As our health system increases the financial responsibility of health care providers, there is increased focus among these providers on reducing costs. Part of this cost-reduction effort involves improving the efficiency and effectiveness of care by ensuring the appropriate use of different sites of care. Clinical pathways can support this effort by going beyond simply which treatments to use and when to use them to also include recommendations regarding where health care services should be provided.
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As the cost and quality differences between various sites of care grow, the selection of specific sites of care becomes increasingly important and complex. One of the most significant differences in costs is seen with hospital-based care. Because hospital outpatient services—including office-based services that are owned by a hospital—are able to charge a separate facility fee, the cost of care in these settings can be significantly greater. This means that, once a physician’s practice is acquired by a hospital, the same treatment in the same infusion chair in the same office can cost significantly more the day after becoming a hospital outpatient service.
Another example of site pricing differences is in the post-acute care facility. As a result of existing Medicare payment policies that focus on phases of a patient’s illness defined by a specific service site, rather than on the characteristics or care needs of the Medicare beneficiary, patients with similar clinical profiles may be treated in different settings—such as long-term acute-care hospitals, inpatient rehabilitation facilities, and skilled nursing facilities (SNF)—at different costs to Medicare. This payment system fails to encourage collaboration and coordination across multiple sites of care and provides few incentives that reward efficient care delivery.
In addition to issues of cost increasing in complexity, the landscape of treatment sites has also become more complex (Table 1), with the growth of infusion centers, convenient care centers, and home care options including telemedicine and paramedic delivered services. Leaving the decision about the most appropriate site of care to patients or to other stakeholders more focused on their own responsibilities, such as shortening lengthen of stay or increasing their own services, can result in poor clinical and economic outcomes.
GUIDING CONVENIENT CARE
An example of the impact of allowing patients to make their own decisions regarding sites of care can be seen in the patient-directed use of retail or convenient care clinics. While retail clinics could serve as an alternative to more expensive physician practice office visits or emergency department (ED) visits, a recent study showed they may actually increase medical spending by leading patients to get more care; rather than replacing a more expensive site of care, 58% of retail clinic visits for minor conditions represented a new use of medical services.1 Those additional visits led to a modest increase in overall health care spending of $14 per person per year. At the same time, this study supported earlier research that found retail clinics provide care that costs 30% to 40% less than similar care provided at a physician’s office and that the treatment for routine illnesses was of similar quality. The study suggested that these savings were more than offset by increased use of medical services, however. Therefore, real cost savings cannot be realized unless the substitution of more expensive sites of care is not accompanied by an increase in overall use of medical services.
Recognizing these opportunities and challenges, the Centers for Medicare & Medicaid Services (CMS) developed a memo directed to state Medicaid programs aimed at reducing non-urgent use of EDs through improving appropriate care in appropriate settings.2 This issue is especially a problem with Medicaid beneficiaries, who use the ED at an almost two-fold higher rate than privately insured individuals.3 Contrary to common belief, this is not due to widespread inappropriate use of the ED among Medicaid beneficiaries, who tend to be in poorer health than the privately insured population; at least two studies found that the majority of ED visits by nonelderly Medicaid patients were for symptoms suggesting urgent or more serious medical problems.4 These studies estimate that non-urgent visits comprise only about 10% of all ED visits by Medicaid beneficiaries and suggest that higher utilization may be, in part, due to unmet health needs and lack of access to more appropriate health care settings. In this context, as most states have recognized, efforts to reduce ED use should focus on improving access to appropriate care settings in order to better address the health needs of the population.
One approach highlighted by CMS is promoting the increased use of convenient care centers, which can occur through pathways. This is based on the fact that two-thirds of emergency visits occur after business hours (ie, weekdays 9:00 AM-5:00 PM). Identifying primary care sites available after business hours is therefore one strategy for improving appropriate access to health care services.5 The private sector estimates potentially $4.4 billion in savings nationwide by increasing urgent care and retail clinic access for patients with non-emergency conditions.6 These efforts require public education, patient navigators, or nurse advice lines to educate beneficiaries about the use of these care sites, guidance that requires the evidence-based structure of a clinical pathway to promote these more efficient and effective alternative sites of care.
