Health Care is Just Too Hard to Use...and It's Not Your Fault

by Michael Booth, Photography by James Chance

Health Care is Just Too Hard to Use ... and It's Not Your Fault.
Health Elevations Spring 2014 Feature

By Michael Booth
Photography by James Chance

Walter Mossberg shook up the technology world by originating that phrasing in 1991. The computers he was talking about have gotten better – you could now run NASA from an iPhone – but health care has not.

Patients with little more than a sore throat or a panic attack show up at full-trauma emergency rooms because that's what "health care" has always meant to them. Or because their doctor's office was closed, and the nurse "help" line was a phone-tree thicket.

The young and the restless might rather pay a fine for bucking the new health insurance mandate because they have no time or patience for Byzantine insurance applications.

Hospital bills are often incomprehensible and a disillusionment to patients even if they're not paying the bottom line.

Mental health care is now theoretically equal under the law to physical care, but patients struggle to connect with a provider.

And will the first person with a short, coherent explanation of "deductible-copay-coinsurance-out-of-pocket-maximum" please stand up?

The storm of criticism that descends on any major health system overhaul can be daunting and can discourage the best-intentioned from bold, public-oriented change. But the Colorado Health Foundation is encouraging health reformers – many mentioned in this issue – to step back and look at the system we are creating through clear eyes. Are we showing Colorado residents the simplest tools to guide their own health and wellness? If we agree on the goal of useful health insurance and accessible health care, have we made it clear how to find those? And are we offering Colorado the right care in the right places at the right time, so that good health is attainable and affordable to everyone?

Health Elevations Spring 2014 Reducing Uninsured
Picturing where Colorado has the highest concentration of uninsured residents can help health leaders concentrate their resources in the areas they can be most effective. [Learn More]

What happens when Colorado consumers don't know how to acquire health insurance or how to use the health care system once they've got it? Billions of dollars are wasted, and worse, Coloradans miss the chance to be as healthy as they could be.

The growing complexity of health coverage and health care – not yet solved by an Affordable Care Act that is itself multi-layered – is not by "grand design," as Northwestern University's Kellogg School of Management professor Joel Shalowitz, MD, puts it. "It's by incremental stupidity."

The private sector, nongovernmental organizations and government agencies work furiously to untangle the mess for consumers. "Right care, right place, right time" is one mantra at Colorado's Centura Health system, the largest hospital network in the region. "We spend a lot of money with people going to the wrong place for care," said Pam Nicholson, senior vice president of strategic integration at Centura.

Yet hospital groups and other health institutions remain at the forefront of many complaints, from their billing practices to a recent "arms race" to build high-revenue emergency department space.

"The health care 'system' is not a system," said Elbert Huang, MD, of the University of Chicago's Center for Advanced Medicine. "It's a hodgepodge of randomly occurring entities." Huang likens the Affordable Care Act's extension of insurance to most Americans to handing a person the keys to a car stocked with outdated road maps.

This year's debate over the race to build emergency treatment space up and down the Front Range – a contest joined by nonprofits and for-profits alike – is a telling example of wider confusion over how to best use health insurance and health care.

The ER is the place that, when you have nowhere else to go, they have to take you in.

"People find emergency departments not only to be the safety net, but it's preferred because it's patient-centered," said University of Colorado Hospital's vice chair of emergency medicine Jennifer Wiler, MD. Patients walk in at any time, get diagnosed relatively quickly, and leave with the answers and medicine they need. "Patients like it," Wiler said.

A recent flurry of studies nudged researchers toward learning why emergency space is a first resort, rather than a last, for many consumers, and what the rest of the health care system could learn from the results.

A Colorado Health Institute exam of ER use in 2012 found a majority of ER patients could not get an appointment at a primary care site or could not use the regular doctor or clinic hours.

Both newly insured and newly uninsured consumers use emergency departments at much higher rates than those who have been stably insured or uninsured for a long time, according to a study by Wiler and others published in the Archives of Internal Medicine.

Patients visit emergency departments because of "lack of timely options elsewhere," according to a recent RAND Corp. study. That review also found the entire health system relying more on ER doctors as triage for inpatient admissions and other options.

What new ideas will help consumers, their insurers and their providers answer the call to simplify, simplify?

Denver Health, swelling with both paying, exchange-driven members of its managed insurance plan and expanded Medicaid patients, "has a SWAT team on this trying to figure it out," said LeAnn Donovan, CEO of the Denver Health Medical Plan.

"I would venture it's as high as 20 percent of people in the medical plan who go to the emergency department shouldn't be there, given what they've got," Donovan said. The most common misdirected complaints include low-acuity situations like coughs and colds, the flu, pink eye, earaches and urinary tract infections.

Many could be "caught" and helped by the existing nursing phone line, which translated nearly 200 different languages last year. But oddities arise that cry out for addressing: 60 percent of Denver Health's Medicaid population is Hispanic, yet they make up only 6 percent of the nursing calls.

Nurses can diagnose a urinary tract infection by common symptoms right over the phone, Donovan noted, and send a prescription to the consumer's nearest pharmacy. A taxi voucher is available to get those without cars to a pharmacy or clinic.

