In the 1980s, Miami's Jackson Memorial Hospital was in the midst of a crisis that strained its emergency department resources almost to the breaking point.
It was shortly after the influx of Haitian refugees—in numbers that would necessitate the creation of a tent city in nearby Homestead just for immigration to process them all—arrived in the city. As these families got jobs and started assimilating into the community, many qualified for public assistance for their medical needs, but they didn't sign up.
Instead, new arrivals would wait until they were so deathly ill that they had little choice but to show up at Jackson Memorial's emergency department, which at the time was the only ED in Miami that handled indigent care. Many of the patients had nothing more than a simple flu bug, but had let it go so long that it had transformed into bronchitis or even pneumonia.
The city's healthcare workers followed the standard playbook, making sure most of the refugees had all the applications necessary to get Medicaid, but hardly any of them would file the paperwork. Finally, some of Miami's social workers dug in and discovered what the problem was: In Haiti, the government was so oppressive that any arm of the government was seen as a threat. The military would raid villages, kidnapping men and boys to either serve in the military or never be seen again. So, when the Haitians arrived in Miami, their distrust of anything resembling government bled over into healthcare. They feared that if they went to a Medicaid office, they would be kidnapped or killed. So, they stayed away until they were so close to death, it didn’t matter.
A cultural issue
The problem was cultural, and that's precisely the issue facing emergency departments today. As we reported recently, ED visits are rising, despite the fact many of those visiting EDs have health insurance through the ACA. Having access to a primary care doctor is very different from actually taking advantage of that access. For years, many of these patients have used the ED as their primary care facility, and they have grown to trust those doctors and staffers. As far as they are concerned, they have no motivation to go to another doctor or clinic, because having a doctor they like and trust is more important to them than helping the healthcare industry get a better handle on utilization.
In that light, I offer a simple solution based on essential marketing principles. If you want consumers to change their habits, you have to go where those consumers are and present them with new options.
In this case, the consumers—or patients—are going to the EDs, so smart hospitals could use their presence there as an opportunity by following what their more commercial competition does in the private 24-hour walk-in clinic business. When patients visit these clinics, they treat it like an ED, but the clinics treat them as primary care patients. They schedule follow-ups and wellness visits as a regular doctor's office and encourage those patients to visit them for preventive medicine and not just emergencies.
Hospital-based primary care
Compared to the cost of increased utilization in the ED, it would be far less costly to simply set up a hospital-based primary care physician's office that is open 24 hours, as an option for patients who visit the ED with non-emergency ailments. Shifting them from the ED would be easy, because most insurance plans have lower co-pays for primary care than for ED care. For those patients with deductible-only insurance plans, the out of pocket cost for the primary care physician would be lower than the ED, as well.
For years, this solution has been suggested, but many hospitals refuse to implement the idea because of the administrative complexities involved. I think they're making a big mistake. It's like ordering a chicken salad sandwich in a restaurant that doesn't have a chicken salad sandwich on the menu—but they do have chicken, mayonnaise and pickles. So, why can't they just make the sandwich?
Hospitals have access to doctors, nurses and empty exam rooms and wards. By using them wisely, instead of making excuses, hospitals on their own could play a role in reducing the expensive over-utilization of their EDs and ease the transition for culturally-resistant patients into a more traditional, affordable and utilization-friendly form of healthcare.