Measuring Value for Low-Acuity Care Across Settings
Published Online: September 14, 2012
Sofie Rahman Morgan, MD, MBA; Meaghan A. Smith, BS; Stephen R. Pitts, MD, MPH; Robert Shesser, MD, MPH; Lori Uscher-Pines, PhD, MSc; Michael J. Ward, MD, MBA; and Jesse M. Pines, MD, MBA, MSCE
Healthcare expenditures in the United States reached $2.6 trillion in 2010, nearly 18% of gross domestic product (GDP).1 Rising costs have led to discussion about value—how invested time, money, and resources improve health. An Institute of Medicine roundtable advocated rewarding “value over volume,” compensating effective care, not “more care.”2 The Affordable Care Act (ACA) also supports the concept through value-based purchasing, accountable care organizations, and bundled-payment programs.3
The role and measurement of value in healthcare is just emerging.4-7 There has been little focus on measuring value in emergency departments (EDs), where 28% of acute care in the United States occurs.8 One subset of ED visits for which value is questioned is low-acuity encounters, often perceived by media, insurers, researchers, and emergency physicians as inefficient resource use.9-12
These visits are controversial for several reasons. Terms like unnecessary, avoidable, preventable, ambulatory-case sensitive, inappropriate, non-urgent, and low-acuity lack precise definitions and are used interchangeably despite subtle differences. They may refer to encounters for conditions that are not life-threatening, not time-sensitive, capable of improving without intervention, or better suited for different settings. They may suggest visits preventable through better primary care or public health measures or those for alternative purposes like seeking food, shelter, or narcotic medication.
Assessing urgency is also itself controversial. Urgency is complicated ex ante by its subjective and dynamic nature. A prudent layperson patient may perceive symptoms as urgent that a doctor does not.13-16 Highly trained providers make inconsistent assessments of urgency at triage,17 and even emergency physicians sometimes alter their initial assessments of urgency after ancillary testing data.14 Urgency is complicated ex post by retrospective measurement. Final diagnoses do not always reflect the potential acuity of presenting complaints.
The estimated range of low-acuity visits (8%-50%) is wide, underscoring the difficulty in quantifying this problem.18-22 The cost associated is unknown, though comparing these figures with total US emergency care expenditures of $51 billion suggests a span of $4 to $26 billion.23 In addition to variability in measuring the impact of low-acuity visits, discussion of this topic often fails to account for perspective—while payers prefer to limit expensive care, patients may desire immediacy or
This paper aims to better the understanding of service setting and value for low-acuity encounters by adapting an existing business model to highlight qualitative and quantitative factors that affect key stakeholder perspectives (patients, insurers, and society). Finally, we discuss how aligning value among groups could guide stakeholders to influence each other and create rational change in the delivery of care.
In business, it is axiomatic that success requires producing value for customers. Although economics in medicine are distorted by the amorphous nature of health, the disconnect between patient expenses and those of third-party payers, and a lack of transparency, the goal of creating value remains unchanged. The Customer Value Equation by Heskett et al models customer perspective and is used to explain the success of companies in industries from airlines to auto insurers24,25 (Figure 1).
In Heskett’s equation, results are the quantity and quality of products. Process quality is customer experience: tangibles (appearance of personnel/facilities), reliability (dependable, accurate performance), responsiveness (timeliness and willingness to help), assurance (staff knowledge and ability to inspire trust), and empathy (caring, individualized attention).26 Price is what the customer pays for the product. And, access cost denotes what the customer must do to acquire it (travel time).
We adapt this equation to low-acuity encounters to understand how setting and perspective affect value (Figure 2). The numerators represent outputs of care (benefits) and the denominators inputs (costs), highlighting the concept that, regardless of perspective, value varies directly with costs and benefits (Table 1). To simplify discussion, we assume patients desiring care will receive it somewhere and not avoid care entirely.
Conscious and unconscious value assessments guide patients in choosing care setting. Table 2 summarizes variables that impact the Patient Value Equation (PVE). To understand how setting influences these variables, one must consider the characteristics and available resources of each (Table 3).
Output: Outcomes as perceived by patient. Patient perceptions dictate the outcome of the PVE. Some patients are less concerned with traditional quality indicators than the impact on their physical and emotional well-being. For example, a patient with a urinary tract infection may be unaware whether she received the recommended antibiotic; however, she is undoubtedly conscious of whether and how quickly her symptoms subsided.
Patients often equate “more” care with better care.27,28 A patient with an upper respiratory infection may prefer knowing that a chest x-ray is normal to having a clinical diagnosis alone. The result is that immediate capabilities, medications, and onsite consulting specialists in EDs may enhance their appeal.
Output: Patient experience. Patients likewise value the experience associated with obtaining care—distance to care, facility quality, and staff courtesy. Patients cite non-clinical factors as playing a larger role than clinical reputation in guiding care site selection.29,30 A need for after-hours care or safety net, difficulty obtaining traditional appointments, and a desire for immediate care drive patients to the ED.31,32 Over time, patients may also develop loyalty to a particular care site based on positive prior experiences.
Survey data on factors that make patients choose retail and urgent care is lacking. Expanded service hours, same-day access, convenient locations, and minimal wait times could play a role. Yet some patients still prefer EDs to alternative settings. One survey concluded that patients were willing to pay an additional $31 to see physicians in a non-retail setting compared with nurse practitioners in a retail setting.33 Shortages or outright absence of retail and urgent care settings in medically underserved areas may also restrict alternatives to the ED.34
By comparison, office-based practices offer a longitudinal, established relationship with providers. Difficult same-day access may outweigh this benefit. Patients report a willingness to pay an additional $82 to be seen the same day rather than to wait 1 or more days.33 This perspective is understandable considering that patients in significant pain may prefer early evaluation over a familiar provider.
Input: Out-of-pocket costs. The denominator of the PVE includes inputs of care, or costs. Patients are often responsible for only a portion of direct expenses such as deductibles, copayments/coinsurance, and a percentage of charges, depending on insurance status. Premiums likely have less impact on patient value because they are sunk costs already paid and unchanged regardless of utilization.
Some data suggest patient finances have minimal impact on seeking care. In a survey of ED patients, few rated ability to pay as an influence on setting selection despite perception that alternative care sites are cheaper.32 Lack of insurance may not drive ED utilization, as visits have risen most among the insured.35-38 ED visit out-of-pocket payments may be minimal for certain insured patients whose insurers pay the bulk of the cost and for certain uninsured patients whose EDs do not collect payment during the visit or pursue collections aggressively. Although several studies show reduction in ED utilization at higher copayments, the effect has been inconsistent.39-43
Few comparative data are available on the impact of patient costs in alternative settings. Uninsured or underinsured plans may limit access to office-based practices. Insurance coverage for retail visits is limited but expanding.44 However, retail clinic users are less likely to be poor and may be able to afford care regardless of coverage.34 Also, transparent pricing at retail clinics may be alluring, as patients can predict their out-of-pocket payment.
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