Context Is Everything - or At Least an Awful Lot!

An ongoing problem in health care is the use of Emergency Rooms as primary care providers. With that in mind, I was interested to see the story, How Oregon Is Getting 'Frequent Fliers' Out Of The ER by Kristian Foden-Vencil on the NPR web site.

The article describes efforts to address the social needs and issues that keep patients out of primary care, and so in the Emergency Room. It looks at one patient as an example, and speaks to the needs he has for housing, clothing, dependable food - all those things that make for stability. With stability, he has been able to avoid expensive ER care and instead see a primary care physician, get necessary medications, and stay on them. Without stability, he has hardly any choice.

This is a well known problem; and, really, this is not a new solution. However, it's not always the first to come to mind. There is some expense in meeting his social needs and in following through with him so that he uses resources effectively. However, as the article notes, those are only a fraction of the expenses generated with avoidable visits to the ER and avoidable admissions to hospitals.

On the other hand, this is very different from our more common use of resources in health care. It involves spending money on folks who aren't at the time in crisis (leaving aside for the moment that social crises that is defined by the social needs). Our current insurance structure (including Medicare and Medicaid), built as it is on paying for procedures and interventions, isn't oriented this way. Some efforts have been made in the past toward that - think HMO's and "capitated care" (providing so much reimbursement per person) - but they were still oriented toward the traditional categories and the traditional venues of health care: medical and nursing and pharmacy care provided in medical and nursing and pharmacy settings. 

This answer is different, if not original. It is investment, really, in the life and situation of a person to provide the resources that prevent crises and so prevent crisis-level health care expenses. 

There are aspects of how health care is changing under our feet that might better coordinate the traditional aspects of health care. The important buzz words are medical home and accountable care organization. These are new to most of us, but there are good ideas behind these words. That said, they are still focused on how we provide and pay for the traditional categories of health care. It remains the case that for so many without the resources that provide social stability those good ideas won't accomplish all we hope.