Emergency room waits grow as more people become insured

Remember when I wrote, way back when, that expanding health coverage without a concurrent increase in primary care access will only worsen emergency room waits?

For instance, consider this, from CNN.com:

What good is having health insurance if you can’t find a doctor to see you? …

… The Massachusetts Medical Society reported that the average wait time for a new patient looking for a primary care doctor ranged from 36 to 50 days, with almost half of internal medicine physicians closing their doors entirely to new patients. And when you consider that Massachusetts already has the highest concentration of doctors nationwide, wait times will likely be worse in other, less physician-abundant parts of the country, should universal coverage be enacted federally.

When patients are forced to wait weeks to obtain medical care, they inevitably find their way into the emergency department for treatment that ordinarily can be handled in a doctor’s office.

That was written in August 2009. Turns out it was pretty prescient.

I read two articles recently that confirms this reality. The first was from the Boston Globe. In Massachusetts, emergency room visits rose by 9 percent from 2004 to 2008, to about 3 million visits a year. One reason? Expanded coverage:

According to a report from the Division of Health Care Finance and Policy, expanded coverage may have contributed to the rise in emergency room visits, as newly insured residents entered the health care system and could not find a primary care doctor or get a last-minute appointment with their physician.

David Morales, commissioner of the division, said several national and statewide studies have shown that expanding insurance coverage does not reduce emergency room visits.

The next day, the Associated Press came out with a similar piece, with a nationwide perspective. It’s not surprising that the country is looking at Massachusetts to forecast national health reform’s effects. And it doesn’t look good for emergency rooms:

Rand Corp. researcher Dr. Arthur L. Kellermann predicts this from the new law: “More people will have coverage and will be less afraid to go to the emergency department if they’re sick or hurt and have nowhere else to go…. We just don’t have other places in the system for these folks to go.”

Kellermann and other experts point to Massachusetts, the model for federal health overhaul where a 2006 law requires insurance for almost everyone. Reports from the state find ER visits continuing to rise since the law passed — contrary to hopes of its backers who reasoned that expanding coverage would give many people access to doctors offices.

I’m on record with supporting health reform, and expanding coverage. I simply don’t think it’s acceptable to have tens of millions of Americans without health insurance. But we have to be cognizant of the unintended consequences if primary care continues it’s disastrous decline.

It will take significantly more than what’s included in the The Patient Protection and Affordable Care Act to convince medical students to go into the field, and prevent current primary care doctors from leaving.  And to those who say physician assistants and nurse practitioners are the answer, they’re not.  First, there’s simply not enough of them to meet the demand, and second, the lucrative allure of specialty practice is also drawing mid-levels away from primary care.

Unless drastic measures are taken soon, the emergency room will surely be the next domino to fall as more than 30 million newly insured patients are set to further strain our health system.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • Donald Green MD

    There are a few issues here. It makes some sense to frame them carefully.

    Physicians knew these changes were coming and some accommodation should be made to deal with it. This problem is not one sided.

    We do not know who these people are and some study to see if they are Medicaid, Medicare, under insured or uninsured in disproportionate numbers than previously.

    People are not pressed for co-payments in hospitals as they are in offices. They just don’t have the money. They are no sicker than they were before and they are not landing in the ER for a checkup. The situation calls for more clarity before making any hard and fast assessments. Kevin it is right to advocate for more primary care but this may be a true/true unrelated situation.

    Further there are as yet no increased insured except Medicaid. These effects will take place in the near future but currently this increased ER population is a continuing trend. I also see a significant number of specialists who use to do some primary care(appropriate or not) now declining to do so. This is not a judgment statement but an observation.

    Many offices now pick and choose what insurances they will accept leaving patients at sea when they get sick. This state of affairs also needs attention.

    The present health care bill is not yet causing its effects but poor planning of our chaotic system may be a factor. The same old conundrums also exist physician payment and insurance premiums.

  • Doc D

    Actually I saw a study in Health Affairs (I think? maybe a different journal). The bulk of ER visits before reform came from Medicaid, not the uninsured, as reform supporters alleged. Now that Medicaid rolls are expanding under reform, the trend has increased.

    We ned to look ay why Medicaid patients go to the ER. In my opinion there are many factors, but one is below-cost reimbursement rates, leading to restrictions on accepting new Medicaid patients. There may be others: some patients I’ve seen don’t see any value in continuity of care, for instance.

  • SmartDoc

    Excellent article.

    I am deeply concerned that the ER system in the US will soon no longer have the capacity to handle true emergencies.

    What will happen to you or a loved one in a serious vehicular accident, when the ER is flooded with vast numbers of Medicaid/Medicare cases of non-emergent issues?

    What will happen when skilled surgeons and other acute care specialists flee ER duty due to the extreme liability risks, nightmarish hours, and increasing poor reimbursement?

  • http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD

    I’m surprised hospitals aren’t opening up two emergency rooms. One that accepts Medicaid and another that does not. Is this illegal? Patients with Medicaid who present at one might be told that the other ER (just down the road there) actually accepts their insurance and be encouraged to go there. There would clearly be a difference in terms of quality of facilities and physicians who are attracted to the two ERs, but at least it is an attempt to preserve some of what still works. Overall, the EMTALA laws and numerous other problems with having third-party payers is at the root of the issue – but in terms of what a hospital could attempt, it is a start.

