What every primary-care physician has long known in his spine, some researchers have just concluded based on a three-year study of health insurance claims from some 2.2 million Americans: Timely primary-care treatment can keep patients out of hospital emergency rooms and cut healthcare costs.
"My first thought is, duh," said Michael Fleming, M.D., president of the 97,000-member American Academy of Family Physicians. "But I'm glad that they looked at this and I'm glad even more that they publicized it. Emergency room care is not very cost-effective care."
The study, released today, was conducted by the Blue Cross and Blue Shield Foundation and the Schneider Institute for Health Policy at Brandeis University. It looked at PPO claims nationwide, focusing on emergency department visits.
It found that patients with what the researchers called "ambulatory care sensitive conditions" such as congestive heart failure, pneumonia, chronic obstructive pulmonary disease, asthma, hypertension and diabetes have "a demonstrated relationship to avoidable hospitalizations."
"There are things you would reasonably expect to manage without access to emergency care," said Allan Korn, M.D., the Blues' chief medical officer. "You can't say that all of these costs will go away, but lots of them do."
The researchers also found that 52% of insured hypertension patients using the emergency department had not visited with a physician in at least a year.
That leads Korn to a troubling conclusion, not specifically part of the study:
"What is absolutely stunning to me, if more than half the patients who go into an emergency room haven't seen a physician in a year, how many of them will be able to understand all those complicated instructions when they go home? Not many."
Worse, Korn said, even after being discharged, many of the patients will not go back to a primary-care physician for follow-up care.
Other survey findings are:
One in five ED visits were for low-acuity conditions, such as rashes and sore throats, best suited for treatment in a primary-care office setting.
The single most important contributor to rising ED costs is the proportion of members -- 10% of those surveyed -- using the ED at least once, and that percentage is rising.
The same researchers are at work, Korn said, on a second study in California comparing PPO patients with HMO patients, who have designated primary-care physicians.
In late March, the American Academy of Family Physicians issued a blueprint for the future of its 97,000-member specialty, which called for primary-care doctors to take back from outsourced entities like insurance companies much of the practice of disease management of chronically ill patients.
One obvious barrier to doing so, the report said, was that most primary-care physicians don't have electronic medical records technology to make disease management practical, and the insurance industry as well government payers, who would derive much of the financial benefits from such systems, don't pay the doctors for them.
A second barrier, according to the report, is even if the information technology were in place, the payers don't have mechanisms in place to pay primary-care physicians for the added DM services such as nurse follow-up and dietary counseling they could provide.
Korn said the Blues plans to invite representatives from the AAFP to a meeting of Blues CMOs this spring. Also, the Blues plans to sponsor a symposium on disease management involving primary-care physicians this fall. Korn said there should be some interesting pilots developing in this area by next year.
Fleming, the managing senior partner of the Family Doctors, a 10-physician group practice in Shreveport, La., said the association will work with the Blues, which says it is willing to help share the cost of providing family physicians with EMRs and developing DM programs.
But, Fleming added, so far, "we haven't seen the rubber meet the road."
"We're going to be pretty aggressive with them. If we are helping them with their bottom line, then some of that needs to come back to the family doctor."