10
billion of a $28 billion budget in New Jersey. I thought, what
could we do to reduce the costs? It is really hurting the
taxpayers, the taxpayers are reeling at the expense the
government is putting on them. So if we could reduce taxes that
would help the whole economy. And we came up with the idea,
several of us came up with the idea of what we call the
Volunteer Physicians Protection Act.
We need more physicians. It is hard to find physicians to
volunteer. They are very strapped by decreasing payments from
third parties and by increasing regulations. So we thought, why
don't we have physicians donate 4 hours a week in a
nongovernment free clinic dotted throughout the State. Then the
only thing we would ask the State to do is to extend the
medical malpractice coverage that they give to the physicians
who work in the medical schools, just extend it to those
physicians as their only reward for doing that time, for
putting in 4 hours a week in a free clinic. The free clinic
could be located within the hospital, so the hospital, when
they see a patient coming in with a sore throat, they could be
going over to this free clinic who should be just a couple
rooms down and the physician who is volunteering could be
taking care of that physician for free at no cost to anybody,
to the taxpayer. That way we could take care of the poor, the
taxpayer would not be impoverished by the system and we could
balance a budget.
In fact, I ran some of the numbers. We were only open 12
hours a week, I figure about maybe a hundred patients a month
we are diverting from the emergency room. They are coming in
with their sore throats, with their ear aches. Sore throats are
the No. 1 reason Medicaid people go to the ER. We are diverting
them. If we were open 72 hours a week, that would be 600
patients. If there were a 100, that would be 60,000 ER visits
we could be diverting. I am just doing the math, which might be
wild. But $720 million we could save in New Jersey just by
doing something like this where instead of spending a thousand
dollars in the emergency room, we spend zero, zero cost to the
taxpayers, a lot less cost to the donors and I think we would
solve the problem.
[The prepared statement of Dr. Eck follows:]
Prepared Statement of Alieta Eck, M.D.
summary
The poor go to the emergency room for non-urgent care because there
is no deterrence. They know that a physician will be there at any hour
and it is easier to just go rather than wait for an appointment.
Patients on Medicaid are twice as likely to go to the emergency room
than those without insurance, as they feel entitled and empowered by
their card. Some feel victimized by the inability to find a physician's
office where the Medicaid card is welcomed, so no amount of teaching
and reasoning will change their behavior unless they choose to go
elsewhere for urgent care.
Increasing payments to physicians as a way of increasing physician
participation in Medicaid is not the answer, as the taxpayers can ill-
afford to pay more. Opportunities for fraud and abuse would simply
multiply as more taxpayer dollars would be flowing out of the State
House. Expanding Federally Qualified Health Centers (FQHCs) might seem
reasonable, but they are extraordinarily expensive to run, 10-20 times
more than non-government free clinics. (NGFCs). FQHCs are funded by
taxpayers. NGFCs are funded by charitable donations.
We see from 300-400 patients per month in the Zarephath Health
Center, a NGFC. We estimate that our small clinic diverts from 100-150
inappropriate ER visits per month. Patients tell us that they would
have come to the clinic had we been open. We are only open 12 hours per
week. So increasing our hours to 72 hours per week would clearly
decrease inappropriate ER use. Greatly increasing the numbers of NGFCs
would lead to a reduction in the number of patients who go to the
emergency rooms for non-urgent care. One hundred similar facilities,
including some located within the walls of the hospitals, could divert
60,000 unnecessary ER visits, saving the taxpayers of New Jersey $60
million per year.
A proposal, The NJ Volunteer Physicians Protection Act (VPPA) is
working its way through the legislature in New Jersey, whereby
physicians would agree to volunteer 4 hours per week in a NGFC.
Surgeons or OB-GYN's might do two cases per month for patients referred
by the free clinic. As the physicians' only reward, we are asking for
the State government to provide medical malpractice coverage for their
entire practices.
Current systems in place include:
The Federal Tort Claims Act--provides free Federal
malpractice coverage for work done in NGFCs.
New Jersey currently provides medical malpractice coverage
to physicians who teach or study in the medical school hospitals.
Echoclinics.org is an organization that is facilitating
the starting of new NGFCs.
Thus, all of the programs are already in place to realign the way
physicians care for the poor. The only legislation required will be to
extend existing medical malpractice programs to the private practices
of all physicians who volunteer for a stated amount of time. Gradually
defunding the highly bureaucratic programs that are not providing
acceptable care to the poor would lower taxes and provide a great
stimulus to the economy. The poor would get continuity of care, and
emergency room use for non-urgent illnesses would dramatically
decrease.
Goals would be to:
Increase access for the poor to friendly non-bureaucratic
care outside of the emergency room.
Indirectly compensate the physicians who provide the free
care by lowering their office overhead.
Relieve the taxpayers of the current unbearable burden of
the Medicaid system.
Change the entire culture of the way we help the poor in
America.
______
Good morning. I am a physician specializing in Internal Medicine. I
welcome the opportunity to speak in front of this committee, and
explain what I have observed in both my 23 years of private medical
practice and the 7 years of volunteering in a free clinic. I believe
that I can give information that will be valuable in helping to develop
policies that would be effective in deterring the unnecessary use of
the emergency room.
Both in the practice where I earn my living, and the free clinic
where I see the poorest of the poor, I count it a privilege to be able
to make a difference in the lives of my patients.
My husband, Dr. John Eck, M.D., and I dropped out of the Medicaid
program a few years after enrolling, realizing that it was causing our
practice to lose money, thus jeopardizing our livelihood. The cost of
filing the claim was greater than the sum Medicaid would pay us several
months later.
the founding of a non-government free clinic
After Hurricane Floyd flooded a small house on the edge of our
church campus at Zarephath, NJ, we convinced the church leadership to
allow us to renovate it and turn it into a clinic. We had read Marvin
Olasky's Tragedy of American Compassion, and we determined to do things
differently--to see the poor for free, to solicit the help of caring
volunteer nurses and support staff, and to work to identify the root
causes of the poverty that brought the patients to us, helping in any
practical way we could. The clinic began operation in September 2003.
It has a 501(c)3 charity status and operates completely by private
donations--with no taxpayer dollars. In fact, we would turn down
taxpayer dollars, as we firmly believe charity should be voluntary.
Volunteers listen to the stories of each person who comes in,
offering kind encouragement. A verse stenciled to the wall in the
waiting room reads, ``Come unto me, all you who labor and are heavy-
laden, and I will give you rest. (Jesus)'' Then a nurse and physician
see the patient to handle common complaints such as a sore throat,
bronchitis, hypertension, diabetes, thyroid disease and sometimes
illnesses that are more serious and life threatening. We bind up the
wounds of their limbs and their hearts. The church has a food pantry
and a clothing thrift shop where some people pay a few dollars for
clothes and many can get them for free. It is not one-size-fits-all
charity situation, but varied help for very different types of people.
We have never advertised, but the patients come--from as far away
as Pennsylvania and New York, an hour and a half away.
Patients are referred by their friends, other patients or
church members.
Patients are referred by the emergency rooms, after they
have been seen there.
Patients are referred by nurses in the hospitals when poor
patients are being discharged and have no primary care physician.
Patients are referred by local pharmacies.
Patients are actually referred to us by the Medicaid
office when patients have complained that they could not find a
physician who accepts Medicaid.
Patients are referred by all the social service agencies
in the area.
We see patients who have just been released from prison,
referred by their parole officers.
We see patients who have been released from psychiatric
hospitals, prescriptions in hand and no means to pay for them. They are
scheduled to see a psychiatrist 6 weeks hence at a State-run
psychiatric facility, but are not given any help in between. We hand
them their medicines if they are available in our little pharmacy. We
handle them medically until they can get to the proper specialists. A
local community food bank has a fund set aside for emergency
prescriptions.
We see unemployed union members who are dejected,
wondering how to pay their mortgages and unable to pay for medical
care.
We see single mothers who bring their little ones to play
with volunteers in our play area, while we take care of mom's medical
needs. We try to have the children leave with smiles on their face and
often a donated teddy bear.
We see children when a pediatrician or family practitioner
are there.
We see people who are, temporarily unemployed and feeling
frightened and vulnerable.
We see patients who are referred to us by the unemployment
office.
We see people who are living in their cars or under
bridges, having been evicted from their homes, estranged from their
families for many reasons including their own poor behavior.
We see patients referred to us by judges in family court.
No one pays a penny, but some put a few dollars into a donation box
at the front desk. This covers some of the $13 average cost per
patient. Medications are handed out for free--donated by pharmaceutical
companies, drug representatives, sample closets of fellow physicians,
and some purchased wholesale. Often we will write for the $4
prescriptions that the free market has made available to all. Every
patient leaves with a grateful heart, as they know that people cared
for them because they wanted to, not because it was their job. All are
treated with respect, empathy and kindness.
Some people are poor through no fault of their own, but many have
made bad choices along the way. They need good advice, role models and
people who will patiently encourage them to make changes that will
empower them to be lifted out of poverty. Zarephath Christian Church
has many programs that fill their social voids--men's breakfasts,
women's luncheons, Bible studies, support groups for those who grieve,
support groups for battered women, marriage ministries and other groups
for all ages.
who gets care at the zarephath health center?
Let me give you some examples of actual patients we have seen:
A 54-year-old gentleman, a carpenter with no work, came in
with severe nasal obstruction from sinus polyps. He was on Medicaid but
could not find an ENT surgeon who would operate for the amount Medicaid
would pay. Why should a surgeon take on full liability for such a low
fee? This man was asking me to fill out disability forms. Instead, I
called an ENT friend and asked what he would charge. We agreed upon a
fair amount and the surgery was done and we paid out of donations we
had received. The very grateful patient came to a men's breakfast at
the church where volunteer workers are spending their free time fixing
up our new clinic facility. He wants to volunteer as well.
A 34-year-old woman came in with palpitations and a tender
thyroid. With no risk factors for heart disease, we gave her medicine
to slow her heart and had her come back the next day where our
volunteer retired cardiologist saw her and confirmed the diagnosis. She
was 100 percent better. The charity system was saved probably $10,000,
as a visit to the ER would have triggered that much in advanced cardiac
testing.
A 25-year-old gentleman walked in with a vial of an anti-
psychotic medication that was to be administered monthly. He had the
paperwork, but no one to administer it. We did.
A 15-year-old girl with no insurance came in with
palpitations and shortness of breath. Our retired cardiologist
diagnosed a cardiac conduction defect that would require a surgical
ablation to cure. He called a colleague who was happy to take care of
her for no charge. Her grateful mother comes in and volunteers to do
clerical work at the clinic.
A couple is overwhelmed with two severely autistic
children. The church has developed a program whereby these children are
given one-on-one supervision in Sunday classes and the parents can
attend church services together. The parents are extremely grateful and
the father, an air conditioning specialist has offered to maintain our
system in our new facility.
A 48-year-old woman came in showing all the signs of the
disfigurement of acromegaly, a disease of the pituitary gland where
growth hormone continues unchecked after puberty. This was diagnosed 10
years ago, but she had no means to pay for care. She went to the
Medicaid office where she was told that the only way to get Medicaid
was to be on welfare. She argued that she wanted to work, but just
needed help with medical bills. She was thus turned away and referred
to us by the unemployment office.
A 50-year-old woman with extreme weight loss and a breast
mass was being worked up for cancer. When no cancer was found, she was
referred to our clinic. It turns out that her very bad teeth were
seeding her bloodstream and causing the abscesses. Antibiotics helped
her gain weight and a dentist agreed to take care of her teeth for no
charge.
A 54-year-old man who had had a kidney transplant came in
with no way to pay for his transplant rejection medicine. This was a
true emergency. We called the township and asked if there was some type
of charity fund for this type of thing. Fortunately, we were able to
get him the medicine he needed.
Today we see 300-400 patients per month and the church has made new
space available for us. We will go from 900 to 4,000 square feet, with
five exam rooms, three intake and counseling rooms, and a large
classroom to teach classes on diabetes and other topics. Our new clinic
will have a dental chair for dentists to volunteer. It is being built
by builders, plumbers and electricians who are working at a reduced
rate and many former patients who are volunteering to do the sheet rock
and spackling. The township building inspector, so inspired by the
stories, has agreed to put the first coat of paint on all the walls for
free. Money is being donated for the work, and we will open in a month
or so, completely debt free. The church has gone from an attendance of
150 to 2,000 in the 7 years the clinic has been in existence. A culture
of caring attracts people.
who goes to the emergency rooms for non-urgent complaints?
Many patients bring their emergency room reports with
descriptions of their ear aches, sore throats or rashes. When we ask
why they went to the ER for such minor illnesses, they tell that they
would have come to our clinic, but we were not open. Because of lack of
physicians who are able to volunteer, our clinic is only open 12 hours
a week.
Patients who are poor and without any assets have
absolutely no restraint when it comes to going to the ER. They know
that there is a physician there
24/7 so do not bother to call an office or clinic to make an
appointment. When I was a resident many years ago I remember one
patient showing me her rash at 3 a.m. When I asked why she was coming
for such a minor complaint at that hour, she said she figured it would
be a good time because we wouldn't be busy. To her, this was a
perfectly reasonable answer.
Patients on Medicaid are twice as likely to visit the ER
for non-urgent conditions than patients with no insurance at all. Their
sense of entitlement, having that Medicaid card combined with their
poor management of their own resources makes a warm, clean ER
environment a pleasant place to spend an afternoon. Since they are not
turned away, they continue to come. They have absolutely nothing to
lose, as they will never see a bill. Any attempts to divert them are
futile.
the cost of providing care for the poor
I note that on the description of today's hearing you claim that
the cost to provide care in the emergency room is $1,000, which is 7
times the cost of providing care in community health centers. This
correlates with the information I have gathered where the costs in
these centers are between $140-$280 per patient visit. Compare that to
the cost of providing care in a non-government free clinic such as
ours--$13, one-tenth to one-twentieth the cost of a federally qualified
clinic. If there were an adequate number of non-government free
clinics, the savings to the taxpayer by keeping people out of the
emergency rooms would be 100 percent, and the cost to the charitable
donors would be minimal.
A federally qualified health center in the next town has a yearly
budget of $14 million--all from taxpayer dollars. (from the IRS Form
990). Ours is $58,000--none from the taxpayers. For the amount it costs
to fund one FQHC, we could fund 250 clinics like ours, and I submit
that the patients would get better, more personalized care.
I do not like to disparage the work of others, but the following is
an eyewitness account of someone who worked in one of those $14 million
FQHCs:
``The bureaucracy was unbelievable. The administrators had no
clue how the care of patients worked. Tons of rules. Lack of
proper supplies. Poor quality of the staff working there,
mostly from the indigent areas. Patients had to wait hours to
go through the registration and verification process which was
very frustrating for them. A normal visit to the clinic took
over 2 hours for a patient. Patients came there not by choice
but because they had no place else to go. It was not a caring
atmosphere. The administration made everything very
difficult.''
This is not really surprising, for when providing charity is a job
instead of a voluntary giving of one's services for no compensation,
the dynamics change. This is not a new concept. In 1853, Rev. William
Ruffner noted that:
``Charity is a work requiring great tenderness and sympathy,
and agents who do their work for a price rather than love
should not be trusted to execute the wishes of donors. The
keepers of poor-houses fall into a business, unfeeling way of
doing their duties, which is wounding and often partial and
cruel to the objects of their attention.''
the nj volunteer physicians protection act
So the question is, ``What would it take to have thousands of non-
government free clinics scattered throughout the country?''
The Zarephath Health Center is open only 12 hours per week as we
have trouble finding physicians to volunteer. Physicians have many
stresses and often struggle to meet all their obligations, suffering
from ever-decreasing third party payments and ever-increasing
administrative burden. Volunteering does not easily fit into their
schedules. Even though the Federal Tort Claims Act (FTCA) gives us free
Federal medical malpractice coverage for the work we do in the free
clinic, it is still hard to find physicians.