CARING FOR THE PATIENT WHERE THEY ARE
One opportunity to promote the use of more appropriate sites of care is to encourage the use of home-based services. For example, the AtlantiCare/Geisinger system (New Jersey) is developing a “home first” program to assist patients and their caregivers, as well as health system staff, to think about the provision of care at home rather than in post-acute or clinic settings. This approach is consistent with the objectives of the triple aim of reducing costs, improving the patient experience, and improving the health of the populations served.
Another way in which at-home care is being promoted is through the expanded role of paramedics, whereby they not only respond to emergencies and transport patients to the ED but also intervene at home to prevent emergencies, treating patients with infections, minor wounds, injuries from falls, and problems associated with chronic diseases like diabetes and congestive heart failure. The objective is to reduce unnecessary ED visits and hospital stays, which can cost thousands of dollars, by providing care at home rather than a much more expensive hospital-based site. This is also being accomplished at home through the use of technology via innovative monitoring, treatment adherence systems, and telemedicine. All of these efforts, when built into clinical pathways, can provide more appropriate site of care recognition thus avoiding more wasteful traditional pathways.
Clinical pathways to direct appropriate sites of care must include the patient and caregivers, as it has been shown that inappropriate selection of site of care often occurs because of patient self-direction. This is especially acute in the SNF, facilities that are staffed to managed a high level of care but are often faced with patients and caregivers that believe that transfer to the hospital setting for care is needed in relatively minor situations.
INTERACT (Interventions to Reduce Acute Care Transfers)9 is a quality improvement program initially designed to assist SNFs with early identification, assessment, intervention, documentation, and communication of changes in a resident’s condition. INTERACT was first designed in a project supported by CMS and is being used as a resource to promote more appropriate site of care. Due to multiple successful applications of INTERACT, the program has been applied to settings outside of SNFs such that the INTERACT resources and principles have application to clinical pathways for all patients.
A specific series of resources developed by INTERACT provide guidance to patients, their caregivers, and SNF providers to better direct care to the appropriate setting, which, in many situations, is through these patients receiving care right where they are. Through the incorporation of these same principles in clinical pathways, the objectives of the Triple Aim can be achieved.
Clinical pathways have an opportunity to call out specific sites of care in order to promote more efficient and effective use of resources. For example, blood transfusions have historically been completed in the hospital setting, but clinical pathways are being developed so that, for the right patient, these services can be completed in outpatient settings as well as within an SNF, resulting in lower costs and in some situations a much more convenient service to the patient. The same is true for uncomplicated deep vein thrombosis or pulmonary embolism, which traditionally have been addressed through the ED into the hospital. Now, clinical pathways are being developed that provide guidance on treating these conditions and others in lower cost, more convenient care settings. In the end, site of care is another opportunity for clinical pathways to help deliver on the Triple Aim for patients, payers, and providers.
References
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2. Mann C. CMCS Information Bulletin. Reducing nonurgent use of emergency departments and improving appropriate care in appropriate settings. Department of Health and Human Services, Centers for Medicare & Medicaid Services, Center for Medicaid and CHIP Services. https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-01-16-14.pdf. Published January 16, 2014. Accessed October 21, 2016.
3. Garcia TC, Bernstein AB, Bush MA. Emergency department visitors and visits: who used the emergency room in 2007? NCHS Data Brief. 2010;38:1-8.
4. Sommers AS, Boukus, Carrier E. Dispelling myths about emergency department use: majority of Medicaid visits are for urgent or more serious symptoms. Res Brief.
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5. Pitts SR, Carrier ER, Rich EC, Kellermann AL. Where Americans get acute care: increasingly, it’s not at their doctor’s office. Health Aff (Millwood). 2010;29(9):1620-1629.
6. Some hospital emergency department visits could be handled by alternative care settings [press release]. RAND Corporation. https://www.rand.org/news/press/2010/09/07.html. Published September 7, 2010. Accessed October 21, 2016.
7. State of New Jersey Department of Health. Facility Types. NJ Health website. htpp://www.nj.gov/health/healthfacilities/about-us/facility-types/. Accessed October 21, 2016.
8. HealthSmart. Facility Type Definitions. https://providerlookup.healthsmart.com/Documents/Helps/Facility_Type_Definitions.pdf. Accessed October 21, 2016.
9. Interventions to Reduce Acute Care Transfers. https://interact2.net. Accessed November 10, 2016.
