27 / 180
183
in a recent study of the KP population requiring acute care
in 2011(Table 3) (25). Key findings included:
KP members
less than 65 had lower ED visit rates
than the rest of the
California population;
KP members over 65 were more likely
to visit the ED
than other California residents over age 65.
Most significant, however, is that KP seniors were a third
less likely to be admitted to inpatient status from the ED,
when compared to Californians over 65 treated in commu-
nity ED’s. These outcomes were based on KP strategies and
practice protocols which contrast with their competitors in
the insurance and hospital industries, and most of Califor-
nia’s medical community.
Electronic health record system
One of the common criticisms of US emergency care is
over-utilization of advanced imaging and other ancillary
services. Another is medical errors based on inadequate data
regarding allergies and medications of individual patients. A
third is transitions of care in the ED not based on a complete
understanding of each patient’s established medical condi-
tions and care plans. Many of these challenges are miti-
gated for KP emergency physicians because of their ability
to access real-time medical information through a system-
wide electronic health record [EHR]. Most EHR systems in
California, as elsewhere in the US, are financed by hospital
systems based on government mandates, but not shared
outside their own secure environment. The multi-billion
dollar EHR project financed by the KP insurance program
was designed to optimize data-sharing between clinics,
hospitals, and physicians treating KP patients.
Telemedicine
In part because of the observations of Billings on Medicaid
populations in New York City, a common refrain of US
health policy makers is that a large percentage of ED
patients could or should be safely treated in community
settings. To reduce ED utilization, however, urgent care for
ambulatory patients must be timely as well as affordable.
KP is one of the few ACO’s to make significant investments
in combining their EHR with clinic capacity for unsched-
uled care, and telephone advice centers staffed by nurses
with ED experience. KP OnCall provides all plan members
with 24/7 access to medical advice, protocol-based algo-
rithms identifying patients needing immediate evaluation
in ED’s. In 2011, KP OnCall processed 850,000 calls from
KP members; most of whom were treated without referral
to ED.
Post Stabilization Care and Repatriation
It is inevitable that many acute illnesses and injuries within
ACO populations will occur when individual patients are at
work or away from their primary clinic and hospital. Approx-
imately 15% of KP member ED visits occur at non-KFH
EDs. In California, the KP Emergency Prospective Review
TABLE 3. EMERGENCY DEPARTMENT UTILIZATION AND HOSPITAL ADMISSION RATES FOR THE US, CALIFORNIA, AND
KAISER PERMANENT (KP) MEMBERS, 2010 AND 2011
POPULATION
UTILIZATION RATES PER
1,000 PEOPLE
ADMISSION RATES
US population (2010)
Total
<
65
>
=65
308,745,538
268,477,546
40,267,984
418
398
548
15.3%
10.2%
40.3%
Non-KP California (2011)
Total
<
65
>
=65
54,30,826,342
27,616,821
3,509,490,000
334
314
456
15.7%
10.9%
41.7%
KP California (2011)
Total
<
65
>
=65
6,821,382
5,926,085
895,297
244
206
496
13.2%
8.2%
27.1%
+ Notes: This table was originally published in Selevan J, Kindermann D, Pines JM, Fields WW. What Accountable Care Organizations Can Learn from
Kaiser Permanente California’s Acute Care Strategy. Popul Health Manag. 2015 Aug;18(4):233-6. Statistics on national and California specific ED utilization
and admission rates come from publicly available datasets. For national data, we used the Healthcare Cost and Utilization Project’s National Emergency
Department Sample (NEDS), the largest all-payer ED database in the US. 16 The most recent data available from the NEDS was 2010. For California data,
we used the 2011 State of California’s Office of Statewide Health Planning and Development Emergency Department and Ambulatory Surgery Data (treat
and release patient visits) and Patient Discharge Data (admitted patient visits).17 Data on KP’s utilization and admission rates came from the Management
Information and Analysis department at KP California.9
[THE ACUTE CARE CONTINUUM IN CALIFORNIA -William Wesley Fields MD FACEP.]