So we, in New Jersey, are working on a solution. Physicians and
citizens have come together to propose the NJ Volunteer Physicians
Protection Act, whereby physicians would volunteer to donate 4 hours
per week in non-government free clinics. Instead of billing for our
services, we are asking that the State extend the same medical
malpractice coverage it now provides to the medical school attendings,
residents and students, to the entire practices of the physicians who
volunteer. The State could simply take the same paperwork used by the
FTCA to identify those physicians who qualify for coverage.
Medical malpractice coverage would be the physicians' only reward--
no claim forms, no CPT codes, no secretaries at either end, no money
flowing from the government to care for the poor. Just liability
protection. The rest of the clinic work would be done with at least 90
percent volunteers, with minimal key paid staff, all funded by private
donors, local fundraisers and corporate donations. From our experience,
there would be no shortage of volunteer nurses and support staff. The
baby boomers are poised to become a huge pool of volunteers with
expertise and experience. There would be no avenue for fraud and abuse,
as no money would be coming in from the government.
An organization founded by a philanthropic couple in Texas called
Echo Clinics (echoclinics.org) has the mission of facilitating the
founding of 10,000 free clinics by the year 2030. We look forward to
working with them here in NJ. They facilitate in identifying core
directors, choosing a free clinic site, establishing the 501(c)3, and
going through the FTCA application.
Senator Bernie Sanders, you hail from the left, where you proclaim
a deep concern for the poor and underprivileged. So I would think that
our idea would appeal to you. Greater and more satisfactory access for
the poor to see physicians of every specialty. This is universal
access.
Senator Rand Paul, as a member of the Tea Party movement, you hail
from the right, which believes in freedom, smaller government and lower
taxes. Our plan ought to appeal to you as the free clinics would
operate with no tax dollars at all. This is limited government.
The NJ State Medicaid budget is $10 billion in a total State budget
of $28 billion. Half of that is for indigent elderly and half is for
acute care. Of the $5 billion for acute care, $2 billion goes to
Medicaid-managed care and $800 million goes to federally qualified
clinics. (data from statehealthfacts.org) Assuming an average 20
percent administrative cost, that means a total of $500 million of
these two entities is paying administrators of the system--people who
do not touch the patients. In the NJ Medicaid budget, $90 million goes
directly to physicians. There is a bit of a disconnect in common sense
here.
Since the Medicaid office is currently directing frustrated
patients to our free clinic, why do we need the middle man? Why would
we need Medicaid managed care if we physicians are willing to manage
the care of the patients for free? Who can argue with free? Since the
State would not be purchasing medical malpractice policies, the only
cost to the State taxpayer would be incurred if an actual lawsuit were
brought. From the experience of the FTCA, these would be rare. It does
not take too much accounting to realize that NJ would quickly save $2
billion if this program were implemented, and the 50 States could save
$100 billion per year.
The Federal Government would be able to lower its Medicaid spending
as well. An added benefit would be the reduction of the estimated 20-30
percent cost of defensive medicine by the reduction of unnecessary
testing done purely to avert potential lawsuits. This would reduce
Medicare spending as well, another $200 billion in savings, according
to studies done during the Bush administration.
I am not suggesting that we dismantle the Medicaid program in one
fell swoop--but give the patients in need a choice. If someone finds
himself ill and with no insurance and no funds, he could go to a
Medicaid office and spend time filling out forms where he might be
rejected, or he could go to a nearby free clinic. Once the word got
out, a well-staffed free clinic that is open for many hours a day would
be a huge deterrent from inappropriate use of the emergency rooms.
Also, each hospital could have several rooms set up where non-urgent
cases could be seen by physicians who would donate their time there.
The free clinics would not have to be free-standing.
Instead of having an entitlement for what might be a temporary
tough time, why not have a place to go for only the time that is
needed? After patients have been helped and are back on their feet, we
will encourage those who find work to access and pay for care at our
practices. Poverty should be a temporary state, not a way of life.
We have a Web site--NJAAPS.org. There physicians and citizens can
read all about the NJ Volunteer Physicians Protection Act and sign up
to voice their approval. So far we have 40 physicians who agree with
the concept, and I do not believe that staffing these clinics will be
difficult.
We have a seminar coming up next month to teach church leaders and
concerned citizens how they can organize and establish a free clinic in
their area. Sometimes it is good to revisit ideas from the past.
Providing medical care for the poor and uninsured is one of them.
Thank you for this opportunity to address this committee.
Senator Sanders. Thank you very much, Dr. Eck.
Dr. Dana Kraus, and I apologize for mispronouncing your
first name a moment ago, is a board certified family physician.
She did her residency at Oregon Health Science University, went
to medical school at Dartmouth Medical School and has a
bachelors in comparative literature from Brown University.
Dr. Kraus, thanks very much for being with us.
STATEMENT OF DANA KRAUS, M.D., FAMILY PRACTICE PHYSICIAN,
NORTHERN COUNTIES HEALTH CARE, ST. JOHNS-
BURY, VT
Dr. Kraus. I would like to thank everyone for the
opportunity to come and speak. What I would like to talk about
really is the transformation of the primary health care system
that has occurred in my rural community in northern Vermont
over the last 5 to 10 years.
What we do now is provide comprehensive, proactive and
integrated health care using three things: The Chronic Care
Model, the medical home and our own innovative community health
team. The Chronic Care Model demonstrated that in order to
provide the best chronic care, the best care for patients with
the--Chronic Care Model indicated that the way to provide the
best care for patients with chronic illness was to have a
prepared and proactive team interacting with an informed and
activated patient.
So it makes no sense to wait for a diabetic patient to come
to the clinic with an infected toe that needs hospitalization
and expensive IV antibiotics. So our patients with chronic
illness, such as diabetes, are scheduled routine visits. Before
they come in my staff knows to order their blood work a week
before. My nurse knows to pull up a template for me so at the
time of the visit I have all of the information that I need
about that patient, their last lab work, their most recent
visits with other specialists, so I can have a very efficient
and very effective visit with that patient.
Now, to get an informed and activated patient, someone who
is really engaged in their care and willing to work to improve
their care is much more difficult. Remember that for patients
with chronic illness, we are asking them, for example, to take
medication when they have absolutely no symptoms of their
illness, we are asking them to give up their Ben & Jerry's and
go for a walk at lunchtime. So in order to help us to motivate
these patients we have developed our community health team.
The community health team is staffed for care coordinators,
by community health workers, people with social work
backgrounds and by counselors and they become then an extension
of the primary care providers. They are the people who connect
our patients to services that already exist. They make sure
that there is no duplication of services. They can help
patients to get affordable medication, transportation to and
from their visits to us or to the specialists. They can help
patients get to their visits or to find daycare or respite care
for their elderly parents.
What is unique in Vermont is that this payment is mandated
by the State and is shared by not just Medicare and Medicaid
but also by the private insurers, so all are cooperating to pay
for this system.
We have aggressively recruited other primary care doctors
who come, partly because of the system of support that we have
to help them work. We have expanded our clinic hours. We
accommodate many new patients. Our community health team
reaches out to patients who are seen in the emergency room and
can offer them a primary care provider if they don't have one,
can help them get access to insurance if they do not have
insurance and they can also provide education at the time of
that outreach so that they can make sure that the patient is
taking their medications, that the patient is understanding
their instructions and that they are improving and can also
educate them about the fact that we have same day appointments
for which they can be seen and also to let them know that we
have 24 hour service. They can always call a physician at any
time to find out where the most appropriate time or place is
for them to get care.
We feel, very importantly, that patients who come to see us
at the clinic get significant benefit over going to the
emergency room. We understand their chronic conditions and know
what medications they are on. We are less likely to repeat
tests or order unnecessary tests. We can do screening for
depression and substance abuse and refer to our counselor, if
that is necessary, as such illnesses tend to increase the cost
of caring for the patient. We can also do preventative health
service. So a patient who comes to see us for a sore throat is
very likely to go out with an updated tetanus vaccine and a lab
slip to have their cholesterol and their blood sugar checked
for preventative health.
What have the outcomes been? In our community we have seen
a significant decrease in ER visits and in hospitalizations. We
have seen an 11 percent decrease in per member/per month costs
based on private insurance claims data. We also feel very
strongly that by providing improved control of chronic
conditions and increased adherence to preventative care, that
in the future we will be seeing significant cost savings. Thank
you very much.
[The prepared statement of Dr. Kraus follows:]
Prepared Statement of Dana Kraus, M.D.
summary
I thank Chairman Sanders, Senator Paul, and members of the
subcommittee for inviting me to come and give testimony about how we in
my community have begun to lower ER visits, decrease healthcare costs,
and improve the health of our patients.
The Problem:
Many unnecessary ER visits
High proportion of medical expenditures to treat
complications of chronic illnesses
Some of the Causes:
Medical system designed for providing acute, reactive care
Shortage of primary care providers
Patients lack adequate insurance, thus avoid preventive
care
Poor patient understanding of proper ER use
Changing behavior is difficult: taking medications, proper
diet, exercising
Background Information:
Northern Counties Health Care is a Federally Qualified
Health Center (FQHC)
Located in rural Northeastern Vermont
25-bed critical access hospital serves 30,000 people, 45
ER visits per day
Our Solutions:
Provide comprehensive, integrated care using:
Chronic Care Model, Medical Home, Chronic Care Team
Increase access to primary care providers
Improve access to health insurance
Patient education about proper ER use
Integrating The Chronic Care Model:
Prepared proactive practice team
Scheduled appointments with tests done and available
Medical data in organized format
Guideline recommendations embedded in the EMR
EMR used to identify patients overdue for care
Informed activated patients
Self-management goals set and reviewed with patients
Written care plans provided and reviewed with
patients
Expansion To The Medical Home:
National Committee for Quality Assurance (NCQA)
Certification
Preventive health maintenance
Improved access to primary care provider
Improved coordination of care
Continuous quality improvement
The Community Health Team (CHT):
Key to our success!
An extension of the primary care providers
Connects patients to existing local services and
coordinates care
Staffed centrally at the hospital and within the Medical
Home clinics
One-stop services, ``wrap services around the patient''
Sets self management goals with patients
Helps to identify and manage most high-risk patients
Provides behavioral health within the medical home clinics
Funded by all insurers
Increased Access to Primary Care Providers:
Aggressive provider recruitment
Expanded clinic hours
Accommodate new patients
Increased availability of acute, same day slots
CHT identifies ER patients without primary care provider,
offers one
Increased Access to Insurance:
CHT works with uninsured patients to access appropriate
programs
Patient Education:
CHT provider post-ER phone calls
Proper use of ER addressed with patient at next clinic
appointment
Additional Benefits of Seeing a Primary Care Provider:
Chronic conditions/medications known
Less likelihood of repeating tests or ordering unnecessary
tests
Screening done for depression and substance abuse
Preventative health issues are addressed and implemented
The Outcomes:
Decreased ER visits
Decreased inpatient admissions
Decreased PMPM costs
Improved care of chronic conditions should lead to future
cost savings
Improved preventive care should lead to further cost
savings
______
I would first like to thank Chairman Sanders, Senator Paul, and
members of the subcommittee for inviting me to come and give testimony
about how we in my community have begun to lower ER visits, decrease
healthcare costs, and improve the health of our patients.
My name is Dana Kraus. I am a board-certified family physician
working at the St. Johnsbury Family Health Center in Vermont. The
clinic is one of six Federally Qualified Health Centers run by Northern
Counties Health Care (NCHC). NCHC has been operating Federally
Qualified Health Centers since 1976. NCHC provides care for over 18,000
patients in three hospital catchment areas in rural northern Vermont,
and also runs two dental clinics and a Home Health and Hospice Agency.
As a Federally Qualified Health Center we offer a sliding scale fee
program so that no one is denied care, and also a low-cost prescription
drug program.
Four of the six clinics are in and around the town of St.
Johnsbury, with a service area of 30,000 people. NCHC provides 40-50
percent of the primary care for this catchment region. Another 40-50
percent is provided by a clinic owned and run by the local hospital, a
25-bed critical access hospital. Our ER currently sees on average 45
patients per day.
chronic care model
The four NCHC St Johnsbury based clinics, in collaboration with the
local hospital, have been participating as a pilot site in the Vermont
Blueprint for Health since 2005 (See Attachment 1). This initial pilot
brought the Chronic Care Model (See Attachment 2) of care to our area,
transforming our care delivery system from a reactive model designed
for acute care, to a proactive model designed to improve the care of
patients with chronic conditions. We have made some fundamental changes
in the way that we see patients with chronic illness. All these
patients are given regular followup visits. Labs and tests are
scheduled prior to the followup visit so that they are available for
review at the time of the visit. We use templates and charts embedded
within our Electronic Medical Record (EMR) to remind providers of
guideline-recognized goals for each chronic condition. We are able to
identify those patients who are overdue for a visit, and are proactive
in contacting them and bringing them back up to date with routine care.
We set self-management goals with patients, and provide written care
plans.
It is known that a large proportion of our health care expenditure
is spent on patients with chronic conditions. Since implementing the
Chronic Care Model, we have seen significant improvements in short-term
outcome measures of our patients with chronic illnesses. For example,
our diabetics have better control of their sugars and blood pressure,
have more frequent preventive eye and foot exams, and are taking
medications known to decrease complications more regularly. Under this
program greater proportion or our hypertensive patients have well-
controlled blood pressure, and more of them are taking aspirin, known
to decrease the risk of heart attacks and strokes.
ncqa medical home certification
Late in 2008 we became one of the first two Vermont Medical Home
pilot sites. All participating clinics underwent National Committee for
Quality Assurance (NCQA) certification for Medical Home status and all
four NCHC clinics, as well as the hospital run rural health center,
qualified at the highest level (level 3). This certification indicates
among other things that a clinic provides enhanced access to and
continuity with a primary care provider, and has a robust electronic
medical record that can be used for population management and
performance feedback. A medical home also emphasizes and promotes
patient self-care and referrals to community resources, and can track
and coordinate care. (See Attachment 3). The Medical Home expands upon
the concept of the Chronic Care Model by addressing preventative health
maintenance, improved access, and continuous quality improvement.
the community health team
Key to our success as a high functioning Medical Home is our
Community Health Team (CHT). Our CHT is made up of a hospital-based
program called Community Connections, and Chronic Care Coordinators and
Behavioral Health Providers that are imbedded within the clinics.
community connections, one-stop services
The Community Connections piece has its origins back in 2002 with a
grant from the Health and Human Services Bureau of Women's Health. A
group of primary care providers and community resource representatives
sat down to discuss how to improve the health of women in the
community. What we found was that we had many existing services, but
there was poor coordination and communication between the various
agencies, and health care providers had trouble referring to and
patients had trouble accessing the existing resources. Thus began the
Women's Resource Center, which in 2006 was expanded to include men and
children, and was renamed Community Connections. Care coordinators and
community health workers staff Community Connections. They work to
connect patients with whatever services they need. Our director loves
to say that they ``wrap services around the patients.''
The key to Community Connections is that it provides ``one stop
services,'' so that providers and patients do not have to negotiate the
complexities of existing disparate agencies. Community Connections
staff work very closely with all of the existing State and private
agencies so as not to duplicate resources. For example, they help
patients get insurance coverage and access to affordable medications.
