PATIENT EDUCATION: What if Primary Care Was as Easy to Access as the ED?

Veronica Jordan, MD, MS

If you are feeling sick and drive down a decent-sized road in a decent-sized city in the United States, you will eventually encounter a blue H sign indicating a nearby hospital. If you follow that H, you will soon see a large red EMERGENCY sign. And if you walk into that Emergency Department, regardless of your insurance status, regardless of your immigration status, regardless of the nature or severity of your illness, you will be seen. It may be 3 a.m. or 3 p.m., a weekend or a weekday, a private hospital or a public one. You may have money or you may not. You may have to wait one or two or 10 hours. But you will be seen.

If you are similarly ill and don’t want to visit the ED, the path isn’t so simple, and the signs aren’t so obvious. If you don’t have insurance, the problem is dire. If you are undocumented, even more dire. But having health insurance is no guarantee. Identifying a primary care office that is accepting new patients is its own challenge. Many local clinics have sixto eight-week waiting lists for “new patient” appointments; others are at capacity. If you do have a primary care physician, there is no certainty that you will be seen today or even this week. You may spend an hour on hold waiting to talk to someone who may ask a few questions and then offer you an appointment for next Thursday. That same person may verify your insurance and inform you that it is no longer accepted or that your concern does not meet criteria for the limited urgent-care appointments available. She may direct you to the ED after all.

National statistics show that about 20% of American adults use the ED each year, and 7% have two or more visits.¹ Of those who are ultimately not admitted to the hospital, 80% say they used the ED because of access, 67% because of the seriousness of their medical problem, 48% because their primary care physician’s office was not open, and 46% because they had no other place to go.²

EDs are designed to offer highintensity response to acute illness and injury. They must be prepared 24/7 for trauma, natural disaster and whatever comes through the door. Unfortunately, a good percentage of the cases that present in EDs are not appropriate for emergency care, as they are either nonurgent, preventable or some combination of the two. Actual numbers are controversial (estimates range from 13% to 71%), but a recent study found that 59% of the reasons for which patients presented in an ED could have been attended to in a primary care office.³

ED care is also much more expensive than primary care: ED visits cost 320% to 728% more than primary care visits.⁴ A 2013 study of 76.6 million visits found that the median charge for outpatient conditions in the ED was $1,233 (ranging from $740 for an upper respiratory infection to $3,437 for a kidney stone), while the median price for an office visit was $145.5 This difference in cost is partly due to the increased care offered in the ED (35% of patients who go to the ED get an x-ray, and 17% get a CT or MRI scan),² partly due to hospital billing, and partly due to the expensive spectrum of services that must be readily available in an ED in case of a true emergency.

Mental health and substance-use disorders (MHSU) account for 12.5% of visits to the ED.⁶ These are often cases in which patients are treated and released over and over again, putting a tremendous strain on resources. Patients with coexisting mental health and substance abuse diagnoses are much more likely than people with diabetes or chronic respiratory disease to use the ED.6 The more severe the mental health problem, the more frequent the ED visit; uninsured MHSU patients have even more visits.⁶ 

Patients seeking primary care and mental-health services in the ED put layered burdens on an emergency system that isn’t designed to manage chronic illness, offer preventive care or provide continuity. As a result, EDs are overcrowded, overburdened and under-reimbursed (ED patients are more likely to be uninsured or self-pay, so up to 50% of ED claims are not paid), and ED personnel have little space or time to do what they do best. In short, our medical system spends a stupendous amount of money to care for patients in an utterly ineffective way.  

What can we do in primary care to relieve the burden on EDs and ensure that patients are getting the right care in the right place?

The answer is simple. Patients need to have someplace else to go, and that someplace else should be their primary care physician (PCP). Most of my patients know that I am a better option than the ED, but heck, half of my family members and most of my friends still don’t quite grasp the concept.

