There was once an assumption that the expansion of Medicaid would yield recipients consuming more primary care services rather than seeking out the Emergency Room as their first stop in health care decisions. Several years after the inception of the Affordable Care Act, we’ve learned this is not the case. A recent Washington Times article pointed out that Medicaid expansion has, in fact, not pushed those using Medicaid benefits to PCPs, rather it has increased the traffic to emergency rooms. So, why are Medicaid recipients two times as likely to seek out care at the emergency room rather than a lower-cost option or using their primary care provider? Simply put, it comes down to benefit design, education, and ultimately consumer engagement. In populations like Medicaid, where benefit design and education on health care consumption are not widely understood or properly communicated, there is poor engagement, which perpetuates inappropriate benefit use.
It's no secret that member confusion around how to use medical benefits continues to be a major driver in inappropriate health care spend. For the Medicare population specifically, a recent Healthmine study showed that only 22 percent of Medicare Advantage members have knowledge of what star ratings mean when it comes to choosing their care. This confusion and lack of knowledge often gets highlighted through the statistics shared around inappropriate benefit utilization (such as inappropriate emergency room visits) and the expenses incurred as a result of chronic conditions.
Finding and eliminating gaps in care continues to be one of the most challenging aspects of the shift to value and better outcomes. As perhaps the most influential payer of all, Medicare is emphasizing shared savings programs to incentivize delivering quality care. Additionally, there has been an industry-wide shift where the focus is no longer on disease management, but rather on population health management as a whole. This makes the opportunity to impact care gaps and quality a much higher priority for at-risk organizations.