They help patients get childcare, transportation, and respite care for
elderly family members. They help patients to connect with local health
education programs, such as diabetes or asthma education, or local
exercise programs. They help patients do their grocery shopping, or go
with patients to their provider visits to be sure that the patient
understands instructions.
chronic care coordinators
The Chronic Care Coordinator works closely with providers to
identify and manage high-needs patients with chronic illness. These are
the patients for example with poor control of their diabetes, asthma,
or heart failure who are at high risk for expensive ER visits and
hospitalizations. They meet with patients during scheduled provider
visits, or separately, and do a lot of phone outreach. They help with
the handoff of patients to Community Connections. They do panel
management using reports pulled from the EMR to identify patients
overdue for health maintenance, such as mammograms, or pneumonia
vaccines, or those patients with diabetes or asthma or hypertension who
are poorly controlled, at high risk of complications, or overdue for a
visit.
behavioral health providers
Our Behavioral Health Specialists are counselors who work within
the primary care clinics. They focus on crisis intervention, or short-
term counseling, in order to keep their schedules open at all times for
new patients. For those patients who need long-term counseling, they
help them find a ``good match'' with a community-based counselor.
Depression is known to frequently co-exist with chronic illness, and
treatment of depression has been shown to improve outcomes. Now that we
have easy access to a counselor, we are screening all patients for
depression. Patients with depression often present to their primary
care provider as well as to the ER with multiple complaints, and these
complaints typically decrease significantly once the underlying
depression is treated.
Behavioral Health Providers help patients with true mental illness
and substance abuse, and also those patients who are having trouble
motivating to care for themselves and their chronic illness. For
example they help patients start exercising, begin a weight loss
program, or more reliably take their medications. Such interventions
lead to better disease control, which eventually means fewer
complications, fewer ER visits and hospitalizations, and decreased
costs.
funding for the community healthy teams (chts)
An important point about our CHT is that Vermont's major private
insurers and Vermont Medicaid fund it as a shared resource. This is an
obligation that is mandated by State law. The State has also been
paying for the share of the CHT belonging to Medicare as well as for
the per-patient-per-month payments to the practices for Medicare
beneficiaries. Vermont was recently chosen as one of eight States to
participate in the CMS Multi-payer Advanced Primary Care Demonstration,
enabling Medicare to be a part of the payment reform in the same
manner. The CHT and Medical Home Clinics provide care for all patients,
regardless of their insurance status.
Under the current payment system, all insurers have their own
separate chronic care management programs, which often provide care via
the phone from distant sites. It is our vision that the local CHTs will
eventually take over much of this redundant and expensive care. We feel
strongly that providing face-to-face care, by people who work in
conjunction with primary care providers and who are intimately familiar
with the local resources, culture and climate will provide more
effective care. For example, rather than recommending an outdoor
walking program during a typical northern winter, our care coordinators
know that there is a daily walking group at the Mall, several Strong
Living classes for seniors, and a diabetic exercise class through the
local hospital.
evidence of success/data
Recent data gathered from hospital statistics have shown a
significant downward trend in both ER visits and hospitalizations in
the last 2 years compared to the 2 years prior to the Medical Home
Pilot. It was anticipated that the ER visit rate would be 60 visits per
1,000 patients, and instead it was 40 visits per 1,000 patients, a 33
percent decrease. Similarly, for inpatient hospital admissions, it was
expected to be just below 10 admissions per 1,000 patients, and instead
was only 7.5 admissions per 1,000 patients, a 24 percent decrease. (See
attachment 4) The decrease in ER visits is due to both avoiding illness
exacerbations that would have led to necessary ER visits, and to
decreasing non-urgent ER visits. Just in a 1-year period between 2008
and 2009, there was a 11.5 percent decrease in per member per month
(PMPM) expenditures in our pilot population, based on private insurance
claims data.
evidence of success/examples
We have endless stories of how the chronic care team has helped our
patients. Daily there are patients who get better care because they
have help applying for health insurance so that they can afford
preventive services, help finding a more affordable medication, help
accessing a counselor for their longstanding depression, or help
getting transportation to their appointments. We anticipated that many
of these interventions would improve the outcomes of patients with
chronic illness and provide cost savings many years down the line. I
think that even we here in our community are surprised and thrilled to
see how quickly our interventions have led to more immediate cost
savings, with decreased ER visits and hospitalizations.
For example, among my patients is a 30-year-old single mother of
three who has asthma and chronic pelvic pain, which lead to frequent ER
visits. She is functionally impaired, and had great trouble affording
and taking her medications. She met regularly with the CHT. She now has
her medications ``blister packed'' at the pharmacy, and has
successfully been taking birth control pills, which have taken care of
her pelvic pain, and now that she is regularly taking her asthma
medications she has had neither ER visits nor even acute clinic visits
for her asthma. Another provider had a gentleman who visited the ER 18
times in 2010 for chest pain. Since being connected with the CHT, it
was discovered that he was not able to afford his medications, and that
depression was contributing to his symptoms. He now has regular care
with his primary care provider, a counselor, and his cardiologist. He
also has insurance to pay for his medications, and has had only one ER
visit in the last 6 months.
addressing non-urgent er visits
There are several components of the Medical Home and Community
Health Team that specifically target reduction of non-urgent ER visits.
These involve (1) assigning primary care providers to those without
one, (2) helping patients access existing insurance options (3)
following up with ER patients to ensure that they are improving and
have proper followup (4) improving access to primary care providers (5)
educating patients about appropriate ER use.
1. Efforts to Increase Patients With Access to a Primary Care Provider
A member of the CCT looks at the ER roster daily. Initially there
were multiple patients each day that did not identify a primary care
provider. These patients were contacted, and whenever possible they
were connected with a primary care provider at one of our Medical Home
Clinics. The Medical Home Clinics have worked very hard to accommodate
new patients. We have had aggressive recruitment of new physicians and
mid-level providers in our community. Two years ago most practices had
very limited new patient appointments. At my clinic alone in the last
12 months we saw over 650 new patients. Just this week I saw a
gentleman who spends 6 months in Vermont and 6 months in Florida. He
and his wife are well-educated, and have health insurance. His wife had
several ER visits last year for what turned out to be giardia. I saw
him as a new patient with similar GI complaints, and he was so
thankful. ``Last year we tried and tried to get in to see a primary
care doctor, and were told there were none available, so we had to use
the ER any time that we needed care.''
2. Efforts to Increase Insurance Coverage
The number of patients without a Primary Care provider has
decreased to such an extent that the CHT now has the time and resources
available to also contact those ER patients without insurance, to work
with them to obtain insurance. Patients with insurance are more likely
to access primary care and preventive services, rather than using the
ER for their care.
3. Followup
At the Medical Home Clinics our Chronic Care Coordinators provide
phone followup with most patients who have been to the ER, or have been
discharged from the hospital. They insure that the patient understands
and is following the instructions that they were given. They also
ensure that they have the medications they were prescribed, that they
are improving, and that they have appropriate followup.
4. Extended Hours and Acute Slots
We have extended hours at our sites, opening several mornings per
week at 7:30, and staying open until 7 p.m. some evenings. We try to
keep ``acute time'' open slots daily at each site. We have a policy at
my clinic that the support staff or triage nurse can refer no pediatric
patient to the ER without consulting a provider. Often these visits are
appropriate for the clinic, and usually we can find a spot in even a
``full'' schedule, or assess the situation and determine that having
the child seen the next day would be appropriate. We are hoping to
extend this policy to adults. We have recently implemented a system
whereby if one of our local health centers is full, an appointment is
found at one of the other clinics, instead of sending the patient to
the ER.
5. Education
During ER followup phone calls, in the case of non-urgent ER
visits, the Chronic Care Coordinators remind patients that we are
available to see patients on a same-day basis. They also remind
patients that there is always an after-hour physician on call to help
determine if ER care is required. They stress the importance of using
the Medical Home Clinic rather than the ER whenever possible. As part
of our nursing intake, every patient is asked about recent ER visits,
and those reports are brought to the provider to review. This gives the
provider a chance to discuss the appropriate use of the ER when the
visit was not urgent.
benefits of seeing primary care provider
We believe very strongly that patients get the best care for most
semi-urgent conditions when they receive care consistently at their own
health center, and preferably by their own primary care provider. That
is where their chronic conditions and current medications that may
impact the acute illness are known. There is no need to repeat labs or
studies that have been done recently, as that information is typically
available at the health center. We screen every patient regularly for
depression and substance abuse. Every visit with a primary health
provider is an opportunity to be sure that all health maintenance and
preventive measures are taken care of. Many a patient comes in with a
``cold'' or a ``sore shoulder'' and leaves with a referral to a smoking
cessation program, an updated tetanus vaccine, or a lab slip to check
fasting cholesterol and blood sugar levels.
Using the Medical Home Model, and with the unique help of our
Chronic Health Team, we feel that we have made a significant change in
the way we provide care in our community. We believe it is through a
combination of improved access and improved care management, along with
ongoing patient education, that we have begun to significantly decrease
ER use. We expect that in the years to come we will see further
significant decreases in the expenses for chronic illness complications
as we continually assist our patients in improving their health.
Attachment 1.--From the Vermont Blueprint for Health 2010
Annual Report, January 2011\1\
Background and History
legislation
The Douglas administration formally launched the Vermont Blueprint
in 2003. The goal at the time was to address the increasing costs of
caring for people with chronic illnesses, with an early emphasis on
diabetes management in response to the overwhelming projected burden of
morbidity and resource utilization. The transition to a more broadly
defined Health Reform agent of change has occurred over time.
Throughout the Blueprint's history, the Legislative and Executive
branches have been critical in its support and development as follows:
---------------------------------------------------------------------------
\1\ Full report available at: http://hcr.vermont.gov/sites/hcr/
files/final_annual_report_01_
26_11.pdf.
2006--The Blueprint officially became law when the Vermont
Legislature passed Act 191, sweeping Health Care Reform that also
created Catamount Health to provide coverage to uninsured Vermonters.
The Act included language that officially endorsed the Blueprint and
expanded its scope and scale.
2007--The Legislature further defined the infrastructure
for administering the Blueprint with Act 71 and mandated ``integrated''
pilot projects to test the best methods for delivering chronic care to
patients--based on the Patient Centered Medical Home model and multi-
disciplinary locally based care coordination teams (Community Health
Teams). The original pilot sites were chosen through competitive
request for proposals processes in 2007 and 2008 from communities that
had been actively involved in Blueprint quality improvement
initiatives. Voluntary payment reform to support these innovations in
health care delivery was introduced. This transition ultimately led to
the Advanced Primary Care Practice model now being implemented
statewide.
2008--Act 204 further defined the Integrated Pilots and
officially required insurer participation in their financial support,
which covered approximately 10 percent of the State population.
2009--Launch of the Vermont Accountable Care Organization
Pilot (ACO)--A project led by the Vermont Health Care Reform Commission
(HCRC) to investigate how ACOs might be incorporated into the State's
comprehensive health reform program.
2010--Act 128 updates the definition of the Blueprint for
Health as a ``program for integrating a system of health care for
patients, improving the health of the overall population, and improving
control over health care costs by promoting health maintenance,
prevention, and care coordination and management.'' It also requires
the Commissioner of the Department of Vermont Health Access to expand
the Blueprint for Health to at least two primary care practices in
every hospital services area no later than July 1, 2011, and no later
than October 1, 2013, to primary care practices statewide that wish to
participate.
advanced primary care practice model and blueprint integrated health
service program
The Advanced Primary Care Practice model (the basis for the
original Blueprint Integrated Pilots and subsequent expansion to the
Integrated Health Service program) is characterized by seamless
coordination of care. It stresses the importance of preventive health--
engaging people when they are well, as well as giving patients the
tools to keep existing conditions from worsening. Patients are
encouraged to become active partners in their own care, and practices
become effective and efficient teams.
As one of the requirements of recognition as a Blueprint IHS APCP,
practices must meet a set of criteria for Patient Centered Medical
Homes, established by the National Committee for Quality Assurance
(NCQA), a non-profit organization dedicated to improving health care
quality. Using the NCQA Physician Practice Connection--Patient Centered
Medical Home (PPC-PCMH) recognition rubric, practices are scored on
their compliance meeting standards related to areas such as access and
communication, patient tracking and registry functions and advanced
electronic communications. These evolved practices create internal
teams, maximizing the effectiveness of their staff and expanding the
definition of their roles within the site and beyond.
Another key IHS requirement is to form Community Health Teams
(CHTs)--locally based groups of multi-disciplinary practitioners that
support patients who receive care in the associated APCPs. The teams
are designed at the local level, informed by community-wide assessments
of local resources and gaps, to help patients with and without chronic
conditions adhere to preventive health guidelines.
payment reform figure 1
Vermont's Integrated Health System APCP model includes two
components of payment reform, which are applied consistently to all
participating public and commercial insurers. Currently, fee-for-
service methodology remains intact, with the reforms below in addition.
1. Enhanced Payments to Advanced Primary Care Practices
All insurers pay each recognized APCP an enhanced provider payment
above the existing fee-for-service payments--calculated on a per
patient per month (PPPM) basis--and based on the quality of the health
care they provide as defined by the NCQA PPC-PCMH standards. In order
to calculate payment, each insurer must count the number of their
beneficiaries that are attributed to a practice, and multiply that by
the PPPM amount.
2. Community Health Team Payments
The Vermont Blueprint emphasizes that the excellent and challenging
work of an APCP must be supported by more than just the NCQA PPC-PCMH-
triggered payments. A dedicated Community Health Team (CHT) provides
this essential range of services. Insurers currently share the costs of
CHTs equally. This support allows the services of a CHT to be offered
free of charge to patients and practices, with no co-pay or prior
authorization. Insurers provide a total of $350,000 per full CHT
annually, which serves a general population of 20,000, with shares paid
to a single existing administrative entity in each HSA. This combined
funding covers the salaries of the core team, allowing for barrier-free
access to the essential services provided. While this ``core'' CHT
often works one-on-one with patients to meet a wide range of needs, the
``functional'' team may be much larger, including members of other
local individuals and organizations who work in partnership with the
CHT and the APCP.
Planning and refining these elements are achieved through consensus
in the Blueprint Expansion Design and Evaluation Committee, and the
details of implementation at the Blueprint Payment Implementation Work
Group. Both groups are well represented by a wide variety of
stakeholders and serve to advise the Blueprint Executive Director. (See
Appendix II for Blueprint advisory committee membership.)
community health teams
The Blueprint's cutting edge payment reforms allow for the
innovative Community Health Teams (CHTs) to provide services free of
charge to the APCP patients. The multidisciplinary CHT partners with
primary care offices, the hospital, and existing health and social
service organizations. The goal is to provide Vermonters with the
support they need for well-coordinated preventive health services, and
coordinated linkages to available social and economic support services.
The CHT is flexible in staffing, design, scheduling and site of
operation, resulting in a cost-effective, core community resource which
minimizes barriers and provides the individualized support that
patients need in their efforts to live as fully and productively as
possible. The CHTs function as extenders of the practices they support,
and their services are available to all patients (no eligibility
requirements, prior authorizations or co-pays).
To ascertain the local Health Service Area's specific needs, the
local IHS workgroup identifies current health services and existing
gaps for patients and providers in participating primary care practices
and the surrounding community. Based on the information obtained, the
group will build the foundation of the CHT by working together to
determine how existing services can be reorganized and what new
services are required.
The overall design of the Blueprint Integrated Health Services
model provides patients with seamless and well-coordinated health and
human services. This includes transitioning patients from patterns of
acute episodic care to preventive health services. Well structured
followup and coordination of services after hospital-based care has
been shown to improve health outcomes and reduce the rate of future
hospital-based care for a variety of patient groups and chronic health
conditions (e.g. reduce emergency department visits, hospital inpatient
admissions, re-admissions). CHT members, hospital staff, and other
community service providers work closely together to implement
transitional care strategies that keep patients engaged in preventive
health practices and improved self-management. A goal of the Blueprint
model is seamless coordination across the broad range of health and
human services (medical and non-medical) that are essential to optimize
patient experience, engagement, and to improve the long term health
status of the population.
