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Monday May 20, 2019

FPs Can Lead on Changes That Keep Patients Out of Hospitals

A few months ago, an attending at my teaching hospital gave a patient $40 when she was discharged. Then, for the first time in a while, Mrs. G went more than a month without being readmitted as a "bounce back." Previously, she had been on a nearly biweekly cycle of readmissions for end-stage renal disease and complicated diabetes. Although a new telemedicine pilot program has helped improve her care, the root cause of her readmissions is her lack of transportation to dialysis. For Mrs. G, the hospital serves as the last stop in a long journey through our failing social service net, and her story illustrates our country's lack of attention to the social determinants of health.

[hospital room with bed and chair]

I dread my months on inpatient medicine. Although the long hours and night float certainly add to my gloom, I've realized the main source of my misery is that inpatient medicine forces me to look under the hood and see just how broken our health care system is. Our maternal-child health service is largely full of joyful admissions, and clinic provides opportunities to keep people healthy or address acute issues that can be remedied. Meanwhile, the hospital is often full of patients whose admissions could have been prevented by more robust primary care and public health systems.

Last month, I encouraged our inpatient team to think about the interventions that could have kept patients out of the hospital. Of course, there were patients with unexpected health events, like a young man with acute appendicitis or the generally healthy older woman who caught pneumonia. But when we looked at it, more than half the patients on our rounding list had an admission that could have been prevented.

For example, we admit patients with chronic wounds whose lack of housing leads to continuous cycles of reinfection. We also admit patients with new-onset heart failure caused by decades of untreated hypertension. We admit patients struggling with addiction and mental health conditions that haven't been addressed. Finally, we admit patients with illnesses they might not have if they had a different ZIP code.

My year on the AAFP Board of Directors has coincided with a number of exciting developments in health care. Most recently, CMS announced it will offer five new payment models that will help move practices from fee-for-service into value-based care. The AAFP has been highly influential in the development of these models, and it is exciting to see this shift toward incentivizing the health care interventions that matter most. If we think creatively, this might include work beyond the hospitals and clinics that are typically considered our arena. When you think about the most complex patients you care for, what key things would actually make a difference in their health?

When I think about the patients on our rounding list, I think about needs that are not really addressed in the hospital. They don't need more labs, more nights in the unit, more imaging, more consults. They need access to affordable housing, a safe neighborhood to walk around in for exercise and a grocery store with fresh vegetables down the street. They need jobs that pay enough for them to work reasonable hours, be able to spend time reading with their children at night and still pay their bills. They need health insurance coverage, mental health and substance misuse treatment, public school improvements, and transportation.

We know that these things impact health outcomes far more than our choice of hydrochlorothiazide versus lisinopril for hypertension. In fact, social determinants are responsible for most of a patient's health status. Yet currently, our health care system is designed to address illnesses once they appear, rather than to prevent them. Family physicians across the country realize this and are part of a number of innovative approaches to address the problem. They are working in mobile health programs to reach beyond their clinics, writing prescriptions for veggies and exercise, working with drivers to pick up patients for appointments, and developing day centers for seniors. These physicians are leading the way, and it's time for the U.S. health care system at large to catch up.

Comprehensive primary care decreases hospital and ER utilization,(www.healthcarefinancenews.com) as well as mortality.(jamanetwork.com) So why does less than 10% of health care spending in the United States go to primary care?(332 KB PDF)

Looking beyond our own borders, there is evidence that greater investment in primary care and social service systems(www.nejm.org) improves health outcomes. Even within the United States,(www.healthaffairs.org) states with a higher ratio of social services to medical care spending have better outcomes in obesity, mental health, myocardial infarctions and diabetes. By redesigning the way we invest in health care and what we prioritize, we could help our patients live longer, healthier lives and likely cut costs at the same time.

After my first year of medical school, I spent the summer volunteering at a clinic in Bolivia that was a few miles off the main highway. When it rained, the bumpy road became impassable and neither we nor our patients could reach the clinic, leading to many missed appointments and missed opportunities for health care encounters. Although the clinic had a number of needs -- insulin, an ultrasound machine, laboratory improvements, etc. -- the most impactful investment would probably be to fix the road. To make improvements in health care, we have to question underlying assumptions and be creative about where we invest our time, money and energy.

As for Mrs. G's case, I have to wonder if the $40 she was given at discharge was the reason she stayed out of the hospital. The ethics of giving a patient cash aside, this is an example of a simple solution to a complex health care problem, resulting in lower costs and better health. A member of our health care team recently suggested to an insurance company that if they arranged dialysis transportation, they'd likely save thousands of dollars in hospitalization costs. More importantly, our patient could spend more of her life at home and less time in the hospital.

As CMS and other entities begin to get on board with the redesign of our health care system, family physicians have an opportunity to lead the way. What needs do our patients have that, if addressed, could keep them healthy and out of the hospital? How can we advocate for programs and policies that address these needs?

I dream of a day when my inpatient rounding list is sparse, hospital beds are largely empty and the patients that do occupy those beds are facing unexpected health events despite their access to comprehensive primary care within a well-functioning public health system. Until then, let's continue to think outside the box about how to build a health care system that truly promotes health for all.

Michelle Byrne, M.D., M.P.H., is the resident member of the AAFP Board of Directors.

Posted at 01:57PM May 20, 2019 by Michelle Byrne, M.D., M.P.H.

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