We need primary care embedded in our communities and our psyches. Last year, when one of my relatives got progressively shorter of breath over a period of months, she didn’t once visit her PCP. Instead, she waited until she was so sick that she had to go to the ED, where she received a new diagnosis of heart failure. A few months later, she had nausea, vomiting and right upper-quadrant pain. Rather than calling her doctor, she again wound up in the ED—this time, flooded with intravenous fluids that were not great for her ailing heart.

In my relative’s defense, her PCP’s office is so overbooked, scheduling so clunky and triage so complex that they probably would have sent her to the ED anyway. Plus, she hardly knew her PCP. In a PCP-centered health system, this lack of familiarity wouldn’t be the case. After all, we PCPs can handle shortness of breath and abdominal pain in the office, and we can often do it better than the ED because we know our patients, can see them again, and are uniquely equipped to prevent similar episodes in the future.

We need to show patients that having a relationship with a PCP will make them healthier and save them money, time and stress. But to do that requires several major overhauls. There need to be enough of us; we need to know our patients, teach our patients and be available to them; and we need to be creative in how we do all of this.

Implementation of the Affordable Care Act has increased the need for PCPs, so we need to enlarge the PCP pipeline by restructuring medical education. This restructuring should emphasize primary care instruction in medical school, foster health-center teaching, change the payment model of graduate medical education, and decrease the financial burden on physicians who choose primary care.^7–9 PCPs must create interdisciplinary teams instead of being dependent on individual physicians, and we must also welcome nurse practitioners and physician assistants to our table.¹⁰ It is literally impossible for us to see the number of patients who need to be seen and do the work that needs to be done without partnering with these practitioners.^11,12

Educating new providers is essential; educating our patients is even more important. Here is a basic question for patients: What constitutes an appropriate ED visit? The most common reason children visit the ED is cold symptoms; the top three reasons for adults are stomach pain, chest pain and fever.^1,3 Nobody should be visiting the ED for a cold, and most stomach pain does not require emergent evaluation or advanced imaging. But patients don’t know that, and when they are ill, they get scared. We can teach patients about appropriate ED use, explaining what is truly an emergency, when they can wait until morning and what they can do in the meantime. We can do all this through office visits and creative media, such as public service announcements, school-based teaching and community health education.^13–15

But to really keep patients out of the ED, we must have an established relationship with them and be available for reassurance when they are scared. I saw a very sick baby last month with bronchiolitis—he was as wheezy as they come. I know the mom well. She is also my patient; she trusts me. With my team’s help, we saw her baby every single day for five days in a row, then every other day, then every third day. The baby got better, and mother and child never went to the ED, despite many friends and family urging them to go.

Truly robust primary care is a marriage of access and trust. We must increase patient access to trusted primary care teams on days, nights and weekends. Our primary care sites need to help patients avoid the ED by offering urgent care through extended hours (early mornings, late nights) and weekends. We need good follow-up with our chronically ill patients to catch them before they get acutely ill. We also need to have more freedom to “see” patients online or on the phone. Our current payment models force us to fill many visits with non-urgent matters, thereby taking up potential urgent-care slots. The payment models also shunt people to the ED rather than saving money and time by helping us attend to them in more creative ways.

When patients who overuse the ED are closely managed by a multidisciplinary team, their ED utilization decreases.¹⁶ These patients respond to individualized care, case management, social work, housing and substance-abuse treatment. At West County Health Centers, we have been working with Partnership Health Plan on projects such as these, and we have seen success. Simple solutions—such as nurse advice lines, weekly medication organizers, home visits and crisis plans— do reduce unnecessary ED visits.

There are countless ways in which PCPs could do a better job of helping patients get the right care in the right place; but perhaps what we really need are signs on the highways and byways directing people toward primary care. Instead of a blue H for hospital, we could have an orange PCP for primary care physicians. And instead of a bright red EMERGENCY, we could have a healthy green PRIMARY CARE.

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Email:  vcjordan@wchealth.org
This article is reprinted from Spring 2016 Sonoma Medicine with permission of the Sonoma County Medical Association. It received SCMA’s Article of the Year Award for 2016.

References

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