Where does the healthcare continuum really begin?

With prevention?

In the home?

With the Primary Care Provider?

In the Emergency Department?

Although an argument can certainly be made for any of the four choices above, I’d like to challenge your opinion and perspective with a different answer…the continuum for many begins with Emergency Medical Services (EMS).

This past year I had the privilege to be included in two standard setting and forward thinking discussion forums-- AHRQ’s 2010 Annual Conference and HCIE Innovators Event as well as Hope Street Group’s Policy 2.0: Using Open Innovation to Reinvent Primary Care Project. Both of these events offered diverse perspectives from diverse participants in academia, corporations and all levels of government and localities who gathered to discuss and make recommendations to improve the health care system. Interestingly, the first responder perspective of EMS was only a footnote in these discussions. I believe that policy makers and leaders within healthcare all too often fail to look outside their sphere of influence and familiarity for answers or more importantly the critical questions. That said, I know this minimalization was not intended or planned, but a result of historical processes and comfort levels.

The numbers…

EMS contributes 15% or 17.25 million patients to the nations 123.8 million annual Emergency Department (ED) visits (CDC, 2008), yet Fire, EMS or Law Enforcement respond to over 240 million 911 calls per year (NENA, 2009). It’s difficult to accurately breakdown the national percentages of 911 call types, but upwards of 60% of EMS calls are generally considered low-acuity or non-emergent. To put this into a local perspective, the City of Tucson AZ with a population of approximately 530,000 (2005) generates approx. 79,000 Fire and EMS 911 calls per year, 84% or ~67,000 of these are medical in nature and 60% of those, ~46,000 require only Basic Life Support (BLS) care (TFD, 2009).

So what does that really mean? It means that the 911 system provides a substantial safety net for the Nation’s healthcare system. While this should come as no surprise, the volume of patients utilizing EMS, Emergency Departments and the 911 system continues to grow. Over 15 years ago, the National Highway Traffic Safety Administration and the Health Resources and Services Administration joined with leaders from the EMS community to put forth an EMS plan that would require significant collaboration with acute care, primary care and public health. This provided one of the earliest, nationwide, use of the scale-up-and spread model and was published as the1996 EMS Agenda for the Future (NHTSA, 1996).

The past…

To implement that vision and professional template, EMS has continued to grow it’s service provision model from one that was historically created for stabilization and transport of the acutely ill and injured; one that was set-up to intervene only when patients needed emergent support; one that operated in relative isolation from other health care and community resources; one that was not involved in the business of ensuring social service follow-up and one that did not have a working knowledge of community health care providers and regional health care organizations (NHTSA, 1996).

The present…

Today, EMS is integrated with other health care providers, public health and public safety agencies to provide community-based healthcare and management. EMS agencies and providers are involved in activities related to prevention education, illness and injury risk, acute illness and injury care, follow-up, treatment of chronic conditions and community health monitoring. This vision is also shared by the Injury Response Division of the National Center for Injury Prevention and Control/Centers for Disease Control and Prevention (NCIPC/CDC) and the American College of Emergency Physicians (ACEP) who have called for a better understanding of roles and collaboration between Public Health and EMS through their Appleseed Project initiative (CDC, 2004).

The reality …

As you can see, EMS has developed into more than a group of fire departments, rescue services and ambulance companies. While providing these additional and collaborative services, EMS remains the public’s emergency medical safety net.  Looking back to those 240 million 911 calls and the 17.25 million EMS-to-ED admissions, it’s clear that a significant amount of health assessment, care and triage occurs outside the hospital walls. In fact, there are no other healthcare providers that see patients in their own home or living environment quite like EMS. The “scene assessment” which is a fundamental EMS skill reveals more information about a person, their living conditions, their health, their support system and their coping mechanisms than any other assessment tool.  How many Primary Care providers, case managers or health plan administrators have this perspective into their own patient’s lives?

From where I sit with over 30 years of experience as an RN in Maternal-Child Health and EMS, I see several important questions that need further discussion and clarification before we can begin to understand how to move forward in improving the healthcare of our Nation.

• How can we better educate individuals to utilize the 911 system for acuity appropriate reasons?
  
• How do we encourage the use of Primary Care practitioners for non-emergent and urgent medical and injury complaints instead of defaulting to the approach of “if this is a medical emergency, please hang up and dial 911?
  
• How do we share the burden of after-hours and weekend low-acuity patient needs?
  
• How do we facilitate better communication and collaboration between EMS, public health, acute and chronic care case management, behavioral health and community services?
  
• How do we move patients calling 911 for non-emergent or non-healthcare reasons into a public or human services system that will better meet their needs?
  

