July 3, 2013 Interesting Reads

NEJMEnvy- Strategy for Reform England vs. US in healthcare. The focus ” on the most positive aspects of each system, the characteristics that should inspire envy, we may find solutions to each country’s challenges just an ocean away.” 

This article covers some key areas that we should consider if we are going to improve our healthcare system. Well worth the read.

Incidental EconomistOn What Do Health Economists Agree? This is an interesting concept looking at ‘positive (as opposed to normative) statements’ Here are a few the post is open to suggestions and comments. 

  • Health insurance does not guarantee good health care.
  • Preventive care does not usually pay for itself.
  • Employees pay for all employer-based health benefits; they offset wages or other benefits.
  • Favorable tax treatment of employer-based health benefits leads to greater employer offers and more generous benefits.
  • Employer-based plans serve a risk pooling function.
  • Cost sharing reduces utilization.
  • Physicians influence patients’ level of utilization.

Webfonts by H&FJ: Introducing Cloud Typography

Great idea. It is a cloud technology for type where typography answers each browser with the right type and fast. I wonder if us mere mortals will notice the difference? 

ED, PCP and Medicaid: A Knowledge Translation Solution

The NEJM published ‘Emergency Departments, Medicaid Costs, and Access to Primary Care-Understanding the Link’. The article examined Washington State’s Health Care Authority effort to curb non-emergency care delivered in ED. ‘By July 1, hospitals accounting for at least 75% of ED utilization by Medicaid fee-for-service clients must submit legal attestations that they are complying with the plan. If they fail to do so, the Authority may proceed with implementing its policy of nonpayment for ED visits it determines to be nonemergency visits.’ 

We all know to well the reasons, since 2008 9.8 million Americans have lost employer-sponsored health insurance. Subsequently Medicaid rolls have burgeoned by 7.5 million. States are looking for ways to cut spending on Medicaid and the low hanging fruit is overuse of EDs.  

A 1996 study researchers posted in 56 ED nationwide interviewed 6,187 walk-in patients in a 24 hour period. The majority cited clinical reasons or preferences, while 45% identified a medical emergency and finally 19% said they sent by an HCP.

Will this type of action help Medicaid beneficiaries to not seek nonemergency ED visits and hit the primary care physicians office? Two well made points: most ill patients can’t differentiate a sprain from a break and 3% to 5% patients identified as nonurgent at the ED by a trained triage nurse needed immediate hospitalization. 

For the low income Americans the ED is the only reasonable choice. If they are turned away because of state policies we may be facing a larger crisis of critically ill patients needing greater care at greater cost. The primary care physician is key here. But it is not the only part that needs to be changed. 

This is a complex system of patients, ED, primary care physicians, nurses, and state government all looking at aspects of this issue differently. Trying to change behavior one audience or system at a time with brochures, letters, email, etc. will largely go unnoticed because as you shore of one part of the system the other falters. Healthcare whack a mole. 

This is the perfect example of where Knowledge Translation can bring behavioral change on a large scale.

 Knowledge Translation is defined as:

“the exchange, synthesis, and ethically-sound application of knowledge—within a complex set of interactions among researchers and users—to accelerate the capture of the benefits of research for Canadians through improved health, more effective services and products, and a strengthened health care system (CIHR, 2004).”

Knowledge Translation is the coordination and active manipulation of new knowledge (e.g how to teach patients to not rely on the ED) and it application to all parts of the system through prior research. KT relies on process improvement within these complex systems, not simply a laying of pamphlets on learners. Or forced economic changes. It is a system wide approach.

In my estimation we need to step beyond Draconian responses to a single aspect of a problem (i.e. overuse of the ED) and look at the entire system. Attack it as a systemic problem including fixing the primary care mess in America. I have not seen a better example of where KT can be applied to change behavior.