Poverty, Not Lack of Care Coordination, Increases Costs

Our small pediatric practice is located in Plymouth, Mass.: "America’s Hometown." We’ve got that famous rock, a replica of the Mayflower in our harbor and, shockingly, a significant number of families struggling to live paycheck-to-paycheck.

Although Plymouth would fit the economic definition of "middleclass," at our office we consistently see a significant number of patients living near or below the poverty line. We have patients who walk long distances to our office due to limited transportation options. We see patients removed from their parent's home due to drug addiction and, worse, parental loss due to overdose. We see kids struggling with their weight because junk food is cheaper than nutritious food. Our patients who are struggling financially tend to smoke at a higher rate and get STDs at a higher rate. These patients tend to have higher rates of mental health issues and more frequent hospitalizations as well. All these issue increase the cost of healthcare.

We have been working with our independent physicians association (IPA) on an accountable care organization (ACO) pilot project. We are moving to prepare ourselves for an ACO contract, probably with our state's Medicaid agency first, and then possibly with private insurance as well.

The IPA has several committees looking at this and our particular committee is looking specifically at clinical aspects of asthma management. We are still in the "brainstorming" phase and are not supposed to - according to the leaders in charge - question details like paying for the ACO at this time. Even early in the process, however, this project has made us realize that we are not being asked to find improved or more efficient ways to manage asthma, we are being asked to solve problems stemming from poverty in our community.

Our committee is tasked with finding ways to decrease the overall cost of caring for pediatric asthma patients, specifically reducing admissions and ER visits. We already have excellent protocols for categorizing asthma, identifying triggers and exacerbations, as well as administering preventative treatment and efficient acute-treatment protocols. Following current protocols, we currently avoid costly ER and inpatient admissions all the time.

The high cost, however, comes from outliers: children with severe asthma, multiple allergies, or confounding medical problems. In the process of trying to identify which patients are at risk for costly admissions, it has quickly and clearly become apparent that poverty is the dominant risk factor. A family's inability to pay for medications, inconsistent housing, and inability to make and keep primary-care appointments are all tied to living in poverty

Physicians are not trained or qualified to solve society's poverty issues. In our opinion, moving our state's Medicaid system to an ACO model shifts the burden of managing poverty away from the shoulder of our political leaders where it rightfully belongs.