View from Washington – Entering the Maze

The problem with access under health reform

The major policy objective chosen by President Obama and most of the Democrats in Congress regarding health reform is one most characterized by “increased access” and/or “universal coverage.” In its recent report, “Jammed Access: Widening the Front Door to Health Care,” the consulting firm of Price, Waterhouse, Cooper’s Health Research Institute (PWC) has done important work trying to strike the difference between universal coverage and universal access. Their observations:

  • Crowded entry points create a rough start to the healthcare journey.
  • The system maze causes false starts and unnecessary stops.
  • Individuals fail to act on their health early.
  • Consumers are open to new methods to enhance access.

With regard to crowded entry points, PWC bucks common notions and off-stated factoids that the uninsured are clogging hospital emergency departments – the most expensive place to treat patients. On the contrary, the study found an inverse relationship between emergency department visits and the uninsured population. Or, said another way, contrary to popular belief and policy discussion, the uninsured are not really the most frequent emergency department users in the United States.

Who is really using our emergency departments?
According to results from the PWC Consumer Access Survey, in the last 12 months, the uninsured actually only make up only 18 percent of ED visits, whereas Medicaid patients come in at a whopping 43 percent. One obvious conclusion – accessing providers is a challenge for Medicaid patients. The study also notes that individuals are not getting timely access to the providers they need or want, particularly for specialty care. The study notes “Increasing ED utilization is often blamed on poor access to physicians; however, there are more doctors per capita today than at any other point in time.” Since 1995, office visits to physician offices are up across the country. The easiest place to access care according to all survey respondents was in pharmacies.

Another little truth about the current status of access in this country is that hospital EDs really are dumping grounds for mental health patients. “Shortages of mental health providers are making EDs frequent boarding areas and referral points,” PWC’s study states. The U.S. government estimates there are currently 56 million individuals with mental health issues that are underserved. With this kind of demand, it is no wonder that psychiatric admissions to hospitals are going through the roof.

Regarding the maze that is our health system, PWC noted that there is a lack of participation in existing programs and the complexities of coordination plague the healthcare maze. Ask a healthcare provider sometime if they ever go to a hospital without taking along someone as their personal advocate. They know how the system is supposed to work, but they still often have someone riding shotgun for them.

As to the maze which is healthcare today for many patients, PWC concludes that “patients need direction” and evidently healthcare providers are not providing enough of it. It is a fair observation to note that healthcare providers are working harder today than ever before – many with dwindling financial resources it should be noted. Nevertheless, as the PWC points out “Healthcare organizations are working hard but not necessarily together.” The fragmented nature of our healthcare delivery system is costing us more than it should in dollars and in lost access.

PWC does note there are some encouraging signs regarding consumer’s views as to how access can be improved, if these new methods are made available. Some of these innovations consumers noted were alternative access via: Internet and other computer technology; telephone consultations; clinical trials; worksite and retail clinics; shared medical appointments; and, utilization of mobile devices (texting).

According to the PWC survey, consumers want to access the Internet for care and not just for information. They want to talk to their physicians by e-mail and participate in online consultations. Consumers said they want online chat rooms monitored by clinicians. Additionally, patients want access to telehealth technology and online support groups. The early track record on telehealth is impressive. A recent Veterans Administration (VA) initiative reduced inpatient days by 25 percent and hospital admissions by 19 percent using telehealth. A startling 73 percent of consumers surveyed by PWC would be interested in using remote monitoring devices.

When universal goes wrong
Why are these findings so important? You only have to look to the state of Massachusetts to see what happened when access was expanded under their universal coverage program. There simply were not enough providers to care for everyone that showed up for care. Also, the old model of access no longer fits the demand. ED volumes stayed high in Massachusetts due to the Medicaid population, and by some accounts, these volumes remain high today. If universal coverage, or some semblance of it, happens as a result of federal health reform, providers who are currently doing more with less are going to have to embrace some of the two main conclusions of the PWC study:

  • Consumers are open to new models of delivery.
  • Organizations will need to step up efficiencies, team with each other, engage in innovation and use rewards/incentives to open access without increasing costs.

Crowded entry points are a problem that must be addressed by providers through innovation and system re-design. The maze that is healthcare delivery for patients must be addressed while at the same time encouraging newly covered individuals to act early on their health conditions. With this study, PWC has added important information to the health policy debate going on in Washington and to a growing challenge for consumers and providers.

About the Author

Robert Betz Ph.D.
Robert Betz, Ph.D., is president of Robert Betz Associates, Inc. (RBA), a well-established federal health policy consulting firm located in the Washington, D.C. area. Additionally, Dr. Betz is an adjunct professor teaching at The George Washington University where he specializes in political science and health policy. For more information about RBA, visit