De-escalating Health Care by Expanding the Right Access

Michael Lee, Jr. 



Most proposals to reduce national health care expenditures revolve around limiting access, either through government regulation or patient-level financial deterrence. However, limited access can, paradoxically, result in patients escalating care into higher-intensity, and higher-cost, contexts. When patients cannot access low-cost outpatient help, they often present to emergency departments (EDs) or other high-cost environments.

The solution is not to limit access indiscriminately, but to improve access to appropriate care—to “right-size” health care. Insurers, physicians, and policymakers each have a role to play in helping patients access the right environments, the right personnel, and the right services. Together, we can de-escalate medical care by helping patients more easily access home care and clinic visits; by expanding the roles of physicians’ assistants, nurse practitioners, pharmacists, and nurses; and by meeting the social and psychiatric needs that often precipitate high-cost ED visits.


The cost of health care in America is rising unsustainably.1 This is not news, but neither the Affordable Care Act nor recent Congressional attempts to repeal and replace it have addressed this central disease of American health care.2 Instead, Democrats and Republicans are arguing over who should pay for these costs—taxpayers, via the government, or consumers, via out-of-pocket costs—while failing to address the underlying problem that has made health care unaffordable for millions of Americans.

Health economists have numerous ideas for reducing national health expenditures. Some liberals advocate direct government regulation of prices,3 while some conservative reformers try to discourage unnecessary health care spending by increasing consumers’ out-of-pocket payments.4 These proposals have merit, but they focus on one core idea: limiting the use of high-priced health care, either through regulation or through financial deterrence. How much, these proposals ask, should we limit access in order to control costs?5

In my experience, though, this isn’t precisely the right question. Limited access can result, paradoxically, in the escalation of care. Every day in my Emergency Department (ED), I see patients who present to my high-cost environment because low-cost options aren’t easily available. Rather than limiting their access indiscriminately, we need to increase their access to the right care.

One teenager came to our ED after he lost his mood stabilizing medications and couldn’t reach his psychiatrist to refill them. A cancer patient’s muscle cramp prevented him from walking to the bus stop to visit oncology clinic, so he had to call an ambulance, which in turn had to bring him to us. In a third case, a little girl had a benign neurologic condition, but nobody had explained this to her mother, who felt too frightened to wait three months for her specialist appointment and brought her to us instead. And we often receive patients transferred for specialty consultations which could have happened over the phone instead, if only we had a system for routing such calls. For these patients, lack of access to something small—a phone call, a taxi voucher, or a clinic appointment—resulted in increased costs. In surveys, the National Center for Health Statistics found that 23% of patients presented to an ER despite knowing that their problem was not very serious, including 12% because their doctor’s office was not open and 7% who had no place else to go 6. Limited access forced them to escalate their care.

To combat this, insurers, physicians, and legislators each have a role to play.

First, we need to help patients access the right environment: solving problems at home or in clinic whenever possible. Insurers should have an emergency medicine physician available via phone to supplement their nurses’ hotlines.7 Rather than insisting that only in-person encounters are billable, they should be thrilled to pay for phone calls or even emails that can keep patients out of EDs. Physicians need to improve our accessibility via phone, email, and clinic visits and embrace payment models which reward us for reducing ED visits. We need help from our legislators as well. New models for treating patients remotely—including via videoconference 8 —will need different standards for malpractice and regulatory compliance, lest these providers simply refer all their patients to the ED anyway.

We need to make it easy, not hard, for families to receive care at home, and to visit clinics after-hours, and to speak to a specialist quickly even if a full appointment isn’t available. We live in a world, instead, where low-cost environments are often inaccessible, and high-cost ones—like my ED—are always there.

Second, patients need to access the right personnel. The training physicians receive is invaluable, but we are in shortage,9 and our patients can tell. As the National Governors’ Association has argued, states can improve access by removing restrictions on physicians’ ability to delegate tasks to physicians’ assistants and nurse practitioners—aptly called physician-extenders.10 Physicians’ groups need to embrace and encourage legislation that expands the role of allied health professionals, including allowing pharmacists and nurses to prescribe medicines based on pre-established protocols. Studies show this can be done safely,11,12 and such laws can shift us towards teaching, leadership, and supervision—reducing our paperwork and freeing us to spend more time on our most difficult cases.

Finally, we need to make sure that patients have access to the right services. Increasingly, patients are coming to EDs with psychiatric illness, substance abuse, or social problems such as homelessness. 13 Desperate, some return to the hospital again and again, incurring disproportionately high costs.14,15 I’m not a psychiatrist, so many stay in the ED, untreated, sometimes for days, until we can refer them to a different facility.13 They don’t need a hospital, where I work in shifts and triage a wide variety of patients. They need somebody who can address their mental and social difficulties over time.

Indeed, several states have found that programs providing home assistance can dramatically reduce medical escalation. Oregon assigned 65 of its highest-cost patients to a clinic that had an outreach worker and a behavioral health specialist, reducing medical expenses by 62% in the first year.15 New Jersey’s Camden Coalition was able to reduce spending among 36 high utilizers by 56% when they began tackling the social needs of their patients.14 Insurers need to embrace—and pay for—these programs, physicians need to facilitate their work, and legislators need to make sure that mental and social health programs are adequately funded.

Together, physicians, insurers, and legislators all have a role in ensuring that our patients have access to the right environments, the right personnel, and the right services. Whenever possible, we need to find ways to meet our patients’ needs—from medications to clinic visits to simple reassurance—without forcing them to come to the ED. If we prove up to this challenge, we have a rare chance to help reduce costs by improving access rather than by limiting it.


Michael Lee, Jr., MD, JD is a pediatric emergency medicine fellow at Boston Children’s Hospital. His research focuses on how the Affordable Care Act altered pediatric emergency department use. The opinions expressed here are those of the author and do not necessarily reflect the position of his affiliated institutions.


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