The Community Health Team serves as the central locus of
coordination and support for patients.
self-management
A central part of the Blueprint's self-management efforts has been
the Healthier Living Workshop (HLW), Vermont's version of the evidence-
based Stanford Chronic Disease Self Management program, offered
throughout the State since 2007. The original workshops are not
specific to any chronic disease, but rather teach patients self-
management skills and provide a peer-support network for individuals
with chronic conditions. HLWs empower individuals as self-managers
through education, support and skill-building exercises, notably, goal-
setting and problem-solving.
This year, the workshops have been expanded to more specifically
target common problems including diabetes and chronic pain. Successful
pilots have paved the way for broader spread statewide. Plans are also
underway to pilot an online Healthier Living Workshop program in
partnership with the Stanford program and the National Council on
Aging.
The Blueprint also helps provide clinical practices with the skills
and resources needed to create a self-management infrastructure--and in
conjunction with the Jeffords Center for Quality at Fletcher Allen
Health Care, offers educational sessions that train coaches and
practice facilitators to assist individual practices with self-
management support. This educational effort has successfully trained
clinic-based practice coaches (``local talent'') to complement the
EQuIP personnel.
health information architecture
The Blueprint works closely with the Vermont Information Technology
Leaders (VITL)--the State-sponsored Health Information Exchange (HIE)--
to develop infrastructure that supports the meaningful use of health
information. The core of this infrastructure is the Blueprint's
centralized registry and Web-based clinical tracking system: DocSite-
Covisint. The registry is used to produce visit planners that guide
individual patient care, and to produce reports that support population
management, quality improvement, program evaluation and comparative
benchmarking.
Data from the IHS APCP sites are sent to DocSite from the point of
care, either entered manually into the Web-based portal or via
interfaces and direct feeds. It is a major goal to facilitate the entry
of data at the point of care while minimizing any disruptions to the
work flow of the practice. This is a major improvement process at the
practice level, facilitated by the EQuIP and internal practice teams.
All aspects of the Blueprint's information architecture are
designed to meet strict guidelines concerning data access and privacy
protections.
Attachment 2.--From the Improving Chronic Illness Care Web site:
www.improvingchroniccare.org
delivery system design
Assure the delivery of effective, efficient clinical care and self-
management support
Define roles and distribute tasks among team members.
Use planned interactions to support evidence-based care.
Provide clinical case management services for complex
patients (2003 update).
Ensure regular followup by the care team.
Give care that patients understand and that fits with
their cultural background (2003 update).
Improving the health of people with chronic illness requires
transforming a system that is essentially reactive--responding mainly
when a person is sick--to one that is proactive and focused on keeping
a person as healthy as possible. That requires not only determining
what care is needed, but spelling out roles and tasks for ensuring the
patient gets care using structured, planned interactions. And it
requires making followup a part of standard procedure, so patients
aren't left on their own once they leave the doctor's office. More
complex patients may need more intensive management (care or case
management) for a period of time to optimize clinic care and self-
management. Health literacy and cultural sensitivity are two important
emerging concepts in health care. Providers are increasingly being
called upon to respond effectively to the diverse cultural and
linguistic needs of patients.
decision support
Promote clinical care that is consistent with scientific evidence and
patient preferences
Embed evidence-based guidelines into daily clinical
practice.
Share evidence-based guidelines and information with
patients to encourage their participation.
Use proven provider education methods.
Integrate specialist expertise and primary care.
Treatment decisions need to be based on explicit, proven guidelines
supported by clinical research. Guidelines should also be discussed
with patients, so they can understand the principles behind their care.
Those who make treatment decisions need ongoing training to stay up-to-
date on the latest evidence, using new models of provider education
that improve upon traditional continuing medical education. To change
practice, guidelines must be integrated through timely reminders,
feedback, standing orders and other methods that increase their
visibility at the time that clinical decisions are made. The
involvement of supportive specialists in the primary care of more
complex patients is an important educational modality.
clinical information systems
Organize patient and population data to facilitate efficient and
effective care
Provide timely reminders for providers and patients.
Identify relevant subpopulations for proactive care.
Facilitate individual patient care planning.
Share information with patients and providers to
coordinate care (2003 update).
Monitor performance of practice team and care system.
Effective chronic illness care is virtually impossible without
information systems that assure ready access to key data on individual
patients as well as populations of patients. A comprehensive clinical
information system can enhance the care of individual patients by
providing timely reminders for needed services, with the summarized
data helping to track and plan care. At the practice population level,
an information system can identify groups of patients needing
additional care as well as facilitate performance monitoring and
quality improvement efforts.
self-management support
Empower and prepare patients to manage their health and health care
Emphasize the patient's central role in managing their
health.
Use effective self-management support strategies that
include assessment, goal-setting, action planning, problem-solving and
followup.
Organize internal and community resources to provide
ongoing self-management support to patients.
All patients with chronic illness make decisions and engage in
behaviors that affect their health (self-management). Disease control
and outcomes depend to a significant degree on the effectiveness of
self-management.
Effective self-management support means more than telling patients
what to do. It means acknowledging the patients' central role in their
care, one that fosters a sense of responsibility for their own health.
It includes the use of proven programs that provide basic information,
emotional support, and strategies for living with chronic illness.
Self-management support can't begin and end with a class. Using a
collaborative approach, providers and patients work together to define
problems, set priorities, establish goals, create treatment plans and
solve problems along the way.
Attachment 3.--From The NCQA Web Site, at http://www.ncqa.org
NCQA's initial Physician Practice Connections--Patient-Centered
Medical HomeTM (PPC-PCMH) program reflects the input of the
American College of Physicians, American Academy of Family Physicians,
American Academy of Pediatrics and American Osteopathic Association and
others in the revision of Physician Practice Connections to assess
whether physician practices are functioning as medical homes. Building
on the joint principles developed by the primary care specialty
societies, the PPC-PCMH standards emphasize the use of systematic,
patient-centered, coordinated care management processes.
NCQA's Patient-Centered Medical Home (PCMH) 2011 is an innovative
program for improving primary care. In a set of standards that describe
clear and specific criteria, the program gives practices information
about organizing care around patients, working in teams and
coordinating and tracking care over time. The NCQA Patient-Centered
Medical Home standards strengthen and add to the issues addressed by
NCQA's original program.
The Patient Centered Medical Home is a health care setting that
facilitates partnerships between individual patients, and their
personal physicians, and when appropriate, the patient's family. Care
is facilitated by registries, information technology, health
information exchange and other means to assure that patients get the
indicated care when and where they need and want it in a culturally and
linguistically appropriate manner.
There are six PCMH 2011 standards, including six must pass
elements, which can result in one of three levels of recognition.
Practices seeking PCMH complete a Web-based data collection tool and
provide documentation that validates responses.
Attachment 4.--From the Vermont Blueprint for Health 2010 Annual
Report, January 2011 \2\
---------------------------------------------------------------------------
\2\ Full Report available at: http://hcr.vermont.gov/sites/hcr/
files/final_annual_report_01_
26_11.pdf.
---------------------------------------------------------------------------
Senator Sanders. Thank you very much, Dr. Kraus.
If it is OK with Senator Paul, I would like to turn the mic
over to Senator Whitehouse to make a comment and ask questions,
if you would like.
Statement of Senator Whitehouse
Senator Whitehouse. I would love to followup a little bit
with Dr. Kraus. First of all, I hope you enjoyed your time at
Brown University in wonderful Rhode Island.
Senator Merkley. And at OHSU.
Senator Whitehouse. I'm sorry?
Senator Merkley. And at OHSU.
Senator Whitehouse. I wanted to ask you a little bit more
about your experience with electronic health records and
integrating them into your practice, how effective have they
been, have you been able to integrate your electronic health
record with the local pharmacy, the local hospital, and other
local specialists. Have you been able to begin to exchange any
data? Just sort of give us an update on how that is going.
Rhode Island is doing a pretty good job. We are hoping that
we will have an actual health information exchange set up
shortly that can do that, we already have a health information
exchange operating on a trial basis. But I know Vermont has
done a lot of work and as a practitioner who works with it
every day I would love to hear your thoughts.
Dr. Kraus. We, for a small rural town, have a very advanced
integrated electronic medical system. All except one private
practitioner of our practices use an electronic health record.
We have an electronic record at the hospital and we have data
that is automatically downloaded from the hospital labs and x-
rays and specialists that come directly into our electronic
health medical record.
We are working on and have recently started inputting our
data to an entire statewide information center. From that we
are now able to pull very helpful patient management reports.
So, I send all my lab work, my blood pressures, my foot exams,
my eye exams and at the touch of a finger I can immediately get
a report of what percentage of my patients who have diabetes
are meeting targets; I can run a list of those patients who are
overdue for a retinal exam; I can run a list of those patients
who are at poorest control so that we can case manage them. So
our electronic health record system is working very efficiently
at this time.
As I mentioned, using the electronic health record allows
us to, at every visit, have the essential information about the
patient at our fingertips and also it can take a patient who
has multiple medical issues, diabetes and asthma and heart
disease, and the system knows that they have all those issues
and can highlight to us, this patient is overdue for a eye exam
and for a flu shot and for an echocardiogram, all within one
system. So it is very efficient and has been very helpful.
Senator Whitehouse. In terms of the finances of your
practice, how is this paid for? Did you get support from the
Federal Government in the Recovery Act? Does Vermont have a
program that supports this? Does your insurance company help
with it or did you do this on your own?
Dr. Kraus. I work for a federally qualified health center,
so it has been through the----
Senator Whitehouse. So it goes through the community health
center?
Dr. Kraus. There have been grants in the State to help
clinics to improve their use of electronic medical records. We
bought the system ourselves but there has been some help to
improve the way that we use it and to integrate it with the
State information system.
Senator Whitehouse. Do you have a private practice outside
or do you practice through the community health center?
Dr. Kraus. I guess I would like to make clear, I work for a
federally qualified health center.
Senator Whitehouse. Yes.
Dr. Kraus. We provide 40 to 50 percent of care in my
community, the other 40--there is another clinic that is a
rural health center that is also funded that provides 40 to 50
percent of care in my community. We have about 50 to 60 percent
of our patients in our community who have Medicare or Medicaid,
about 40 percent of our patients are private. So my private
practice is my Federal health center, that is the way--I see
patients who are poor and have no insurance, I also see
bankers, I see lawyers. I take care of everybody. We are the
community health center for everybody.
Senator Whitehouse. Understood. Let me just close, my time
is running out. I want to thank Senator Sanders for holding
this very important hearing. He has shown a lot of leadership
in this area.
I just want to add that in Rhode Island our experience has
also been that there has been really considerable leadership
shown by these community health centers in terms of developing
an electronic health record system and utilizing the
efficiencies that it allows, as well as the improvements in
patient care, and the improvements in doctor awareness of
medical information. Although it was a chore for them to get
through the initial adoption process, if you go to the
Thundermist Health Center in Woonsocket which is probably one
of our leaders on this, and you tried to take away their health
information technology, you would have a war on your hands.
They really see the value of it.
Senator Sanders. You would need emergency care treatment,
is what you are saying?
Senator Whitehouse. You would need emergency care
treatment, exactly.
[Laughter.]
Senator Sanders. OK.
Senator Whitehouse. Thank you very much, Doctor.
Senator Sanders. Thank you very much.
Senator Merkley.
Statement of Senator Merkley
Senator Merkley. Thank you, Mr. Chair. Dr. Kraus, do you
have any plans to go to Kentucky?
Dr. Kraus. I am quite happy in Vermont. Thank you.
Senator Merkley. I am just struck by the fact that you have
been at Oregon Health Sciences University and then--did I catch
that right?
Dr. Kraus. Yes.
Senator Merkley. And then at Brown University, now serving
in Vermont, so----
[Laughter.]
Senator Merkley [continuing]. Only one stop left for this
panel.
When you mentioned the same-day appointments, I thought,
that is certainly different than the stories I hear from folks
every day about the challenge of getting in the front door of
the health care system where they may call with a concern and
find that the only appointment they can get is months out,
which could drive them to seek care in an emergency room,
potentially.
How have you been able to accomplish that kind of
flexibility and capacity?
Dr. Kraus. It can be a dilemma for this, in fact, we are
struggling at this point to convince our administration to keep
our same day appointments, because what happens is if you leave
appointments and they aren't filled, then that is not very good
for the bottom line. So there always has to be a very careful
balance to book enough patients.
But we, for example, we have a policy in my clinic that no
child ever goes to the emergency room without that being run by
a provider. So if a triage nurse takes a call or a front staff
person takes a call about a kid, they are either offered an
appointment today, whether we have space or not, and if the
staff feel that there is no space it is run by a provider and
we can often make a decision that we know the family, we know
the child, they can be seen tomorrow or we will say, just bring
them in. It is usually a quick visit, we don't want our kids to
go to the emergency room. We are trying to extend that to
adults as well, that we would never say to a patient we cannot
see you today.
Senator Merkley. I certainly applaud that vision and the
fact that you have been able to make it work on the ground.
I also wanted to ask you, on your community health teams,
do you have a changing role in terms of the types of
responsibility nurses and nurse practitioners carry or any kind
of insights there that would be helpful to us?
Dr. Kraus. Our nurse practitioners have and always have
really had an independent practice. I know that in some
practices everybody has to have a primary care doctor and then
if they have an acute illness or they have a physical and they
don't have complicated issues, then they see the nurse
practitioner. Our nurse practitioners in our clinic have their
own complex panels of patients. If they have a patient that
they feel has so many complexities and they are feeling
overwhelmed, they will transfer the care to a physician, but
they really work equally with us. They certainly ask us
questions about our patients.
Senator Merkley. When someone calls needing an appointment,
how is it determined, internally, whether this person should go
to a nurse practitioner or to a doctor, for example?
Dr. Kraus. We are all primary care providers, that is why I
don't use the term primary care physician, I use the term
primary care provider. My kids see my nurse practitioner as
their primary care provider. The first option is always to have
an appointment made with the patient's primary care provider,
if possible. If that person is not available, then with one of
the others of us.
Senator Merkley. So there is a provider assigned to each
patient?
Dr. Kraus. Absolutely. We all have our separate panels but
we have access to each other's notes and certainly are able to
see each other's patients if the opportunity is needed. But we
try and have patients see their own provider as much as
possible.
Senator Merkley. Thank you.
Now Dr. Cunningham, you noted that sometimes hospitals
resist shifting care out of emergency departments, as I
gathered because of financial reasons. That suggests that
perhaps the high cost at an emergency room is probably related
to the structure and the services provided but partly just
related to a pricing structure within the institution, in which
case shifting folks out of an emergency room we may be
overstating the savings. Is that a possibility?
Mr. Cunningham. I think some of the estimates about the
savings on a per visit basis may be a little bit high because
it is hard to compare on an apples to apples basis, because the
intensity of visits in an emergency room tend to be higher. I
think the studies that have really tried to make an apples to
apples comparison have shown that it is maybe two to three
times higher in an emergency room. But then you also have to
consider the downstream cost savings that if you get people
into a medical home and you get better continuity of care there
could be additional savings down the road, so it is kind of
hard to estimate exactly what the total cost is. But, you know,
it is difficult even on a per visit basis to do so.
Senator Merkley. I want to thank you all for the work you
are doing and I am out of time, but Dr. Eck, I will be
interested in following up to understand better, if the law was
changed, how much expansion of volunteer time you think would
occur and the overall impact it might have. Thank you all.
Senator Sanders. OK. Thank you, Senator Merkley.
Senator Paul.
Senator Paul. Thank you. Miss Draper, are you familiar with
the Hyde amendment?
Ms. Draper. No, sir, I am not.
