New Jerseyans who are high users of hospital care often visit multiple hospitals, according to a new study by Rutgers and the Camden Coalition of Healthcare Providers released Monday.
The researchers said such fragmented hospital care could undermine efforts by the health care system, spurred by the Affordable Care Act, to deliver consistent, coordinated care – especially to patients with chronic conditions like diabetes and heart failure who account for a major share of the nation's medical bills. A key goal of the ACA is to better manage these high risk patients, both to improve their health and stem the rise of health care spending.
The study, published in the journal Medical Care, was led by Katherine Hempstead of the Robert Wood Johnson Foundation in Princeton who during the study was at the Rutgers Center for State Health Policy. Joel Cantor, director of the Rutgers CSHP center, Derek DeLia, a professor at Rutgers CSHP and Jeff Brenner, executive director of the Camden Coalition were co-authors of the study. Tuan Nguyen, a Rutgers doctoral candidate at the time of the study, also contributed to it. He is now on the faculty of the University of Southern California.
Brenner and the coalition have won national recognition for more than a decade of work that helped reduce the frequent and costly hospital admissions by low-income Camden residents. The coalition has gotten the city's hospitals, health care professionals and social service agencies working together to improve the medical care of the city's sickest people.
The study looked at 291,147 New Jersey adults who had at least two inpatient hospital stays during any 24 month period between 2007 and 2010. The study found that 25 percent used more than one hospital. Among those with the highest number of hospital visits, fragmented hospital use was higher. Of the patients with 15 or more hospital admissions, more than half used more than one hospital.
"One of the things that surprised us was how prevalent (multiple hospital use) was," Hempstead said. The study found that individuals with multiple chronic conditions were more likely to get fragmented hospital care. About 80 percent of the study population has two or more chronic conditions, she said.
She said it's not necessarily bad for a patient to use various different hospitals. For example, someone might schedule a surgery at one hospital, and later be admitted to a different hospital after a car accident.
However, she said, "The kind of fragmentation that seems to be the most potentially troublesome is when people are going to different hospitals for treatment of basically the same thing," such as complications of diabetes. "Then you feel that's probably not good for continuity of care, it's probably high cost and it might not be good for outcomes. There's a very good chance that hospital A doesn't know about the visit to hospital B, so there's a lack of coordination there."
Cantor said fragmented care is an issue for Medicare Accountable Care Organizations that have been launched in the past few years under the ACA, including more than a dozen in New Jersey, which strive to deliver more coordinated medical care to Medicare patients. Health care providers get to share the money that Medicare saves if care is delivered more efficiently. He pointed out that all the hospitals in a region don't necessarily belong to the same Medicare ACO, and if hospital care is fragmented, it puts patients at risk for poor care coordination.
"The entities collaborating within the ACO have a huge incentive to work together to improve care, but those outside, not necessarily," Cantor said.
New Jersey is also close to launching its new Medicaid ACO where health care providers will share the saving they achieve for the Medicaid program. It will also cover health care for low income individuals and families. Cantor said that unlike the federal Medicare ACOs, the state's Medicaid ACOs will require all the hospitals within the geographic area of the ACO to participate in the ACO.
"We think that's a good thing," Cantor said. "It does not solve the problem 100 percent, because somebody could still go to a hospital outside the ACO region, but I think it goes a long toward assuring that coordination can happen across facilities."
The tendency for lower-income individuals on Medicaid and Medicare to have frequent hospital admissions is well documented. The Camden Coalition and the Trenton Health Team have had success reducing excessive hospital admissions.
But, a surprising finding of the study was the prevalence of fragmented hospital care by people covered by private health insurance.
"Privately insured and middle aged people had somewhat higher risk, even than Medicare patients" of getting fragmented hospital care, Cantor said. "That was surprising to me."
Hempstead said one trend that could reduce fragmentation is the move by health insurers to offer plans where members save money by using providers within a certain network.
"Patients have a pretty big financial incentive" to stay in-network, but also have the option of paying more to go out of network, she said.
And expansion of electronic medical records could eventually make fragmented hospital care less of an issue, she said. The goal is for individuals to have a personal electronic medical record that can be accessed by the health care system, regardless of where they are.
"We're definitely not there yet, but it's someplace we could be before too long," she said.
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