In the article written by Joanisabel González about the performance of hospitals in Puerto Rico, possible reasons that explain these results are mentioned.
In addition to those cited, there are other forces that propitiate these dire results. The most significant is the pressure exerted by payers, which directly impacts the results.. The pressure is that hospitals and doctors will discharge the patient as soon as possible, causing many patients to not be in stable conditions to go home and that being at home cannot receive sufficient continuity of care to maintain your stable health condition and avoid having to return to the hospital in a short time, in readmission.
There is also the fact that the transition from hospital to home is not the most effective, causing interruptions in treatment that motivate the patient to destabilize again.
There is another important line, that the patient requires a refer ’referral’ to see the specialist. The patient or his relatives who do not want to go through this bureaucratic process imposed by the plans prefer not to manage the referral and in this way their treatment options are limited. By not accessing his specialist, the patient becomes complicated in his condition and ends up seeking to solve the lack of access to his specialist by going to an emergency room where they end up admitting him, because the instability or complexity of his condition so requires. While the patient is admitted, a specialist will evaluate it, without the need for a referral, but we have to recognize that this is the most inefficient and ineffective way of receiving the evaluation and treatment that he needs.
Lastly and most importantly, a quote from the study authors is mentioned where they indicate that “hospitals and payers (medical plans) could work together to reduce perverse incentives to patients to overuse the emergency room.”
Of course they could work, but as people on the street say, “from saying to deed there is a long way.” In the way that these forces are configured at the moment, the economic benefit for the payers of imposing controls – such as the use of referrals to visit specialists, reviewing hospital stays and denying the payment of the days they consider unnecessary- They represent a significant economic impact for these to voluntarily discontinue these practices.
The ball is in the court of the payers. They are the ones who set the payment rules and therefore the calls to take the initiative to summon the parties. Hospitals and doctors are receptive to working with alternatives. It is a matter of aligning interests and looking for solutions to improve these important quality metrics.
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