Senator Paul. The Hyde amendment is an amendment that has
been around since the 1970s that prohibits Federal money from
being spent on abortions. According to the Alliance Defense
Fund, which I would like to insert the comments from them into
the record, there is evidence that money for community health
centers is actually going to abortion providers.
[The information referred to above can be found in
additional material.]
The specific example they bring up is the Institute for
Family Health in New York City which gets millions of Federal
dollars but also is listed by NARAL as a pro-choice abortion
site of recommendation by NARAL in New York City. I think it is
illustrated by Dr. Kraus' testimony that there is not really a
distinction between community health centers and private
practice. Her private practice and her community health center
are located in the same venue. I am not saying she does, but it
sounds like there are people around the country who are using
that money basically to provide for a center that also performs
abortion. I think the division between what is private practice
and what is community center is very hard to delineate and
separate and I find it troubling that I think this goes against
the spirit and actually probably the letter of the law with
regard to the Hyde amendment.
I was wondering if the GAO has any mechanism for looking
into whether Federal funding is being used in community health
centers for abortions.
Ms. Draper. We have not looked at that, as far as I know.
This particular study was looking at strategies that health
centers have implemented to really divert the non-urgent use of
emergency departments.
Senator Paul. Can you look into that for me and give me an
answer as to whether or not Federal funding is going to pay for
abortions at community health centers?
Ms. Draper. We can talk about that after the hearing if
that works for you.
Senator Paul. Yes, I would like to have that information
and if the GAO could send that to me.
Another question for Miss Draper is that it looks like when
you look at the statistics on these community health centers,
72 percent of the patients arriving at them have insurance,
Medicare, Medicaid and private insurance. So we are looking at
38 percent that you are helping that have no other venue. My
question is, it seems to me that you have a 72 percent
duplication rate with other providers who would be providing
these services. Many other doctors are taking Medicare, many of
them are taking Medicaid, many of them are taking private
insurance, so once again, when we look at a budget that is $2
trillion over budget, do we really need to be duplicating
services that are available in the private sector?
Ms. Draper. According to a 2009 UDS--Uniform Data System--
data from HRSA, about 80 percent of the patients that are seen
in community health centers, overall, are either uninsured or
have Medicaid. The remaining 20 percent are Medicare or
privately insured.
Senator Paul. I guess that contradicts data that we have
from the government, from the Health and Human Resources that
shows 72 percent being Medicaid, Medicare or other private
insurance and that only about 38.2 percent are uninsured. The
other thing is that a lot of this can be siphoned off, in a
sense Dr. Kraus gives a perfect example of what is part of her
clinic and what is not part of her clinic. The patients she
sees with insurance are not part of the clinic and the ones
that are, so it would look like she would have a very high
percentage in that case. But, according to the statistics from
the Health and Human Resources, 72 percent of these people have
insurance of one form or another and it would appear to me that
we are duplicating a process where there is also a private
sector alternative.
I would like to take the remainder of my time to thank Dr.
Eck for coming today. I think her story is incredible. I think
that we really have gotten to the point in our society where we
do not differentiate between charity of the heart, really
giving voluntary, and people who are simply working for the
government. Those who would give of their time voluntarily, I
think earn a great deal of respect and deserve our respect and
admiration. Also really the idea that a lot of this could be
done through the private world. We have had government crowding
out charity now for decades and the idea that this can be done,
I know it from firsthand in my experience with the Lions Eye
Clinic in my practice, and I commend Dr. Eck and thank you very
much for coming.
Senator Sanders. Thank you very much, Senator Paul.
Let me just, for the record, pick up on a point that
Senator Paul raised. The Hyde amendment simply prohibits
abortions being performed by facilities that receive Federal
funding. To my understanding there have been a number of
studies which suggest that FQHC's, which do receive--community
health centers, which do receiving Federal funding, do not
perform abortions. Period. That is my understanding.
Let me go to Dr. Kraus, because she comes from the State of
Vermont. Why not.
[Laughter.]
I would like to mention to folks that the area that she and
her clinic are in is one of the lowest income areas in the
State of Vermont, it is the northeastern part of our State, we
call it the Northeast Kingdom. A lot of folks there are working
at low wage jobs. There is an agency there, an FQHC, one of the
very first in the State of Vermont, started by the gentleman
behind me, David Reynolds, who now works for me.
One of the interesting things, and Dr. Kraus correct me if
I am wrong, is that in one of the poorest parts of a rural
State because of the FQHC's there, and I think you have what,
six locations now? Six locations in small towns. They have gone
a very long way to solve the crisis of primary health care
access which exists in many parts of the country. Is that a
fair statement, Dr. Kraus?
Dr. Kraus When you look at our quality measures compared to
other places across the country they are improved. If you look
at our ER visits and our hospitalization rates, they are
declining whereas in areas of the State that have not
instituted the sort of changes that we have made they are
raising or staying stable. We have more advanced use of the
electronic health record than in most parts of the State and
the country.
Senator Sanders. But what I am getting at, if we were to
talk about that region of the State of Vermont, called the
Northeast Kingdom, people would tell you there are a lot of
problems that exist. Right? We don't have enough jobs, wages
are too low, etc. Probably people would not say that access to
primary health care is one of the major issues, despite the
fact that it is one of the lowest income areas of the State. Is
that a fair statement?
Dr. Kraus. I think we do a wonderful job of trying to get
patients in to see their primary care providers.
Senator Sanders. So the point here is that in a rural area,
in a low-income area we have gone a long way through the
establishment of six satellite programs to provide quality,
cost-effective health care to the people of that area.
I know Senator Paul mentioned before, I think picking up on
a point that Dr. Eck made about smiles when somebody walks in
the door. I have been to every one of the clinics in the
Northeast Kingdom, and you know what, they smile there too. I
don't think Dr. Kraus sees herself as a government worker. I
think she is working very hard along with the other physicians
and nurses and medical personnel there who have great spirit. I
have been to all of the clinics and they do a great, great job.
Dr. Kraus, I want to ask you one brief question. I want to
get to Dr. Eck in a second. Talk a little bit, because in a
sense the thrust of the hearing today is how we provide quality
care and try to save money, both for taxpayers as well as the
overall system, in terms of keeping people out of the hospital.
I know the hospital up there, my son was born there 42 years
ago, so I know the hospital in St. Johnsbury. How are you doing
that and is it working?
Dr. Kraus. When you look at the outcomes, the numbers--for
example, there was a study looking at Medicaid patients
specifically and in our community, as well as in the other
pilot community that has had a medical home and a community
health team, there has been a significant bending of the curve.
There was a steady increase in costs taking care of Medicaid
patients. When we looked at our two communities there was a
significant decrease in that steady increase. That was seen
also, but not as too much of an extent, in the one community
that has only had this grant for 1 year. When they looked at
nonpilot sites across the State, the Medicaid costs continued
on the same projection. So there was evidence that what we have
been doing started to significantly decrease the costs of care,
at least for Medicaid patients.
In the private sector they did a per member/per month
analysis and showed that we had an 11 percent decrease in the
per member/per month costs of caring for patients. This was a
$48 cost--$48 decrease per member in the communities where we
had this team. It costs the State about $4 per member/per team
in running the community health team and in extra reimbursement
that we get at the pilot sites per member/per month. So they
got a $48 saving for a $4 investment. This is the private
insurers.
We feel that our community health team that really helps
patients to navigate the system so that they are able to
decrease barriers to getting excellent health care has really
helped, so that we are decreasing emergency room, both non-
urgent emergency room costs by being open and also by keeping
people healthier so they are no longer needing to use the
emergency room or the hospital.
Senator Sanders. OK, thanks.
Let me ask Ms. Draper and then maybe Dr. Cunningham. I want
to get to Dr. Eck in one second. I am going to give the mic
over to Senator Paul when I am finished.
Is it fair to say that honest people can have differences
of opinion ascertaining what is, in fact, utilization of
emergency rooms, whether it is for a true emergency or not? In
other words, we can agree that if somebody got shot it is an
emergency. If somebody has a common cold, it is not an
emergency. But there is a lot of gray area in between that.
The report, the GAO report that we looked at suggested that
maybe 8 percent, as I recall, of utilization in emergency rooms
were nonemergent. I have heard statistics which go as high as
50 percent. Is it fair to say that there may be some
differences of opinion as to the extent of nonemergency use of
emergency rooms?
Ms. Draper. I think that is fair to say. The non-urgent
classification is really someone who needs to be seen within 2
to 24 hours. It is not that the care that they receive in the
emergency room--it is not inappropriate care, but they may have
been able to be seen somewhere else at a more cost-effective
setting.
Senator Sanders. OK. Dr. Cunningham, did you want to
comment on that?
Mr. Cunningham. Yes, I would agree. I think about 15
percent of visits are visits that need to be seen, either
immediately or within 15 minutes. The emergency----
Senator Sanders. What are your--I'm sorry, 15 or 50?
Mr. Cunningham. Fifteen percent----
Senator Sanders. Fifteen, yes.
Dr. Cunningham [continuing]. Are true emergencies in that
sense. So yes, there is a whole range of visits that fall into
the urgent and the semi-urgent category. I think probably where
you see the differences in terms of the estimates or where
people say that it is appropriate or not--or inappropriate,
probably reflects that group. I think furthermore, whether it
is appropriate or inappropriate probably depends on whether
there is other resources in the community for people to go to.
If it is 3 a.m. on a Sunday morning and there is no other place
to go, well I don't think it would--most people would say it is
inappropriate to go to the ER for maybe a semi-urgent problem.
Senator Sanders. OK. Thanks.
Let me just ask Dr. Eck a question. First of all, thank you
very much for what you do. Your volunteer activities are much
appreciated.
Let me ask you this, in a sense, philosophical question. We
have gone a little bit into philosophy today. I believe, many
people in my own State believe that health care is a right, R-
I-G-H-T, regardless of income. That every American has the
right to the best quality health care that the system can
offer, regardless of income. That if you are a low-income kid,
or you are a wealthy kid, you have the same opportunity to
access the health care system. Do you believe that?
Dr. Eck. I believe that every person ought to get good
health care. The Hippocratic Oath says that I would provide
health care regardless of whether the person pays me or not. I
definitely believe that people need health care. The question
is how do we do that.
Senator Sanders. If I may? I will give you a chance to
respond. We all know people do need health care when they get
sick. But is it a right? Should all people, regardless of
income, have access to the same quality system or should we
have a two-tier or three-tier system, in your judgment?
Dr. Eck. If health care is a right then so is food care and
shelter care and clothing care. Food, clothing and shelter I
think are at least as important as health care and yet we don't
expect the government to provide food, clothing and housing to
everybody.
Senator Sanders. Not to everybody we don't, but we do have
a food stamp program which does provide to low-income people.
Dr. Eck. When you call something a right--it is different
to have a right--a freedom to act and to do what is best for
one's family in a free America, it is another thing to have
your rights impose obligations on other people. That is a whole
different philosophy, and I am not so sure that is what the
Constitution guarantees.
Senator Sanders. OK. Let me ask you this, and I have gone
on too long, I am going to give it over to Senator Paul.
Again, I applaud you for your free services and your
volunteer efforts, but don't you think it is a little bit
apples to oranges to say that, if somebody does something for
nothing obviously the cost is going to be lower than somebody
who is paid. A physician is usually paid, nurses are paid,
surgeons are paid. Two questions--I mean isn't that basically
true? Second of all, it is one thing to run a primary health
care free clinic, as important as that is. Somebody walks into
your office, they are diagnosed with cancer, they have to go to
a hospital for an extensive number of tests and treatments
which could run up tens of thousands of dollars. How does that
person pay for that in a free clinic environment?
Dr. Eck. In the United States you will notice people aren't
dying on the street. People are taking care of patients and
people are coming down with cancer, have no insurance, they are
getting medical care. The hospitals absorb it, the oncologists
take care of them for free. That is already being done. It is
not as bad as it sounds.
What we are suggesting though is what we have in this
country is patients are taking on the liability of patient--or
physicians are taking on the liability of taking care of
patients who are not paying them, and yet the liability is
huge. And that is why the whole idea of the malpractice
coverage in exchange for free care.
I have spoken with physicians, informally and I have done
internal polls. I will send out an email--Survey Monkey--and
ask them, would you do this, would you provide 4 hours a week
of free care in a nongovernment free clinic where you get no
compensation. Every specialty says yes, they would do it in a
heartbeat. I am suggesting that neurosurgeons maybe do two
cases a month, maybe an obstetrician do two deliveries a month
for free and that would account for their post-op time. They
all say that they would be happy to do that.
So we are talking no money, we are not going to--it is
free. How can you argue with free? And it is universal access.
How can you agree with that? It sounds like something on your
side of the alley.
Senator Sanders. OK. Thanks very much.
I have gone over my time. I am going to give the mic over
to Senator Paul.
Senator Paul. Thank you very much.
With regard to the idea of whether or not you have a right
to health care, you have to realize what that implies. It is
not an abstraction. I am a physician, that means you have a
right to come to my house and conscript me. It means you
believe in slavery. It means that you are going to enslave not
only me but the janitor at my hospital, the person who cleans
my office, the assistants who work in my office, the nurses. If
you have a right to their services basically once you imply a
belief and a right to someone's services, do you have a right
to plumbing, do you have a right to water, do you have a right
to food, you are basically saying that you believe in slavery.
You are saying you believe in taking and extracting from
another person.
Our founding documents were very clear about this. You have
a right to pursue happiness, but there is no guarantee of
physical comfort, there is no guarantee of concrete items. In
order to give something concrete or someone's service, you have
to take it from someone. So there is an implied threat of
force.
If I am a physician in your community and you say you have
a right to health care, do you have a right to beat down my
door with the police, escort me away and force me to take care
of you? That is ultimately what the right to free health care
would be. If you believe in a right to health care you are
believing in basically the use of force to conscript someone to
do your bidding.
Now just because it is a noble thing to believe that we are
obligated, as Christians, we are obligated through the
Hippocratic Oath, we have always done this. Since the beginning
of modern medicine we have always provided 100 percent access.
I do it in exchange for privileges. I do it because I believe
in the Hippocratic Oath, but my hospital also says to me, ``You
can only operate in this hospital if you agree to see everyone
coming through the emergency room.'' I always have. We have
always treated. We have always had 100 percent access through
our emergency room. Those were for emergencies, they are not
the best place for primary care, we all agree with that, but we
have always had 100 percent free access.
Going back to one specific question with Dr. Kraus, do you
receive, personally, more money because you work in a Federal
clinic? Do you get higher Medicare and Medicaid reimbursements
to you personally for working in a health clinic?
Dr. Kraus. Me personally, I think I get well below the
national average for an annual income of a primary health
provider.
Senator Paul. But do you specifically get more from
Medicare and Medicaid because you have a health clinic?
Dr. Kraus. Me, personally?
Senator Paul. When you have billed--do you, as a physician,
get a higher rate because you work in a health clinic? I
believe the answer is yes.
Dr. Kraus. I am paid by a salary. The health center is
reimbursed at a higher rate, but me as a salaried position is
given the same salary that I would--I also would note, that I
was taught to be self-sufficient and hardworking, that is how I
was brought up. When I look at our budget and I see that there
is a big component of my budget coming as a grant from the
Federal Government, that doesn't make me happy. The reason that
I am getting that grant, however, is because the current health
care system is not reimbursing primary care adequately in the
first place. If there was adequate reimbursement for primary
care physicians in the first place, then we wouldn't require
the extra funding for a federally qualified health center.
Senator Sanders. This is going to be an interesting year, I
will tell you that.
[Laughter.]
I think it is fair to say that Senator Paul and I have some
slight philosophical differences.
All right. My profound question to Dr. Kraus is, do you, as
an employee at a federally qualified health center consider
yourself as a slave?