Communication, collaboration, connectivity, consistency and caring are all functions of healthcare, yet as the patient numbers and range of patient complaints increase, we all need to utilize each others skills, knowledge and expertise to meet the needs of our patient population. Reaching out to our colleagues may be the first step toward improvement, integration and understanding of our healthcare system.

http://www.911dispatch.com/info/fact_figures.html

http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/nhamcsed2008.pdf

http://cms3.tucsonaz.gov/sites/default/files/imported/data/demographic/eecpop00_05.pdf

http://www.nena.org/911-statistics

http://www.cdc.gov/injury/publications/index.html

http://www.nremt.org/nremt/about/emsAgendaFuture.asp

http://www.tucsonaz.gov/fire/AnnualReport.pdf

As a health care practitioner, I often hear things like, “Expanding primary care will not bend the cost curve; all primary care doctors do is postpone the time of eventual death. The patient lives longer and ultimately develops new and more costly diseases that are the consequences of aging.“

Ever hear these arguments? It’s fascinating - intuitively, this makes sense to me.  In the cold calculus of health care economics, good primary care may prevent disease and extend life, but as they say – taxes and death are both inevitable.  And death costs money.  I have to believe that postponing a sudden death at a younger age with a prolonged illness and likely ICU stay at an older age is costly.

I’m making two huge sweeping assumptions here.  First - Primary care saves lives.  Second – when you die older, you cost more to the system.  I did a quick literature search to see that I could find to answer these questions.  So let’s question the first assumption – does primary care save lives?

Mackinko et al. did an interesting little interesting literature review in the International Journal of Health Services in 2007. They pooled together a series of studies, re-cut the data in order to assess primary care effect size and the predicted effect on health outcomes of a one-unit increase in primary care physicians per 10,000 population. What they found was interesting - Primary care physician supply was associated with improved health outcomes, including all-cause, cancer, heart disease, stroke, and infant mortality; low birth weight; life expectancy; and self-rated health. Pooled results for all-cause mortality suggested that an increase of one primary care physician per 10,000 population was associated with an average mortality reduction of 5.3 percent, or 49 per 100,000 per year. In other words, 49 more people would live each year with the addition of just one more doctor.  Not bad.

I am assuming this is not surprising. Primary care physicians include family medicine doctors, internists, pediatricians, and in some instances, obstetrician–gynecologists. Currently, primary care accounts for about one third of the physician workforce in America. For many, primary care physicians are the first contact for a person with an undiagnosed health concern, they provide patients with the opportunities to prevent disease and they offer continuity and coordination of care for many complex conditions. Given their pivotal role in delivering care, it follows reasonably that they will save lives.

Now the second question – does primary care save money?

This is the tricky one. But one of my favorite studies on this question is from Lubitz et al. from his New England Journal article entitled “Health, Life Expectancy, and Health Care Spending among the Elderly” in 2003. They found that elderly persons in better health had a longer life expectancy than those in poorer health but had similar cumulative health care expenditures until death. A person with no functional limitation at 70 years of age had a life expectancy of 14.3 years and expected cumulative health care expenditures of about $136,000 (in 1998 dollars); a person with a limitation in at least one activity of daily living had a life expectancy of 11.6 years and expected cumulative expenditures of about $145,000.  In other words, a healthy spry grandmother who still does all her own cooking may live longer, but she will cost the system about the same amount of money as her sister who requires round-the-clock nursing assistance.

When a colleague of mine worked briefly in Canada, he looked at cost data that showed that annual health care costs for patients who lived rose over the course of life. This is not surprising. Costs for patients who died (of natural causes) were pretty constant - dying of breast cancer costs the same at 55 as 85. So if you simply prolong life, then costs will go up. Of course, if you enable people to work longer, then GDP goes up, so costs as a percent of GDP are mitigated. So retirement age becomes a factor. This is Canadian data, but I doubt the US is that different.

But the question is can we decrease those annual costs of living and dying, and is primary care critical to this? The answer is yes. Changes in the structure of primary care practices as well as the reimbursement can reduce costs. An example is care coordination - several pilots have shown that if you improve the coordination of care of high-risk patients, they generate fewer costs. Massachusetts General Hospital’s CMS Demonstration project is one successful example. Tom Bodenheimer reviews other examples in a recent New England Journal of Medicine Article.

Note that I did not ask “does prevention save money?” If asked, I’m not sure I could defend the assertion that “prevention saves money.” For example, screening costs can exceed the cost of treatment if only a small portion of a population would get sick without any preventative services. As a society, it might be cheaper to simply treat, and not always prevent.

The question I asked, however, was “does primary care save money?” The role of the primary care physician is not just prevention. Not to be heavy-handed, but I do believe they are the guardians of health – they help the patient navigate and coordinate the complex decisions of life and health – of prevention and treatment. I believe this is how the primary care physician helps control costs – by helping patients make rational decisions about their care, and providing the longest and healthiest life as possible.

These are just some quick thought starters. I now hand the conversation over to you. I encourage you to use Policy2.org to more fully engage each other, challenge and explore the data, and construct the story that helps us tell the American people that primary care physicians play a vital role in creating a healthier country with greater economic opportunity for all.

About The Author:

Sree Chaguturu is currently an internal medicine physician at Massachusetts General Hospital / Harvard Medical School and a health care consultant at McKinsey and Company.  He provided primary care for a number of years in a community health center in Charlestown, Boston.