|By the Innovations Exchange Team|
“We need to invest more resources to increase primary care capacity and help underserved patients avoid unnecessary emergency department visits.” —Herbert C. Smitherman Jr., MD, MPH, FACP
Inappropriate and costly visits to emergency departments are common among medically uninsured and underserved patients. Dr. Herbert C. Smitherman Jr., an internal medicine physician specializing in care for the underserved, has been a leader in efforts to address this problem by connecting vulnerable patients with medical homes that can provide ongoing primary care. For more than 24 years, Dr. Smitherman has worked with diverse communities in Detroit to develop urban-based primary care delivery systems. In 1999, he helped launch the Voices of Detroit Initiative in Wayne County, which has improved access to care for more than 74,578 individuals in the Detroit area. A key component of the initiative is its Emergency Department Intervention Program, which helps transition underserved patients from emergency departments to primary care settings.
Innovations Exchange: Please explain the importance of care coordination for underserved patients seen in emergency departments.
Dr. Smitherman: Patients who are underserved or on Medicaid are disproportionately seen in emergency departments, which have more than 120 million visits annually. Many of these patients seek emergency care for medical conditions that should be treated in primary care settings. Unnecessary visits to the emergency department by underserved patients are much more expensive than primary care visits, and the high cost of uncompensated care is affecting the bottom line for many hospitals. This has led to growing interest in developing programs to help these patients get care at community clinics or office practices. Such patients often have a real need for medical assessment, and a simple phone call to a primary care office might be enough. But patients without a regular source of primary care often rely on the emergency room for routine care. We need to invest more resources to increase primary care capacity and help underserved patients avoid unnecessary emergency department visits.
What barriers do underserved patients need to overcome to avoid unnecessary visits to the emergency department?
Some of the main factors are concerns about medical bills, loss of income because of the need to take time off from work to see a physician, lack of transportation, childcare issues, and limited primary care office hours. When we tell patients they will get discounted or possibly free primary care services (depending on their income), many still fear that they will receive a “huge bill” later. Difficulty in taking off time from work is a big issue. It’s important to keep in mind that, nationally, approximately 80 percent of the uninsured come from working families. In Detroit, about 56 percent of the uninsured are employed. For hourly workers with limited transportation resources, regular clinic hours are often not compatible with their work schedules.
How much progress has been made in addressing this problem?
Nationwide, there has been only limited progress in reducing unnecessary emergency department visits by patients without access to primary care. Many efforts have been small projects that involve little more than hiring a care coordinator, with limited funding from grants or local health departments. To achieve significant intermediate and long-term cost savings, a hospital, health system, or community needs to develop a comprehensive program and make upfront investments to expand primary care capacity. The decision to do that depends in part on the community and local health systems being willing to pursue innovative approaches to building a collaborative and coordinated community-wide system of care. Hospital administrators know that they have to do something different to connect people to primary care services. When hospital administrators say they don’t want to spend the money, we tell them, “You’re spending money already.”
What is the Voices of Detroit Initiative?
The initiative is a collaborative partnership between local health departments, hospitals, and other organizations that serve vulnerable and uninsured populations in the Detroit area, with the goal of improving access to high-quality health care. In 1998, we received a 5-year grant from the W.K. Kellogg Foundation to develop the infrastructure needed to link 27,500 underserved patients (approximately 14 percent of the uninsured population in the city) to primary care providers. Detroit’s high levels of poverty and uncompensated care had been threatening to cripple our health care infrastructure, and the economics forced us to take action. We developed an emergency department diversion strategy to help patients who are chronic visitors to our emergency departments for primary care needs and who are not linked to the area’s limited safety-net primary care system. Our goal was to demonstrate the value of using improved care coordination to connect such patients to primary care medical homes.
How does the program help patients avoid reliance on emergency departments?
The Voices of Detroit Initiative conducts active outreach from emergency departments to safety-net primary care settings. We have patient navigators and community outreach workers in every emergency department in Wayne County. For uninsured patients who agree to participate, our case managers work with primary care providers who have agreed to provide care to these vulnerable patients at no or significantly discounted costs. Federally Qualified Health Centers are the core of this primary care network. In addition to providing access to primary care services, our case managers do whatever it takes to help patients get to medical appointments. We operate a primary care clinic that’s open evenings and on Saturdays; we help them pay for transportation, and we connect patients with childcare providers when that’s needed. Once we get patients into a primary care setting, we find that there’s a high likelihood they will continue to get care there, as opposed to the emergency department. The biggest challenge is getting them to that first visit.
What other programs have been pursuing similar goals?
At some level, this kind of effort is being made in dozens of places, such as Boston, Cincinnati, Cleveland, Miami, Milwaukee, and a consortium that serves patients in Indiana, Kentucky, and Ohio. Those of us involved in the Voices of Detroit Initiative have spoken with many of the people who have developed these programs in recent years. There are only so many ways to link people to primary care, and sharing successes and failures with one another across the nation is an important way to improve the health care system. Above all, getting people—especially those with few resources—out of emergency departments and into primary care settings requires an active intervention, with adequate resources and infrastructure, because it will not happen spontaneously.
