The New York Times reported recently on the staggering number of hospital readmissions within one month, three months, and six months after release, too often with no intervening visit to a primary care provider:
As many as a fifth of all Medicare patients are readmitted within a month of being discharged, according to the study, and a third are rehospitalized within 90 days.
Half the patients who returned to the hospital within 30 days of undergoing treatment other than surgery apparently did not see a doctor before they went back.
The high rate of hospital readmissions is “one of the fruits of an increasingly fragmented health care system,” said Dr. Stephen F. Jencks, a former Medicare official who is an author of the study, which analyzed Medicare claims information for 2003 and 2004. […]
Many elderly patients who leave the hospital with a chronic illness like heart failure or diabetes are left to cope largely on their own. They often do not receive clear instructions on what medications they should be taking, and they frequently have difficulties making doctor appointments to continue their treatment outside the hospital.
“When you get out of the hospital, you need to have an active interaction with the health system,” said Dr. [Anne-Marie J.] Audet of the Commonwealth Fund, which also provided a grant to the nonprofit Institute for Healthcare Improvement to work with states to try to reduce the number of times patients go back to the hospital. “The patient has to be seen.”
While the article focuses on the cost of such readmissions to the health care system as a whole, Dr. Audet’s comment touches upon a key to fulfilling our shared human right to health care that isn’t currently being discussed: care coordination. Even with insurance cards in everyone’s pocket, the promise of a health care system that provides access to quality care for everyone cannot be fulfilled with the current fragmented health care system (to paraphrase my health law professor, you can’t even call it a "system" because it’s so dysfunctional). Addressing a lack of insurance coverage is an important first step, but we must also address a lack of organized and effective management of preventative care and chronic illnesses.
Enter the "medical home," a health care setting that enhances access to providers and timely, well-organized care. The medical home is about changing the current dynamic from one where health care is thought of an emergency or crisis that is dealt with by insuring against it (as one does against home fires or car accidents) to one where we actually consider our well-being as vital to our exercise of our other fundamental rights and ability to achieve our full potential. The first step in doing this is changing the entry point into the health care system from the hospital emergency room or urgent care clinic to the medical home, centered around a primary care provider. This may not seem like a revolutionary step, but in the United States, sadly, it is: Over 1/3 of Americans under age 65 do not have a primary care doctor.
And as it turns out, having a primary care provider, especially one working within a medical home designed to maintain and improve your health prior, and not just after, stepping foot into a hospital, is good for you. Medical homes are proven to result in better management of chronic conditions, as mentioned, but also increases the appropriate use of preventative screenings meaning that possible illness is caught more quickly, improves primary care itself, reduces duplicative testing or dangerous conflicts of medications, and reduces the health care access disparities too often found in underserved communities.
A medical home isn’t a silver bullet; there have been examples of it working well (as in the case of the patient satisfaction and effectiveness seen in the Veterans Administration health care system and coordinated care hospitals like the Mayo Clinic) as well as examples of it not working (as with the mixed results in a JAMA study of 15 attempts to create medical homes). But where institutions have on a broad scale commited to making sure that the health care that is being provided is coordinated, evdience-based, and dedicated to keeping families in the best possible health, the results can be dramatic.
Dramatic results often require large-scale action, and establishing coordinated care as a national standard might best occur if included in consideration of current reform discussions. Because health care reform needs to be more about just making sure we all have insurance cards; it needs to be about changing the system to one with a priority on protecting our health.