Another Denver Health goal is to establish more urgent care clinics within the year, by plotting ER usage from the consumer's home ZIP code. The city-based health network also contracted recently with Walgreens retail clinics, authorizing payment for convenient consumer care at the widespread drugstore locations.

Centura is also deepening its relationship with Walgreens, locations that have proven popular for everything from high school sports physicals to strep tests.

The parent of St. Anthony, Penrose-St. Francis and other hospitals tries to use visits at affiliated Walgreens clinics to make "warm transfers" of patients who don't yet have a primary care home. In a warm transfer, the Walgreens Take Care nurse practitioner puts the patient on the phone live with a virtual resource center run by Centura, as opposed to the "cold transfer" of just handing over a phone number and hoping the patient uses it later.

Patients who came through one of the Connect for Health Colorado exchange insurance plans using Centura as the exclusive medical provider are offered a free primary care visit, lab workup and risk assessment. They also get a loaded gift card to spend on future health care.

Centura signed an agreement with Walgreens to study the work flow between the retail clinic nurse practitioners and physician assistants, and the local primary care doctors. Even chronic-disease patients could use the convenient retail locations to manage their care. "An NP or a PA working to the full level of their license can do a lot," Centura's Nicholson said.

Meanwhile, the primary physician practices Centura has absorbed or affiliated with will be required to extend after-hours access, with office hours and doctor-staffed call centers, within two years, officials said.

"Getting a doctor" after signing up for insurance is, among some Colorado groups, a cultural assumption that not everyone follows.

Servicios de La Raza in Denver has seen a heavy caseload of consumers who have heard about the Affordable Care Act and want to take the next step. Some see a Medicaid health coverage guide, others see a guide tapped into Connect for Health's private insurance offerings, as part of the "no wrong door" concept of health access. Often in the Latino community, the first step is integrating the very concept of health care for a family where "Mom was going to urgent care, Dad was going to Campesina clinics, and kids had access to Medicaid," said Mirna Castro, CCARES program manager for Servicios.

Some learned they had access to private insurance through their employer, "and we'll say, 'You need to go to your HR department,'" Castro said. "And they'll say, 'No one speaks Spanish at my HR!'"

While focusing during the winter and spring on signing people in a health insurance plan of any kind, Servicios will be among the agencies changing focus over the summer to the "get a doctor" step. "We need to start talking about where is the right place to go for care," Castro said.

The sprawling New West Physicians group, based in Golden, is redoubling efforts to get its patients out of the ER and to better, more responsible care.

New West, with 80 providers, 16 locations and 160,000 patients, launched its own urgent care office with extended hours two years ago. It is watching demand carefully, and plans another urgent care location.

A nurse practitioner reviews a daily report on all New West patients who went to an ER the day before, then follows up on their symptoms. If they went in for a migraine, for example, then an office visit and better medication could prevent the next "frequent flier" ER trip.

Feature 1 Image - Hive PracticeThe practice is also redesigning itself around a "hive" model of primary care, matching patients to a team including a physician, a midlevel practitioner and two medical assistants. The doctors concentrate on the complex cases, while other team members treat lesser complaints. "We're hopeful that will improve waiting times and other frustrating aspects," said Ken Cohen, MD, chief medical officer of New West.

Cohen is among those making the argument that government systems could influence ER use by charging copays for Medicaid users, or creating other incentives or small penalties. "A $10 copay makes big changes," he said. "I firmly believe some financial responsibility results in a huge behavior shift."

Physician and state Sen. Irene Aguilar, a Denver Democrat, agrees insurers and government planners might need to consider more sticks as well as carrots. The first proposals will be attacked, but inappropriate use costs the whole system, Aguilar said. A combination of patient education and firm redirection to different care could make such changes "socially acceptable," she said.

Salud Family Health Centers, with nine clinics stretching from the northeast Denver suburbs toward the Nebraska border, is using a "patient portal project" with state Medicaid to give worried patients more options.

Salud is working to link every patient with an online sign-in, providing direct emailing to doctors and nurses, and access to labs and medical records, appointment calendars and prescription refill requests. If an online depression-screening questionnaire adds up to a cry for help, a mental health provider reaches out to the patient.

A patient with an earache recently used the portal to explain symptoms to her doctor. The provider advised to keep using an antibiotic for 24 hours before going to the ER, and the symptoms resolved.

Salud has about 13,000 of its 73,000 patients connected to the portal and plans to reach half in 2014, officials said.

University's Wiler has worked with the Aurora-based hotspotting program, Bridges to Care, on a set of frequent ER patients separate from those discovered by the Triage program. Patients with four or more ER visits in six months can get a mental health consult and home visits from a nurse practitioner to sort out underlying problems.

The coordinated care has cut emergency use by 50 percent in the group, successful enough that Wiler would like to see the threshold reduced to three ER visits in six months. "Our early results are very promising," she said.

But a key attitude, she added, is to not just look around a busy ER and sound like a scold.

"It's unfair to blame patients for their choice of site of service," Wiler said. "It's the responsibility of the health community to educate people and cross that disconnect, to remove the barriers so patients want to go where it's best for them."

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