What about providing primary care within emergency departments?
It’s unusual for an emergency department to develop its own primary care service. But increasingly, insurers are saying they will only pay at a primary care reimbursement level for primary care diagnoses and services in an emergency department. This has led some hospitals to have primary care providers in the emergency department, but doing that just perpetuates the problem by encouraging patients to go to the emergency room for all of their problems. Rather than offering primary care services in the emergency department, we as a nation should be ramping up primary care capacity in our communities. This is especially important due to growth of the elderly population and the decreasing number of primary care physicians.
Providing onsite primary care also can lead to misleading results in terms of cost reduction. For example, the University of Mississippi Medical Center set up an electronic referral system for connecting emergency department patients to community primary care clinics. The program reduced return visits to the emergency department for primary care, but the reported cost savings were attributed to reductions in primary care services in the emergency department. Such reductions are not true savings, because primary care should be provided in the community. Programs should quantify the cost savings achieved by an intervention that transitions patients to primary care by measuring reductions in preventable emergency department visits and avoidable hospitalizations, as well as overall improvements in community health outcomes.
What information is needed to assess the value of such programs?
The biggest problem is a lack of bottom-line information about the impact on costs. Also, it’s important to track data and report on the total population of patients who could benefit from the intervention. Having such information would make it easier to evaluate a program such as Milwaukee’s Emergency Department Coordination Initiative, which also uses case management and an electronic scheduling system to ensure that underserved patients have a medical home. When we know the denominator—the total number of patients who are approached about participating in such a program—it’s easier to gauge how effective it has been in reducing utilization and costs.
How successful has your program been?
During the first 5 years (1999 to 2004), the Voices of Detroit Initiative identified 6,535 people as eligible for public insurance programs and linked them to primary care services, and connected another 18,838 people who lacked health insurance to participating primary care providers. Overall, the program has facilitated primary care access for 74,578 underserved Detroiters since 1999, including the 25,373 who participated in the first 5 years of the Voices of Detroit Initiative’s Emergency Department Intervention Program. Overall, that program has transitioned 55 percent of active enrollees out of emergency departments into primary care settings, resulting in a 42-percent cost reduction in preventable emergency department visits and avoidable hospitalizations. We estimate that our program has saved roughly $22 million annually by reducing the number of preventable emergency department visits and hospitalizations for the intervention population. Extrapolating to the entire Detroit underserved population, we estimate the total cost savings to be $168 million out of roughly $400 million in total uncompensated care costs in the community.
How might health care reform under the Affordable Care Act affect the problem?
The Affordable Care Act extends health coverage to millions of previously uninsured Americans, but in Detroit and other areas with a shortage of primary care providers, expanded health coverage without the appropriate primary care capacity could overwhelm the medical safety net. This could exacerbate the problem of emergency departments being inundated by patients without a primary care medical home. In addition to supporting health centers with a mission to care for underserved patients, we must find ways to meet the challenge of providing adequate primary care and preventive services in community physician offices. Communities that have invested in expanding the primary care capacity that is needed to serve their community will reap the future benefits of the Affordable Care Act.
Additional Information and Related Profiles on the Innovations Exchange
Voices of Detroit Initiative
The AHRQ Health Care Innovations Exchange features profiles of programs that have sought to ensure that underserved patients seen in emergency departments have ongoing access to primary care:
Formalized, Technology-Enabled Referral Relationships Between Medical Center and Community Clinics Enhance Access and Reduce Inappropriate Emergency Department Visits
Emergency Department-Based Case Managers Throughout County Electronically Schedule Clinic Appointments for Underserved Patients, Allowing Many to Establish a Medical Home
Hospital Partnership Offers Pathways-Based Case Management Program, Leading to Enhanced Access to Appropriate Care for Uninsured
Chesney JD, Smitherman Jr., HC, Taueg C, et al. Taking care of the uninsured: a path to reform. Wayne State University Press, 2007.
About Herbert C. Smitherman Jr.
Herbert C. Smitherman Jr., MD, MPH, FACP is President and CEO of Health Centers Detroit Foundation, a Federally Qualified Health Center Look Alike that serves the underserved and uninsured in the city of Detroit and Wayne County. He is also the Assistant Dean of Community and Urban Health, and Associate Professor of Internal Medicine at Karmanos Cancer Institute, Wayne State University School of Medicine. His research focuses on health issues in underserved populations and their access to appropriate health care. Dr. Smitherman serves as a member of the Editorial Board of the AHRQ Health Care Innovations Exchange.
Disclosure Statement: Dr. Smitherman reported having no financial interests or business/professional affiliations relevant to the work described in this perspective.