I read an interesting opinion piece today by Rep. Joe Baca (D-California) in the Huffington Post. He brings up an issue that he feels hasn’t been addressed enough in the health care reform debate – “emergency care in many of our nation’s hospitals is in bad shape, and doctors and patients are paying the price.” The article goes on to explain that hospitals are in bad shape because of their requirement to provide emergency care for any and all people whether they have insurance or not. He cites the unfortunate fact that over 70 hospitals in his state have closed down due to financial pressures.

His solution: “adequately reimburse for the mandated emergency services they provide.”

This is certainly a solution, and probably a fair one at that – hospitals should be reimbursed appropriately for the services and care they provide. But part of the reason why the financials of our hospital’s emergency rooms are an issue is due to how they are being used. Too many people use emergency rooms as a primary care facility – seeking medical care for the flu or a sore throat or a minor fever.

This is a behavioral issue, not necessarily a money issue. We as an industry need to do a better job in educating people on how to responsibly engage the health care system. This is particularly important for the underserved population that accepts publicly funded health coverage. As a Medicaid managed care company, we believe this is a significant part of our role since many of our members are faced with poverty and typically access health care when and where it is most convenient. It’s why we assign case managers to our members. It’s why we look closely at ER utilization rates to identify opportunities to reach out to our members and educate them on appropriate usage. It’s why we have a 24-hour nurse line devoted to helping our members determine if their medical condition is a true emergency. It’s why we provide value-added services to our members like transportation to doctor appointments.

But providing these services must be balanced with patient accountability and sufficient access to primary care providers. The entire industry – insurance plans, providers, hospitals, advocacy groups, government – needs to embrace the idea that educating people about proper health care engagement is a critical strategy to lowering costs and increasing quality of care.

We certainly see the prospect of increasing Medicaid eligibility nationwide as a positive step toward helping underserved people access care without sending them to bankruptcy court. But giving people a shiny, new medical card means little without investing in resources which guide people to the appropriate setting – especially those who are more worried about where to get their next meal or how to put off an eviction.

People need to understand the difference between an emergency and non-emergency medical need. People need to understand the potential impact they have on the system when they miss a doctor’s appointment. Or the effect it has on the system when a person decides not to take his/her medication as prescribed.

This needs to become an industry effort. We can keep on throwing money or taking away money from various aspects of the health care system. But when it comes down to it, we need to address the behavioral aspect of users. We need to educate people about how to engage, and we need to find creative ways to do so.

What ideas do you have around how to better educate people about accessing the health care system?

One Response to “Money Can’t Solve Everything…Some Issues Require a Shift in Behavior”

1. Shan Seitz says:

   March 18, 2010 at 11:34 am

   I like that you bring up patient accountability in your article, and I would encourage CareSource to take a more active role in holding their members accountable. On your website you publish your member’s rights and responsibilities…but, there are no repercussions for your members who fail to meet their responsibilities. For example, providers who fail to submit their claims in the time frame established in their contract the repercussion is that provider does not get paid for the service provided and must write off the balance…however, if your member fails to present their insurance information to that provider(which is their responsibility per your website) there is absolutely no consequence to them as a member. What are your plans for holding your members accountable for their responsibilites as a CareSource member? I completely agree that reaching out and educating patients is helpful, but when as a member you are not held accountable for your responsibilites their is little incentive to be an active, educated participant in your personal contribution to health care reform.