[Laughter.]
Dr. Kraus. I love my job. I chose there. I do not feel like
a slave. Thank you.
Senator Sanders. Ms. Draper, the implication, again from my
friend Senator Paul, is that we have kind of solved the problem
of health care access in America, that any place in the
country, I guess anybody who has a problem, if you are on
Medicaid, if you have no health insurance, maybe if you have
health insurance, you can just walk in the door tomorrow and
find a doctor to treat you. Is that true, in your judgment?
Ms. Draper. There is a huge body of literature that
discusses the difficulties, particularly Medicaid beneficiaries
have to finding a physician. There are many physicians who are
unwilling to accept Medicaid patients and also for those who
are uninsured face equally challenging or maybe more so
challenging access issues.
I think you can look at the experience in Massachusetts
with reform and, the issue there is that wait times have
increased for people who have already had insurance and even
more so for those who are newly insured. I think I saw one
study where the wait times had doubled from 17 days to 30-some
days for people that are with reform.
There are some lessons learned. I think there is a Kaiser
Family Foundation study that talked about some lessons learned
from the Massachusetts' experience and a couple of those are
that, when you have insurance coverage initiatives, that there
will be a higher demand for primary care services--particularly
from low-income and underserved communities and also that there
needs to be an investment in primary care. We see in many parts
of the country that there are major shortages of primary care
physicians. Those are some of the lessons from the
Massachusetts' experience.
Senator Sanders. All right. My last question is for Dr.
Kraus, again picking up on Senator Paul's comment. As you know,
Vermont is moving toward a Medicare for all single payer
approach. Are you worried that if we consider health care as a
right in the State of Vermont that the St. Johnsbury Police
Department, in the middle of the night, is going to break down
your door and force you to treat a patient. Is this an
immediate concern of yours?
Dr. Kraus. No.
Senator Sanders. OK. Thank you.
I want to thank Senator Paul for being here. It was a
provocative, interesting discussion. I want to thank mostly the
panelists for being here. I think we are discussing an issue of
great important. Again, thank you all for your participation.
The meeting is now adjourned. The record is open for 10
days for any additional comments.
Thank you. The meeting is adjourned.
[Additional material follows.]
ADDITIONAL MATERIAL
Prepared Statement of Matthew S. Bowman, Esq., Legal Counsel,
Alliance Defense Fund (ADF)
I write to discuss the occurrence of abortions and illegally
compelled participation in services such as abortion at Federally
Qualified Community Health Centers (hereinafter FQHCs) that receive
Federal funding from section 330 of the Public Health Service Act as
well as from various other Federal sources.
1. fqhcs can perform abortions, and some do
Despite some public comments to the contrary, FQHCs can and do
perform abortions. For example, the Institute for Family Health in New
York, NY is an FQHC and its cluster of clinics have received millions
of Federal dollars annually for many years. The abortion advocacy
organization NARAL Pro-Choice New York lists the Institute for Family
Health Sidney Hillman Family Practice and Phillips Family Practice as
performing surgical and medical abortions.\1\ The Institute for Family
Health's Web site also indicates that one ``Sidney Hillman'' clinic
doctors works at Planned Parenthood.\2\
---------------------------------------------------------------------------
\1\ See http://prochoiceny.org/boc/sect3_4.shtml (last viewed on
May 6, 2011).
\2\ See http://www.institute2000.org/health/manhattan/hillman.htm
(last viewed May 6, 2011).
---------------------------------------------------------------------------
This is merely one example. Another abortion advocacy group, the
Reproductive Health Access Project, provides detailed guidance on the
ways in which FQHCs can perform abortions while working around some
restrictions relating to their Federal funding.\3\ FQHCs have many
referral and other connections with abortion providers, such as in
South Carolina, where Planned Parenthood boasts that the founder of
PP's Aiken County clinic, Margaret Weston, went on to found local FQHCs
under the name of the Margaret J. Weston Community Health Centers.\4\
---------------------------------------------------------------------------
\3\ See http://www.reproductiveaccess.org/getting_started/faq.htm
(last viewed on May 6, 2011).
\4\ See http://www.plannedparenthood.org/health-systems/history-
28077.htm (last viewed May 6, 2011).
---------------------------------------------------------------------------
2. fqhcs might be using federal money for abortions and related
services
Several Federal law loopholes apparently allow FQHCs to use Federal
funds to pay for abortions and related services, and FQHCs may already
be doing so. For example, the above-mentioned Institute for Family
Health in New York has already received Federal funding under the
``Affordable Care Act Teaching Health Center (THC) Graduate Medical
Education (GME) Payment Program.'' Nothing in the Patient Protection
and Affordable Care Act of 2010 (PPACA) prohibits the funds directly
appropriated under PPACA from being used for abortions. Such
restrictions on PPACA appropriated funds were proposed but rejected in
the legislative process.
The Hyde amendment, an annual Labor/HHS appropriations rider,\5\
prohibits using funds from that appropriations package on any abortion
or on health coverage that includes coverage of abortion. But the Hyde
amendment does not apply to funds appropriated directly to PPACA
including $11 billion that PPACA directly appropriates for FQHCs.
(Although the Hyde amendment does apply to any funds in the same trust
fund as Hyde-applicable funds, PPACA creates a separate trust fund for
its FQHC funds. PPACA, 10503.) And even if an entity gets funds to
which the Hyde amendment does apply, such as section 330 funds, the
amendment does not prohibit the entity from performing abortions--it
only prohibits the entity from expending Hyde-applicable funds on any
abortion.
---------------------------------------------------------------------------
\5\ See, e.g., Omnibus Appropriations Act, 2010, Div. D, tit. V,
507.
---------------------------------------------------------------------------
President Obama's Executive Order 13535 issued in connection with
PPACA does not fix this loophole. The order states, ``I hereby direct
the Secretary of HHS to ensure that program administrators and
recipients of Federal funds are aware of and comply with the
limitations on abortion services imposed on CHCs by existing law.'' But
in ``existing law,'' the Hyde amendment does not restrict PPACA-
appropriated funds.
3. fqhcs claim to be violating federal conscience laws
A leading FQHC advocacy organization recently told the Department
of Health and Human Services that its FQHCs are apparently forcing
their employees to assist abortion-related activities and other
practices in violation of longstanding Federal conscience statutes.
The National Association of Community Health Centers (NACHC), whose
Web site claims to represent at least 1,250 CHCs around the country,
sent a letter in September 2008 asking that HHS not require its FQHCs
to comply with Federal statutes that are applicable to them. Those laws
require FQHCs not to force their employees to violate their
conscientious beliefs. NACHC declared that if the centers were actually
made to comply with these Federal statues, patients would be deprived
of ``access'' to services that their FQHCs are providing.\6\
---------------------------------------------------------------------------
\6\ See http://www.nachc.com/client/documents/
Provider%20Conscience%20Role%20Comments
%209.25.08.pdf (last accessed on May 6, 2011).
---------------------------------------------------------------------------
For example, FQHCs, by virtue of their receipt of funds of section
330 and/or Title X of the Public Health Service Act, must comply with
42 U.S.C. 300a-7(d), which prohibits the FQHCs from requiring any
``individual'' to ``perform or assist in the performance of any part of
a health service program . . . funded in whole or in part'' by the HHS
funds, ``if his performance or assistance in the performance of such
part of such program or activity would be contrary to his religious
beliefs or moral convictions.'' Moreover, by virtue of the Weldon
amendment (attached to Labor/HHS appropriations at 508), FQHCs that
participate in Federal programs funded by HHS cannot ``subject[] any
institutional or individual health care [professional] to
discrimination on the basis that the health care [professional] does
not provide, pay for, provide coverage of, or refer for abortions.''
Nonetheless, at pages 4 and 5 of its letter to HHS, NACHC
specifically objected to its centers being required to comply with this
exact statutory language that applies to them. NACHC even specifically
objected that its centers must not be forced to follow the law
prohibiting them from forcing employees to ``refer for abortions'' in
violation of the Weldon amendment.
Despite the fact that 42 U.S.C. 300a-7(d) says no employee of a
FQHC can be required to even assist in ``any part'' of a program even
partially funded by HHS, NACHC opined that disaster would follow if HHS
actually enforced this language against FQHCs, because it would cause a
``substantial negative impact'' on the services that FQHCs already
deliver.
It is necessarily true that if FQHCs are presently providing a
service, and if their being made to comply with conscience-respecting
statutes would reduce their provision of that service, then the FQHCs
must be presently discriminating against present or prospective
employees who conscientiously object to assisting in those services.
The NACHC letter is therefore an admission that FQHCs are engaged in
widespread violation of Federal conscience statutes.
NACHC lamented that its FQHCs must be able to force individuals to
assist in the performance of parts of their federally funded programs
against their religious beliefs, including ``a vast array'' of services
that FQHCs perform themselves, and a ``wide'' practice of referring and
counseling patients to obtain ``services that the health center does
not (or cannot) provide'' from ``a wide network of community
providers.''
NACHC objected that centers should not be required to follow
Federal statutes that prohibit them from forcing individuals to assist
in morally objectionable federally funded programs, because ``if health
care personnel and support staff are allowed to ``opt-out'' of
performing services which they find objectionable, effectively health
centers will be unable to meet their statutory and regulatory
obligations to furnish required services to all residents of their
service area.''
In other words, even in NACHC centers that do not perform abortions
themselves, the FQHCs use Federal money to counsel and refer patients
for abortions at locations such as nearby Planned Parenthood centers
(the ``wide network of community providers''), and the FQHCs do commit
other potentially objectionable practices, but they claim they will not
be able to do such things unless they are allowed to force employees to
participate in violation of Federal law.
______
American College of Emergency Physicians,
May 8, 2011.
Hon. Orrin Hatch,
104 Hart Senate Office Building,
Washington, DC 20510.
Dear Senator Hatch: On behalf of the American College of Emergency
Physicians (ACEP), I am writing to share with you information about the
Nation's emergency departments that I believe will be very useful in
preparation for your hearing on Wednesday. Based on the title of the
hearing, ``Diverting Non-urgent Emergency Room Use: Can It Provide
Better Care and Lower Costs,'' ACEP wants to be sure that the members
of your subcommittee have all of the relevant facts at their disposal
when discussing this significant issue.
First, the Center for Disease Control and Prevention's (CDC) 2008
study states that of the nearly 124 million annual patient visits to
emergency departments, only 8 percent have non-urgent (``needing care
in 2 to 24 hours'') conditions. By comparison, the number of non-urgent
patients in 2005 was 14 percent. Furthermore, the CDC states that the
term ``nonurgent'' does not imply unnecessary.
Second, it is important to understand that all services provided in
the emergency department, including physician services, account for
less than 2 percent of the Nation's health care costs. According to the
Agency for Healthcare Research and Quality (AHRQ), total spending on
emergency care in the United States was $47.3 billion in 2008. However,
total health care expenditures were estimated at $2.4 trillion in 2008.
Third, while it may cost more for patients to visit an emergency
department than to obtain services at a physician's office or community
health center, the comprehensive care available in the emergency
department, due to our access to diagnostic imaging, lab tests, other
physician services, etc., is unequaled. Unlike most other health care
providers, our services are available 24 hours a day, 7 days a week,
and 65 percent of emergency department patients arrive after normal
business hours. Emergency departments are prepared to diagnose and care
for the most complex medical conditions, and physicians regularly refer
their patients to us. In a poll ACEP recently conducted, 97 percent
reported that patients are referred daily to their emergency
departments by primary care physicians.
Emergency physicians and their departments are essential to the
Nation's health care delivery system. They are truly America's health
care safety net and many emergency physicians dedicate their lives to
injury prevention and educating the public about how to prevent medical
emergencies. However, the reality of the Nation's population
demographics, as well as physician shortages and an analysis of those
seeking emergency care, show that dissuading patients from using
emergency departments is not likely to be an effective strategy. In
addition, the nature of emergencies, which are unscheduled events, and
the needs of patients must be taken into account as policymakers and
health care stakeholders develop new paradigms for how health care will
be provided in the future. We look forward to working with the HELP
Committee and the Primary Health and Aging Subcommittee as it works to
balance health care costs and the need to maintain a vibrant emergency
care system.
Sincerely,
Sandra Schneider, M.D., FACEP,
President.
______
U.S. Government Accountability Office (GAO),
Washington, DC 20548,
April 11, 2011.
Hon. Tom Harkin, Chairman,
Committee on Health, Education, Labor, and Pensions,
U.S. Senate.
Hon. Bernard Sanders, Chairman,
Subcommittee on Primary Health and Aging,
Committee on Health, Education, Labor, and Pensions,
United States Senate.
Subject: Hospital Emergency Departments: Health Center Strategies That
May Help Reduce Their Use
Hospital emergency departments are a major component of the
Nation's health care safety net as they are open 24 hours a day, 7 days
a week, and generally are required to medically screen all people
regardless of ability to pay.\1\ From 1997 through 2007, U.S. emergency
department per capita use increased 11 percent.\2\ In 2007, there were
approximately 117 million visits to emergency departments; of these
visits, approximately 8 percent were classified as nonurgent. The use
of emergency departments, including use for nonurgent conditions, may
increase as more people obtain health insurance coverage as the
provisions of the Patient Protection and Affordable Care Act (PPACA)
are implemented.\3\
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\1\ In order to participate in Medicare, hospitals are required to
provide a medical screening examination to any person who comes to the
emergency department and requests an examination or treatment for a
medical condition, regardless of the individual's ability to pay.
Social Security Act 1866(a)(1)(I), 1867 (codified at 42 U.S.C.
1395cc(a)(1)(I), 1395dd). Medicare is the Federal health program that
covers seniors aged 65 and older, certain disabled persons, and
individuals with end-stage renal disease.
\2\ 1n 1997, there were an estimated 35.6 emergency department
visits per 100 people compared to 39.4 visits in 2007. See P. Nourjah,
``National Hospital Ambulatory Medical Care Survey: 1997 Emergency
Department Summary,'' Advance Data, no. 304 (1999), and R. Niska, F.
Bhuiya, and J. Xu, ``National Hospital Ambulatory Medical Care Survey:
2007 Emergency Department Summary,'' National Health Statistics
Reports, no. 26 (2010).
\3\ For purposes of this report, we refer to the Patient Protection
and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119, as amended
by the Health Care and Education Reconciliation Act of 2010, Pub. L.
No. 111-152, 124 Stat 1029, as PPACA. According to estimates from the
Congressional Budget Office (CBO), an additional 32 million individuals
are projected to obtain health insurance coverage by 2019; CBO also
estimates that gaining insurance increases an individual's demand for
health care services by about 40 percent. See D. Elmendorf, Director,
CBO, ``Economic Effects of the March Health Legislation'' (presentation
at the Leonard D. Schaeffer Center for Health Policy and Economics,
University of Southern California, Los Angeles, CA, Oct. 22, 2010).
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Some nonurgent visits are for conditions that likely could be
treated in other, more cost-effective settings, such as health
centers--facilities that provide primary care and other services to
individuals in communities they serve regardless of ability to pay.
Care provided in an emergency department may be substantially more
costly than care provided in a health center. The average amount paid
for a nonemergency visit to the emergency department was seven times
more than that for a health center visit, according to national survey
data.\4\ While there are many reasons individuals may go to the
emergency department for conditions that could also be treated
elsewhere, one reason may be the lack of timely access to care in other
settings, possibly due to the shortage of primary care providers seen
in some areas of the country.\5\
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\4\ According to estimates from the 2008 Medical Expenditures Panel
Survey (MEPS), the average amount paid for a nonemergency visit to an
emergency department was $792, while the average amount paid for a
health center visit was $108. Similarly, the average charge for a
nonemergency visit to an emergency department was 10 times higher than
the charge for a visit to a health center--$2,101 compared to $203.
