Edward A. Rose, M.D.
System architects are great at creating systems of care that are attractive and user-friendly, but, like many strip malls, the systems often go underutilized because people cannot get to them or cannot afford them. The local Emergency Department is often the health care delivery system of choice for the indigent because they are always open, don’t require an appointment, and don’t require payment at the time of service. Patients don’t even need insurance to receive care. Unfortunately, the Emergency Department is also the most expensive way to get care for minor ailments and is not designed to provide chronic care.
One significant barrier to care for many populations is the lack of health care insurance. The Affordable Care Act (ACA) of 2014 was enacted in an effort to address that lack of insurance that might be creating a barrier to health care.1 While children have historically been covered through state Medicaid programs, the ACA was successful in reducing the number of adults without insurance. The ACA fundamentally changed the way insurance and healthcare systems work together to improve health care access, quality, and individual and public cost. Because the lack of access to health care and insurance coverage promote health disparities, the ACA and subsequent versions can have a significant impact on access to care.1 The sudden surge of millions of previously-uninsured people now wanting care has introduced multidimensional strain on the health care system as a whole.
Best laid Plans
And has it worked? Has the ADA lead to more efficient health care with more equal access to that care? This is unclear so far. Clearly more data are needed. In the meantime, public and private payers are developing newer methods of reimbursement based on value of care, rewarding integrated systems of care that are accountable for higher quality with lower costs. Pay-for-performance programs may encourage health care providers to open their doors to a broader population of patients needing improved access but are highly controversial because they may inadvertently penalize health care providers who attempt to care for people with pre-existing illnesses and a higher burden of illness.2
As the health care pendulum continues to swing, a system should evolve that reaches acceptable compromises to the majority of stakeholders. One solution that has been proposed is the Medicare Accountable Care Organization (ACO) program, designed to reduce costs while improving quality of care for Medicare beneficiaries.3 Unfortunately, many underserved people are not Medicare beneficiaries, and the same dynamic exists whereby systems that provide care for the sickest are often negatively affected by the ACO evaluative systems. Medicaid ACOs have also been established to create a system that is more inclusive.
A relatively recent innovation has been the patient-centered medical home (PCMH), a system of care that has been promoted in major primary care organizations. This is a model with five key attributes: comprehensive care, patient-centered care, coordinated care, accessible services, and quality and safety. The PCMH strives to improve access to care for underserved patients and families through extended office hours, improved communication, and intelligent appointment systems. At the same time, PCMH initiatives work to reduce costs of care.4
The PCMH model should include a health equity dimension. These systems would promote preventive care and community-based services that reach more people who do not currently have access to care. Research into effectiveness is still lacking as refinements to the model continue to be called for. There are so many different versions of PCMH that it is difficult to directly compare systems to devise best practices.
The good news is that large and powerful organizations, including the US government, are recognizing disparities in access to care for certain populations of people, and significant research dollars are being committed to address this important social issue.
1Chen J, Vargas-Bustamante A, Mortensen K, Ortega AN. Racial and ethnic disparities in health care access and utilization under the Affordable Care Act. Medical care. 2016 Feb;54(2):140.
2Frean M, Gruber J, Sommers BD. Premium subsidies, the mandate, and Medicaid expansion: Coverage effects of the Affordable Care Act. Journal of Health Economics. 2017 May 1;53:72-86.
3Kaufman BG, Spivack BS, Stearns SC, Song PH, O’Brien EC. Impact of accountable care organizations on utilization, care, and outcomes: a systematic review. Medical Care Research and Review. 2019 Jun;76(3):255-90.
4Shi L, Lee DC, Chung M, Liang H, Lock D, Sripipatana A. Patient‐centered medical home recognition and clinical performance in US community health centers. Health services research. 2017 Jun;52(3):984-1004.