Thursday, March 27, 2014

With insurance available, ED visits rise

My friend and colleague Peter Smulowitz and co-authors have documented what many of us noticed anecdotally at the time.  Looking at Massachusetts following the introduction of universal health insurance coverage, they found:

Compared with the 2-year period before reforms started to go into effect, emergency department visits increased by up to 1.2% during the 1-year implementation and by up to 2.2% during the 2-year period after reforms were fully in effect.

The study is in the Annals of Emergency Medicine.  News@JAMA summarizes key points:

The authors analyzed all emergency department visits in Massachusetts between October 1, 2004, and September 30, 2009. The data included records from 69 hospitals, accounting for some 2 million annual outpatient emergency visits, 850 000 inpatient admissions, and 150 000 observation stays. Reforms that expanded health care access in the state were implemented between October 1, 2006, and September 30, 2007.

Several factors drive these trends, the Annals authors wrote. They named transportation, ability to take time off from work or find child care, emergency departments’ 24-hour availability, limited availability of primary care services, distances between the emergency department and a primary care physician, and the perceived efficiency and expertise of emergency departments.

“Our study suggests that other states should be prepared for equal or greater influxes of patients into the [emergency department] after health care reform is fully implemented,” the authors wrote.

Kristin Gourlay, a columnist at Rhode Island NPR, notes:

Another study from Oregon found something similar. So we've got two studies now suggesting that health care reform - the Affordable Care Act, extending health insurance to more Americans - may not necessarily be moving the needle on something we thought it would: reducing the number of costly ER visits made by the uninsured who can't afford care elsewhere. The big hope was that the more people got health insurance, the fewer would need to come to the ER for routine care.

According to these studies, it turns out that it's not just the uninsured who use the ER for health problems that could be taken care of by a primary care doctor or in another outpatient clinic. People with insurance may be using the ER for those kinds of health problems, too. No one's suggesting that there aren't legitimate emergencies represented in this data. But it suggests that people may have been waiting to get some things taken care of, or that they haven't been able to find a regular doctor.

It's not clear to me who had that "big hope."  Many of us projected that the ACA was not likely to lead to bending the curve of health care costs.  Its main purpose was to provide health insurance.  That's good and important, in and of itself.


Anonymous said...

Here's the problem: most of my doctors are overloaded and it can take weeks to months to get an appointment. Once you are in, if you don't have an appt. they tell you to go to the ER. So the ER is listed as a 'catch all'. Same for most urgent care as they have to send you there for things as they don't have CT scans, ultrasounds, etc.

That is messed up.

Barry Carol said...

Is there any data on the extent to which the growth in ER visits is being driven by lower income people? I think there was an article in Health Affairs not long ago that described how low income people find the ER more convenient for them and they perceive it as higher quality than community based care that they may have access to. They also see the ER as a one stop shop where they can get imaging and other necessary services all in the same visit. Many of these people don’t have cars and can’t easily take time off from work to visit specialists or imaging centers so they go to the ER instead even if the issue is not absolutely urgent. I’m not sure what the answer is aside from hospitals maybe having a walk-in clinic next to or near the ER than non-urgent cases can be directed to.

Anonymous said...

This is only a surprise because people did not study human behavior first. Rather than placing all clinics in neighborhoods, most should have been placed next to or near every busy emergency room. Then referrals could have gone from the ER to the clinic rather than the person failing to get an appointment (or not knowing how) ending up in the ER.
Guaranteed the folks seeking help this way are of low income with few resources and are doing the only thing that makes sense to them - if you need help you get a doctor and doctors are at the hospital. The people that designed the flawed system are in shock that it does not work, but those of us watching this unfold predicted exactly this behavior which will increase costs and result in even worse service.

Anonymous said...

Paul - If something can't go on forever, it won't. This rise in federal and state spending (much of it on healthcare) can not continue to rise as it will bankrupt us at every level. We have a $17 trillion national debt and growing AND $128 trillion in future unfunded liabilities for Medicare and Social Security. So here we are handing out more free health insurance which just adds to the problem. This will break at some point and it is not going to be pretty.

Keith said...

If you insure a popoulation that has traditionally only had access to care through the emrgency room, it stands to reason they will continue to use this as their main source of care. Only if health care systems are incentivised to try to re-direct this care to less costly settings will they actually do so.

Also, giving patients Medicaid with its poor levels of reimbursement does not mean these patients will have easier access to primary care.

Anonymous said...

the data does account for two changes in Healthcare delivery, first a general trend by pcp to send walkins to the er rather than interrupt a busy office schedule and secondly insurance preauthorization requirements and Medicare rules make it easier to send to the er. More than 80 percent of hospital admits are now through the er.