MEPS is a set of large-scale surveys of families and individuals, their
medical providers, and their employers across the United States.
\5\ In 2009, we reported that patients' lack of access to primary
care services was one factor that may contribute to emergency
department crowding. The report, which provided a followup to a 2003
report on emergency department crowding, also noted that crowding
continued to occur in hospital emergency departments and that some
indicators of emergency department crowding--such as the amount of time
patients must wait to see a physician--suggested that the situation may
have worsened. See GAO, Hospital Emergency Departments: Crowding
Continues to Occur, and Some Patients Wait Longer than Recommended Time
Frames, GAO-09-347 (Washington, DC: Apr. 30, 2009), and Hospital
Emergency Departments: Crowded Conditions Vary Among Hospitals and
Communities, GAO-03-460 (Washington, DC: Mar. 14, 2003).
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Health centers may serve as a less costly alternative to emergency
departments, particularly for individuals with nonurgent conditions.
Like emergency departments, the nationwide network of health centers is
an important component of the health care safety net for vulnerable
populations, including those who may have difficulty obtaining access
to health care because of financial limitations or other factors.
Health centers, which are funded in part through grants from the
Department of Health and Human Services' (HHS) Health Resources and
Services Administration (HRSA), provide comprehensive primary health
care services--preventive, diagnostic, treatment, and emergency
services, as well as referrals to specialty care--without regard to a
patient's ability to pay. They also provide enabling services, such as
case management and transportation, which help patients access care. In
2009, more than 1,100 health center grantees operated more than 7,900
delivery sites and served nearly 19 million people. With increased
funding from PPACA--projected to be $11 billion over 5 years for the
operation, expansion, and construction of health centers \6\--health
center capacity is expected to significantly expand, with the National
Association of Community Health Centers estimating that health centers
could more than double their capacity to 40 million patients by
2015.\7\
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\6\ Specifically, PPACA appropriated $9.5 billion for fiscal years
2011 through 2015 to a new Community Health Centers Fund to enhance
funding for HRSA's community health center program. It also provided
$1.5 billion over that same time period for the construction and
renovation of community health centers. Pub. L. No. 111-148, 10503,
124 Stat. 119, 1004 (2010); Pub. L. No. 111-152, 2303, 124 Stat. 1029,
1083.
\7\ National Association of Community Health Centers, Expanding
Health Centers Under Health Care Reform: Doubling Patient Capacity and
Bringing Down Costs (Bethesda, MD, June 2010).
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Given the increased use of emergency departments, concern over
adequate access to primary care, and increased Federal support for
health centers, you requested that we examine how health centers may
help reduce the use of emergency departments. In this report, we
describe strategies that health centers have implemented that may help
reduce the use of hospital emergency departments.
To conduct our work, we interviewed officials from 9 health centers
about strategies that they have implemented that may help reduce
emergency department use. We selected health centers to provide
geographic variation and to ensure that health centers serving rural
and urban areas were represented. We based our selection on our review
of relevant literature published in the past 5 years and interviews
with officials from HRSA and experts, specifically representatives from
the National Association of Community Health Centers and individuals
who have conducted research on health centers and emergency department
utilization. We also e-mailed all State and regional primary care
associations--private, nonprofit membership organizations of health
centers and other providers--to identify specific health centers in
their jurisdictions that had implemented strategies that may have
reduced emergency department use.\8\ (Enc. I provides selected
characteristics of the individual health centers interviewed.) To gain
additional insights and perspectives on the information obtained from
the nine individual health centers, we also conducted group interviews
with officials from multiple health centers operating in three
States.\9\ In our interviews, we asked health center officials to
describe the strategies they have implemented that may help reduce the
use of emergency departments for conditions that might also be treated
in other care settings, such as health centers. We also asked health
center officials to describe key factors contributing to the
strategies' success and any challenges to implementation. Additionally,
we requested any data or evaluations the health centers had on the
effectiveness of each strategy implemented. We also collected
information about health centers' strategies from the literature and
our interviews with agency officials and experts.
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\8\ We received responses from 21 of 52 regional and State primary
care associations we contacted.
\9\ Specifically, we conducted group interviews with officials from
6 health centers in Colorado, 13 health centers in Pennsylvania, and 9
health centers in Wisconsin. Similar to our individual health center
selection, these States were selected to provide geographic variation
and to ensure that health centers serving rural and urban areas were
represented.
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We conducted this performance audit from November 2010 through
April 2011 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit
to obtain sufficient, appropriate evidence to provide a reasonable
basis for our findings and conclusions based on our audit objectives.
We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objectives.
results in brief
Health centers have implemented three types of strategies that may
help reduce emergency department use. These strategies focus on (1)
emergency department diversion, (2) care coordination, and (3)
accessibility of services. For example, some health centers have
collaborated with hospitals to divert emergency department patients by
educating them on the appropriate use of the emergency department and
the services offered at the health center. Additionally, by improving
care coordination for their patients, health centers may help reduce
emergency department visits by encouraging patients to first seek care
at the health center and by reducing, if not preventing, disease-
related emergencies from occurring. Finally, health centers employed
various strategies to increase the accessibility of their services,
such as offering evening and weekend hours and providing same-day or
walk-in appointments--which help position the health center as a
convenient and viable alternative to the emergency department. Health
center officials told us that they have limited data about the
effectiveness of these strategies, but some officials provided
anecdotal reports that the strategies have reduced emergency department
use. Health center officials described several challenges in
implementing strategies that may help reduce emergency department use,
such as the difficulty in changing the behaviors of patients who
frequent the emergency department. HHS provided a technical comment on
a draft of this report, which we incorporated.
background
Emergency department visits are often made at night and on weekends
by patients with varying sources of payment and levels of severity. Not
all emergency department visits may be necessary; some visits may be
handled in less costly settings or even avoided altogether through
better management of chronic conditions. Lack of awareness of other
sources of care, lack of access to primary care and other providers,
and financial barriers can contribute to emergency department use,
including use for nonurgent conditions. Health centers, which are
required to serve patients regardless of ability to pay, are an
important safety net provider for financially or otherwise vulnerable
populations.
Emergency Department Use
There were an estimated 116.8 million emergency department visits
in 2007, according to the most recent publicly available report from
HHS's National Center for Health Statistics (NCHS).\10\ For a majority
of these visits (about 65 percent), patients arrived in the emergency
department on weekdays from 5 p.m. to 8 a.m., and on the weekends.
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\10\ NCHS is an agency within HHS's Centers for Disease Control and
Prevention that compiles statistical information to guide actions and
policies to improve health. Annually, NCHS collects data on U.S.
hospital emergency department utilization using a nationally
representative survey, the National Hospital Ambulatory Medical Care
Survey.
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Emergency department visits were made by patients with varying
sources of payment. Individuals with private insurance coverage
represented the largest percentage of emergency department visits
followed by those with health insurance coverage through Medicaid or
the State Children's Health Insurance Program (CHIP).\11\ (See table
1.) Research indicates that Medicaid patients have a disproportionately
higher share of emergency department use compared to patients with
other sources of payment.\12\
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\11\ Medicaid is a joint Federal-State program that finances health
care for certain low-income adults and children. CHIP is a joint
Federal-State program that finances health care coverage for children
in families with incomes that, while low, are above Medicaid
eligibility requirements.
\12\ See, for example, Committee for the Future of Emergency Care
in the United States Health System, Hospital-Based Emergency Care: At
the Breaking Point (Washington, DC: National Academies Press, 2007).
Table 1.--Emergency Department Visits by Source of Payment, 2007
------------------------------------------------------------------------
Number of
visits Percentage
Source of payment (in of visits
thousands)
------------------------------------------------------------------------
Private insurance............................... 45,580 30
Medicaid \1\.................................... 29,379 25
Medicare........................................ 20,133 17
No insurance \2\................................ 17,926 15
Unknown \3\..................................... 10,484 9
Other \4\....................................... 4,587 4
------------------------------------------------------------------------
Source: GAO analysis of National Center for Health Statistics data.
Note: There were 116.8 million emergency department visits in 2007.
Because more than one expected source of payment may be reported per
visit, the total number of visits by source of payment exceeds 116.8
million and the sum of the percentage of visits by source of payment
exceeds 100 percent.
\1\ Medicaid includes visits where the payment source was the State
Children's Health Insurance Program.
\2\ `The National Center for Health Statistics defines no insurance as
having only self-pay, no charge, or charity as payment sources.
\3\ `Unknown includes visits where the payment source was either unknown
or blank.
\4\ Other includes visits where the payment source was workers'
compensation or other.
Patients present to the emergency department with illnesses or
injuries of varying severity, referred to as acuity level.\13\ Each
acuity level corresponds to a recommended timeframe for being seen by a
physician--for example, patients with ``immediate'' conditions should
be seen within 1 minute and patients with ``emergent'' conditions
should be seen within 1 to 14 minutes. In 2007, urgent patients--
patients who should be seen by a physician within 15 to 60 minutes--
accounted for the highest percentage of visits to the emergency
department. Nonurgent patients--patients who should be seen within 2 to
24 hours--accounted for 8 percent of visits. (See fig. 1.)
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\13\ NCHS developed time-based acuity levels based on a five-level
emergency severity index recommended by the Emergency Nurses
Association.
Studies have shown that some emergency department visits may have
been avoided through the use of appropriate and timely primary care and
preventive care.\14\ Additionally, better management of chronic
conditions, such as diabetes, asthma, and congestive heart failure,
could also reduce the need for emergency department visits.
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\14\ For a review of literature on emergency department
utilization, including utilization of the emergency departments for
potentially preventable conditions, see D. DeLia and J. Cantor,
Emergency Department Utilization and Capacity, Research Synthesis
Report No. 17 (Princeton, N.J.: The Robert Wood Johnson Foundation, The
Synthesis Project, July 2009).
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There are a number of factors that contribute to the use of
emergency departments. Some patients may believe the emergency
department provides more convenient, comprehensive, and better quality
care than care provided in other settings. In addition, some patients
may be unaware of alternative sources of care available within their
community or may experience difficulty accessing primary or specialty
care. Specifically, patients may have difficulty finding providers
willing to accept new patients; patients with certain types of health
coverage, such as Medicaid; or patients who are uninsured. There may
also be difficulty finding providers with available and convenient
appointment times. For example, studies have found that emergency
department utilization is higher in areas with fewer primary care
providers, including areas with fewer health centers, and that growth
in emergency department visits among patients with mental health
conditions has coincided with reductions in the general availability of
mental health service providers.\15\ Finally, some patients may
perceive the emergency department to be an affordable source of care,
as emergency departments generally provide medical screenings to
patients regardless of their ability to pay.
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\15\ See, for example, P. Cunningham, ``What Accounts for
Differences in the Use of Hospital Emergency Departments Across U.S.
Communities? '' Health Affairs, vol. 25, no. 5 (2006), and P.
Cunningham, K. McKenzie, and E. Taylor, ``The Struggle to Provide
Community-Based Care to Low-Income People with Serious Mental
Illness,'' Health Affairs, vol. 25, no. 3 (2006).
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HRSA's Health Center Program
To increase access to primary care services for the medically
underserved, HRSA provides grants to health centers nationwide under
Section 330 of the Public Health Service Act.\16\ Health centers
participating in HRSA's Health Center Program are private, nonprofit
community-based organizations or, less commonly, public organizations
such as public health department clinics. Health centers are required
to have a governing board, the majority of which must be patients of
the health center.\17\
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\16\ 42 U.S.C. 254b.
\17\ 42 U.S.C. 254b(k)(3)(H). Under certain circumstances, the
requirement for a governing board may be waived, such as for centers
funded to serve only one or more of the following: homeless, migrant,
or public-housing populations.
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Health centers also are required to provide comprehensive primary
health care services, including preventive, diagnostic, treatment, and
emergency services. Moreover, they are required to provide referrals to
specialty care and substance abuse and mental health services. Health
centers may use program funds to provide such services themselves or to
reimburse other providers.\18\ A distinguishing feature of health
centers is that they are required to provide enabling services that
facilitate access to health care, such as case management, translation,
and transportation. Additionally, HRSA requires health centers to
provide services at times and locations that ensure accessibility and
meet the needs of the population to be served, and to provide
professional coverage for medical emergencies during hours when the
center is closed. Health center services, which may be offered at one
or more delivery sites, must be available to all individuals in the
center's service area with fees adjusted based on an individual's
ability to pay. Uninsured individuals are charged for services based on
a sliding fee schedule that takes into account their income level.
---------------------------------------------------------------------------
\18\ Health centers funded to serve homeless individuals are
required to provide substance abuse services.
---------------------------------------------------------------------------
Health centers primarily serve low-income populations in medically
underserved areas. According to HRSA data, in 2009, the majority of
health center patients whose family income was known had income at or
below the Federal poverty level.\19\ In addition, 38 percent of health
center patients were uninsured and 25 percent spoke a primary language
other than English, the latter of which could indicate a potential
barrier in accessing primary care at other settings that do not offer
translation services. In 2009, half of all HRSA-funded health centers
were located in rural areas.
---------------------------------------------------------------------------
\19\ Family income was known for approximately 75 percent of health
center patients.
---------------------------------------------------------------------------
Research has shown that the annual health care expenditures for
patients receiving care at health centers were lower than those for
other patients. For example, one study showed that average health care
expenditures for a person who received care at a health center were
$3,500 compared to $4,594 for a similar person who did not receive care
at a health center.\20\
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\20\ The study, which compared 2006 annual medical expenditures of
people who received care at health centers and those who had not, made
adjustments for an array of factors, including age, gender, income,
insurance coverage, and health status. See L. Ku, P. Richard, A. Dor,
E. Tan, P. Shin, and S. Rosenbaum, ``Strengthening Primary Care to Bend
the Cost Curve: The Expansion of Community Health Centers Through
Health Reform,'' Geiger Gibson/RCHN Community Health Foundation
Research Collaboration, Policy Research Brief No. 19. (Washington, DC:
The George Washington University School of Public Health and Health
Services, June 30, 2010).
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health centers have implemented three types of strategies that may help
reduce emergency department use
Health centers have implemented three types of strategies that may
help reduce emergency department use, namely strategies for (1)
emergency department diversion, (2) care coordination, and (3)
increasing the accessibility of services, according to our interviews
with experts and health center officials. Our review of the literature
also identified similar types of strategies.
Emergency Department Diversion. Health centers' emergency
department diversion strategies are intended to encourage certain
emergency department patients to use a health center as an alternative
to emergency department care. Such diversion strategies, which
generally are implemented in collaboration with a hospital, focus on
educating emergency department patients on the appropriate use of the
emergency department; informing them about the services offered at the
health center; and arranging appointments at, or referrals to, the
participating health center. Emergency department diversion strategies
may be targeted at patients whose visits are nonurgent, who lack a
regular source of care, who are uninsured or who have Medicaid, or who
are frequent users of the emergency department.\21\ According to the
health center officials we interviewed, their diversion strategies most
commonly focused on preventing future visits to the emergency
department, typically involving health center or hospital officials
interacting with patients after those patients were seen by emergency
department physicians. However, a Colorado health center's program
refers emergency department patients triaged with less acute conditions
to walk-in appointments for treatment at the health center's site,
located less than a mile from the hospital. (See table 2 for other
examples of emergency department diversion strategies implemented by
selected health centers.) According to health center officials, for an
emergency department diversion strategy to be successful, there must be
good communication between the health center and the hospital and buy-
in from the hospital's administration and emergency department staff.
Such buy-in is essential because, according to experts and health
center officials we interviewed, hospitals and emergency department
physicians may face financial disincentives to divert patients.\22\
---------------------------------------------------------------------------
\21\ Health center officials we interviewed provided varying
definitions of frequent users, ranging from individuals with 2 or more
visits per year to individuals with 12 or more visits per year.