  • Marc Gorayeb, MD

    You get what you pay for. If it’s free…

  • Dr. J

    Emergency departments are experiencing a crisis that is really about a confluence of factors that have little to with any individual hospital, and everything to do with the structure of society. These issues are therefore not solvable by any changes any single emergency department might make, so in spite of advance and innovation in ED’s this is a loosing battle.
    A couple of the reasons for unmanageable departments:

    1) Many patients have no idea what is an actual emergency. In spite of the fact that we are healthier and longer lived than ever we seem to believe we are weak, disabled, and that the axe of fate hangs above our necks. Advertisements constantly warn that any ache or twinge could be the fine edge of death’s axe and they are scared. Our families are so disjointed and spread out that there is usually no one to turn to for a second opinion, or a ‘Do you think I should worry about that?’.

    2) We (both patients and physicians) believe that technology is king, so even basic cases are subjected to tests and time and slow down department flow.

    3) We believe everything must be explained. It is not enough to know that the twinge in your chest is not anything serious, an explanation must be had.

    4) Fear of litigation means that common sense and timely evaluation are secondary to good documentation to keep out of future legal trouble.

    So in the end a great deal of our business is people who are scared and unsure if they are sick or well. Most of the time they are easily identified as well (most life threatening emergencies are recognizable immediately or with an initial set or tests), with a tiny chance they are sick. The result is what I think of as ‘The Great Rule Out’, that is that the miss rate for virtually anything is unacceptable, and so an extensive set of testing is required before physician and patient are comfortable enough for discharge. In many cases the emergency department is actually the risk stratification department. That is not to say that we don’t identify anything important, we do, but we need to consider the how and why of what we do, not just how we ‘move the meat’ if we are really going to think about the function and use of the emergency department.

  • M. Osler MD

    Increasing ER visits in the aftermath of healthcare reform has been a hot topic long before Dr Kellermann’s report. Are they correct? Of course they are and the Administration is taking the “conventional” wisdom expoused by the experts, such as increasing the number of PCP(or paying them more) and FQCHCs, to try and avert such a calamity. Your last few paragraphs would lead one to believe that this is the path we should go down, although in greater numbers then presently budgeted. Taking such a path is going to be a catastrophe for America and its citizens. The answer just isn’t that simple. I agree we need more of both, but they will NOT reduce the number of ER visits. They are independent of each other. There is no correlation between; PCP or FQCHC density in a state, Medicaid PCP fees, PCP Medicare to Medicaid index, or percent of state population on Medicaid, to the ER utilization rate in a state. The only thing we know is that the ER utilization rate in all states are going up and they will increase even faster under the administration’s healthcare reform. Present healthcare reform will, as the English like to say, “make a bloody mess of things” when it comes to ER utilization. How messy? You’re looking at an extra $125 billion over the next ten years for every 1 % above the historical ER expense growth rate before reform. It will probably be closer to 2-3 percent above the historical growth rate or $250-375 billion dolars more than CBO predicits.
    There is an answer for all this. It not only markedly decreases ER visits, but increases PCP capacity, FQCHC capacity, bends the over all cost curve down and saves taxpayers a fortune. The program was acutally placed before the Administration and on the Presidental Transition Healthcare Innovation blog, but was “removed” as TOO disruptive to the status quo, but that’s another blog.

  • http://www.healthbeatblog.org maggiemahar


    The Accountable Care Act provides funding to double the capacity of Community Health Centers

    By the time reform kicks in, many health centers will have expanded while new ones will have been built.
    Massachusetts didn’t have this added capacity.

    These health centers are usually open after hours, and are designed to provide medical homes for those who now use the ER as their primary care provider. Many provide excellent care–for example, the centers Dr. Neal Calman runs in New York and the surrounding area.

    The only problem is that many hospitals may be loathe to give up the patients crowding their ERs. They get a fair number of admissions from insured patients who show up at the ER (even if those patients don’t always need to be hospitalized, some hospital administrators urge ER staff to admit them)
    and hospitals make a great deal of money on the battery of tests routinely administered to people who come to an ER..

    But planner are already working on ways to redirect much of the traffic to Community Health Plans.

    Who will staff them? A combination of doctors (including some specialists, ) and nurse practioners, R.N.s adn physicians’ assistants, working together.

    The legislation addresses the nursing shorting by hiking pay for nursing school teachers and offering loan forgiveness for nursing students. (In the past we haven’t had enough nursing school teachers because the pay was so low; thus a long line of qualified applicatnts couldn’t be admitted.

    Finally, generous loan foregiveness and scholarships for Med students will make it possilbe for more students coming from low-income famlies to go to med school. Research shows that they are much more likely to be willing to work in inner city neigihborhoods and low-income rural areas where they grew up. They are also more likely to choose to work in clinics. And of course we need more diversity in our medical work force . . I think more med schools will be reaching out to low-income students.

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