\22\ Officials from one health center stated that some emergency
department physicians are paid based on volume and, therefore, may be
less willing to divert patients. Additionally, experts and health
center officials indicated that hospitals may have an incentive to only
divert uninsured patients, who may provide no payment to the hospital
or health center.
Table 2.--Examples of Emergency Department Diversion Strategies Used by
Selected Health Centers
------------------------------------------------------------------------
Description of emergency
Health center (State) department diversion
strategy
------------------------------------------------------------------------
Baltimore Medical System (MD)............. The health center works with
a local hospital to link
eligible patients--
specifically, Medicaid and
uninsured patients with two
or more emergency
department visits in the
previous year--to a primary
care provider at the health
center.
Brockton Neighborhood Health Center (MA).. The health center works with
two local hospitals to
develop treatment plans for
health center patients
identified as having 12 or
more emergency department
visits within a year.
LifeLong Medical Care (CA)................ As a participant in a
countywide initiative, the
health center collaborates
with other providers in the
community to provide
linkages to services and
manage care for frequent
emergency department users,
defined as patients who had
10 or more visits in 12
months, or 4 or more visits
in each of 2 consecutive
years.
------------------------------------------------------------------------
Source: GAO analysis of information obtained through communications
with, and documents provided by, officials from selected health
centers.
Care Coordination. By coordinating the care of their
patients, health centers may help reduce emergency department use by
working to ensure that patients first seek care at health centers
instead of emergency departments and by focusing on the prevention of
disease-related emergencies. Care coordination may include establishing
a plan of care that is managed jointly by the patient and the health
care team, anticipating routine needs, and actively tracking progress
toward patient care plan goals. Health center officials we spoke with
described two types of care coordination strategies--the medical home
model and chronic care management. The medical home model uses a care
team led by a physician who provides continuous and comprehensive care
to patients with the aim of maximizing health outcomes.\23\ Chronic
care management focuses on monitoring and managing chronic conditions,
such as diabetes, asthma, and heart disease, through preventative care,
screening, and patient education on healthy lifestyles. (See table 3
for examples of care coordination strategies implemented by selected
health centers.) Some health center officials we interviewed noted the
importance of including mental health services and patient education as
key components to the success of care coordination. They also noted
that health centers' electronic medical records, especially when
compatible with hospital systems, are helpful in coordinating care but
that acquiring the technology can be expensive.
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\23\ Under the medical home model, the care team is responsible for
providing for all of a patient's health care needs or appropriately
arranging for care with other qualified professionals. This includes
the provision of preventive services and treatment of acute and chronic
illness.
Table 3.--Examples of Care Coordination Strategies Used by Selected
Health Centers
------------------------------------------------------------------------
Description of care
Health center (State) coordination strategy
------------------------------------------------------------------------
Health West (ID).......................... The health center
coordinates care for
patients with chronic
diseases, such as diabetes
and cardiovascular disease,
by proactively scheduling
appointments for care. The
health center's physicians
indicate when patients need
to come in for their next
visits. The information is
recorded in the health
center's electronic medical
records and a report is
generated each week
identifying patients due
for appointments. Health
center staff then contact
each patient to schedule an
appointment.
Lincoln Community Health Center (NC)...... The health center has
education and support
groups for patients with
certain chronic conditions,
including diabetes and
hypertension. The groups
include patient education,
such as food and nutrition
instruction provided by a
dietician; social support,
such as a walking club to
encourage exercise; and
medication management and
guidance on prescription
compliance. In addition,
health center staff work to
coordinate care for all
patients by, among other
things, following up on
missed appointments and
scheduling appointments to
coincide with patients'
needs for prescription
refills.
Northern Counties Health Care (VT)........ Through its medical home
model, the health center's
primary care physicians are
responsible for
coordinating all levels of
patient care, including
referring patients to
specialty care, and
connecting patients to
community services. The
primary care physicians
work with a team of
providers, including
behavioral health
therapists and chronic care
coordinators, to ensure
that patients receive
necessary care. For
example, patients may be
referred to the behavioral
health therapist for
smoking cessation or
assistance managing drug
and alcohol dependence.
------------------------------------------------------------------------
Source: GAO analysis of information obtained through communications
with, and documents provided by, officials from selected health
centers.
Accessible Services. Health centers employ various
strategies to make their services accessible and to raise community
awareness of the services they offer, which can help position the
health center as a convenient and viable alternative to the emergency
department. Such strategies include expanding health center hours to
include evenings and weekends; providing same-day or walk-in
appointments; providing transportation to health center locations; and
locating health center sites in convenient places, such as in or near
hospitals, schools, and homeless shelters. Health centers also use
strategies to provide care to patients outside of the health center,
such as through telemedicine, home visits, and mobile clinics, and may
use translators to reduce linguistic and cultural barriers to care. In
addition, health centers may engage in outreach activities to increase
awareness of their services. For example, a health center in Wisconsin
works with individuals at local community agencies that serve the poor
and uninsured, including public health workers, clergy, and social
workers, to encourage them to refer individuals to the health center
for services. (See table 4 for other examples of strategies health
centers have implemented to increase the accessibility of their
services.)
Table 4.--Examples of Strategies Used by Selected Health Centers to
Increase the Accessibility of Their Services
------------------------------------------------------------------------
Examples of strategies to
Health center (State) increase accessibility of
services
------------------------------------------------------------------------
Access Community Health Network (IL)...... The health center has
several strategies to help
ensure that its services
are accessible and that the
community is aware of the
services offered. For
example:
Community Health Centers (OK)............. To increase access to its
services, the health
center:
United Neighborhood Health Services (TN).. To increase access to its
services, the health
center:
------------------------------------------------------------------------
Source: GAO analysis of information obtained through communications
with, and documents provided by, officials from selected health
centers.
Health center officials told us that they had limited data about
their strategies' effectiveness at reducing emergency department use
and indicated that because health centers often implemented multiple
strategies, evaluating the effectiveness of any one would be
challenging. Officials from one health center we spoke with did have an
evaluation of the countywide emergency department diversion program it
participated in, which found that emergency department visits for
participating patients decreased by 63 percent 1 year after patients
enrolled in the program. Other health center officials provided
anecdotal reports of the impact of various strategies they implemented.
For example, health center officials from Pennsylvania reported that
offering extended hours did help reduce the use of the emergency
department. Additionally, officials from a health center that provides
care coordination indicated that they have seen an increase in routine
visits, which they believe is helping to prevent some emergency
department visits.
Health center officials described several challenges in
implementing strategies that may help reduce emergency department use.
Specifically, officials noted that some services, such as those
provided by case managers, are generally not reimbursed by third-party
payers, but instead must be funded in total by the center.\24\ Another
challenge, according to health center officials, is that health centers
do not benefit from any cost savings resulting from reductions in
emergency department visits. Additionally, health center officials
noted that it is difficult to change the care-seeking behaviors of
certain patients who frequently use the emergency department, including
those who are homeless or have substance abuse and mental health
problems. Finally, some health center officials noted challenges with
recruiting the necessary health providers to serve their patients.
Given that the demand for services may increase as more individuals
gain health insurance coverage as a result of PPACA, several health
center officials we spoke with reported that they have applied for, or
expect to apply for, additional health center funding from HRSA to
expand services (such as by hiring new providers), open new sites, or
renovate existing sites.
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\24\ We previously reported that care coordination services are
generally not covered by health insurance. See GAO, Health Care
Delivery: Features of Integrated Systems Support Patient Care
Strategies and Access to Care, but Systems Face Challenges, GAO-11-49
(Washington, DC: Nov. 16, 2010).
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agency comments
We provided a draft of this report to HHS for review and comment.
HHS provided a technical comment that we incorporated.
As agreed with your office, unless you publicly announce the
contents of this report earlier, we plan no further distribution of
this report until 30 days after its issue date. At that time, we will
send copies of this report to the Secretary of Health and Human
Services, and other interested parties. In addition, the report will be
available at no charge on GAO's Web site at http://www.gao.gov.
If you or your staff have any questions, please contact me at (202)
512-7114 or [email protected]. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last
page of this report. GAO staff members who made key contributions to
this report are listed in enclosure II.
Debra A. Draper,
Director, Health Care.
Attachment I
Characteristics of Individual Health Centers Interviewed, 2010
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Latest Number of Percentage of patients by coverage status in
Number weekday Saturday patient 2009 \2\
Health center (State) of closing hours \1\ visits in -----------------------------------------------
sites time \1\ 2009 Uninsured \3\ Medicaid \4\ Medicare Private
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Access Community Health Network (IL)...................... 58 10 p.m. Yes 799,065 32 55 4 9
Baltimore Medical System (MD)............................. 12 7 p.m. Yes 168,552 20 48 11 21
Brockton Neighborhood Health Center (MA) 2 8 p.m. Yes 100,586 31 60 5 4
Community Health Centers (OK)............................. 4 7 p.m. No 49,768 73 18 4 5
Health West (ID).......................................... 6 6:30 p.m. No 23,000 47 17 12 24
LifeLong Medical Care (CA)................................ 9 9 p.m. Yes 170,098 28 35 26 11
Lincoln Community Health Center (NC)...................... 7 8 p.m. Yes 139,694 80 12 6 3
Northern Counties Health Care (VT)........................ 8 \5\ 7 p.m. No 76,250 8 26 22 44
United Neighborhood Health Services (TN).................. 16 10 p.m. Yes 89,454 51 34 4 11
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Source: GAO analysis of information obtained through communications with, and documents provided by, officials from selected health centers.
\1\ Evening and Saturday hours may not be available at all of a health center's sites and evening hours may not be available all weeknights.
\2\ The totals may not add up to 100 percent because of rounding.
\3\ Uninsured also may include self-pay patients, those who paid out-of-pocket.
\4\ Medicaid may also include people enrolled in the State Children's Health Insurance Program.
\5\ The health center also offers a home health and hospice program, which provides services 24 hours a day, 7 days a week.
Attachment II.--GAO Contact and Staff Acknowledgments
GAO Contact
Debra A. Draper, (202) 512-7114 or [email protected].
Staff Acknowledgments
In addition to the contact named above, key contributors to this report
were Michelle B. Rosenberg, Assistant Director; Jennie F. Apter;
Matthew Gever; Carolyn Feis Korman; Katherine Mack; Margaret J. Weber;
and Jennifer Whitworth.
______
New Jersey Primary Care Association, Inc., (NJPCA),
May 12, 2001.
Hon. Bernard Sanders, Chairman,
Primary Health and Aging Subcommittee,
Committee on Health, Education, Labor, and Pensions,
428 Senate Dirksen Office Building,
Washington, DC 20510.
Dear Chairman Sanders: Thank you for allowing the New Jersey
Primary Care Association to submit testimony on the subject of
``Diverting Non-urgent Emergency Room Use: Can It Provide Better Care
and Lower Costs?'' We understand that there was a hearing on this topic
on May 11, 2011 and the Federally Qualified Health Centers (FQHCs) have
a great deal of experience with this subject.
New Jersey has 20 FQHCs that serve approximately 430,000 patients a
year with over 1.3 million patient visits. These health centers have
seen tremendous growth over the years with a 124 percent jump in their
uninsured patients from 2002-9. New Jersey, unfortunately, was one of
the States that had many distressed hospitals. Twenty-four have closed
since 1992. In many cases, it was the FQHC who stepped up to ensure
that the community still had access to good quality health care. FQHCs
expanded services, sites, and providers and at present have 103 sites
in 19 of the 21 counties. In addition the State of New Jersey
recognizes that FQHCs are low cost, are comprehensive, and that they
provide good quality care. As such, the State, through a bipartisan
effort, has ensured that State funding flows to these centers so that
thousands have access to primary and preventive care. The FQHCs in New
Jersey average $1.17 per day for care which is far lower than the cost
of getting care in an emergency room.
New Jersey FQHCs have worked in partnership with hospitals to
conduct emergency room diversion programs for quite some time. Timely
use of primary and preventive care services reduce the need for
episodic care that patients receive in hospital emergency rooms (ERs)
when medical conditions go undetected and untreated. It is widely
acknowledged that when patients have a regular source of care or a
health care home, they are more likely to be in better health and less
likely to be hospitalized for preventable conditions.
Many New Jersey health centers have collaborative relationships
with their area hospitals to reduce inappropriate ER usage by their
patients. One New Jersey health center, North Hudson Community Action
Corporation (NHCAC), has been recognized in a NACHC publication as
having a successful medical home delivery model that focuses on
reducing ER usage by their patients. NHCAC, located in northern Hudson
County has been a federally qualified health center since 1994. It
serves about 70,000 patients annually via nine sites and one mobile
center. The broad array of services provided by the center includes
adult medicine, pediatrics, dental, prenatal and obstetrics and
gynecology, mental health, and substance abuse treatment. Services are
available 6 days a week with many sites open until 7 p.m. on weekdays
and for extended hours on Saturdays. The main site is open until 10
p.m. on 4 days of the week and on Sunday for at least 6 hours. In an
effort to provide health care that is easily accessible, continuous,
timely, and comprehensive, NHCAC, in collaboration with Palisades
Medical Center, has initiated an Emergency Department (ED) diversion
program. Under this program, health center doctors provide care within
the hospital through a 24 hours a day, 7 days a week with on-call
service for pediatrics and OB/GYN. The program seeks to address the
health care needs of NHCAC's uninsured and underinsured patients who
may be frequent users of the ED. Once a patient is seen by an on-call
doctor at the ED, patients are given appointments at the health center
for their timely followup care. The health center reserves
approximately five appointment slots a day from 1-3 p.m. for these
followup visits at the health center. The primary goal of this program
is to improve and establish continuity of care for patients. Since the
program's inception, both Palisades Medical Center and NHCAC have
reported decreased overcrowding in the ED and improvement in receipt of
continuous primary care by patients.
Two other centers are also working hard to promote timely use of
primary and preventive care services and reduce unnecessary ER visits
for their patients. In 2008, two New Jersey FQHCs, the Monmouth Family
Health Center (MFHC) and the Newark Community Health Center (NCHC)
received funding from CMS through the New Jersey Office of Medicaid to
collaborate with two partnering hospitals to implement an ER Diversion
project. The project titled ``Community Partnership for ED Express Care
and Case Management'' is focused on identifying Medicaid patients who
present at the ERs of the two collaborating hospitals for primary care
conditions; treating and educating them on the proper use of the ER
services; educating the patients on the benefits of having a primary
care home; and setting them up for followup visits at the partnering
health centers; and tracking patient care at the partnering health
centers to evaluate the impact of the project. The focus of this
project is on reducing inappropriate ER usage, educating patients on
the benefits of having a health care home, and in the process improving
the overall health status of the patients that show up in the ERs. As
of December 2010 both Express Pilot EDs have handled 8,718 project
patients and 7,596 of those patients have been referred to the
partnering health centers for followup care. Another key component of
this project was the ability of the hospital to use a terminal to pull
up the appointment system of the FQHC to set up an appointment while
the patient was still at the hospital.
Health centers in New Jersey are very focused on the use of
Electronic Medical Records (EMR) and adoption of Health Information
Technology (HIT) to ensure better quality and safety in patient care
and reduce costs. More than half of New Jersey FQHCs have implemented
their systems and are now linking with hospitals and with State
agencies for seamless care. In addition, 95 percent of the health
centers have used or are still using chronic disease patient
registries. Health information technology can help providers improve
quality of care, reduce medical errors, increase efficiency, reduce
duplicative services, provide timelier patient/provider interactions
and in the process provide significant savings in the delivery of
healthcare services.
Katherine Grant-Davis,
President and CEO.
[Whereupon, at 11:30 a.m., the hearing was adjourned.]