Health reform will drive up ER visits, like it did in Massachusetts

Health reform will drive up ER visits, like it did in MassachusettsWhenever I get asked about how the Affordable Care Act will impact health care, I always say, “look at Massachusetts first.”

That’s because Massachusetts serves as a model for what’s coming ahead for the rest of the country.

As I wrote in 2009, Massachusetts did not provide the primary care infrastructure for near-universal care, which I predicted would drive up emergency room visits.

Sometimes, it hurts to be right.

In a recent Boston Globe piece two years later,

… when the Massachusetts Legislature made health insurance mandatory five years ago, supporters of the first-in-the-nation law hoped it would keep patients out of hospital emergency rooms.

Patients with insurance, the theory went, would have better access to internists, family practitioners, and pediatricians, lessening their reliance on emergency rooms for routine care.

There is more evidence today that it did not turn out that way.

Three-quarters of Massachusetts emergency room physicians who responded to a survey last month said the number of patients in their ERs climbed in the last year.

Nothing illustrates the primary care problem better than this chart, courtesy of The Incidental Economist:

Health reform will drive up ER visits, like it did in Massachusetts

Having health insurance doesn’t guarantee access to care. Period.

The Affordable Care Act didn’t do nearly enough to expand the number of primary care providers. And yes, I’m accounting for physician assistants and nurse practitioners, who also are swayed by the allure of specialty practice.

Massachusetts already has a primary care infrastructure superior to much of the country, so it’s frightening to think what will happen in poorer states with less generalist provider access.

What’s happening today in Massachusetts ERs will be replicated in hospitals nationwide come 2014.

Brace yourselves.

Kevin Pho is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of, also on FacebookTwitter, and LinkedIn.

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  • eRobin

    We could import docs from other countries. Would solve a few problems at once:

  • Rob Lindeman

    Is it a certainty that access to non-emergency level of care will solve the problem? More doctors? Like Kevin says, my state is already saturated with health care providers. I suspect ACA money is being ill-spent.

    In the absence of DISINCENTIVES to use emergency services, I can’t see how we’re going to reverse the trend.

  • Angela Caffaratti, MD

    I am always amazed at what patients think is an emergency. I also know patients find ER more convenient and employers don’t allow people to miss work for illness let alone doctors appointments.

    • Rob Lindeman

      It’s even more amazing what triage nurses consider an emergency.

      I’m referring here specifically to the survey forms that are filled out in triage and appear later in the National Hospital Ambulatory Medical Care surveys. It is based on these data that the claim is made that only 12% of ED visits are non-urgent in nature. On closer inspection, the severity of complaints are being “up-coded”. For example, otitis media and pharyngitis are coded as “semi-urgent” or “urgent”. Common-sense analysis of these data reveals that approximately half of all ED visits do not require emergency level of care.

    • stitch

      How about all these hospitals that are now providing a way to look up the wait time for the emergency room?

      If you can take the time to wonder about, and look up, the wait time, it’s not an emergency. Period.

  • girlvet

    You are making an assumption that healthcare reform caused this. There are many other factors involved:

    1) People have lost their insurance when they lost their jobs and wait til they are really sick and then come to ER,
    2) There are more old people and they are sicker.
    3) Doctors offices exist 9-5 and it is difficult to get an appointment.

    Nice effort on your part to blame comphrehensive health care though…..your view is simplistic.

    • bladedoc

      Ah yes the administration’s aplogists’ cry: IT WOULD HAVE BEEN WORSE!

      Just the same as “if not for the bailout, unemployment would have been worse” (even though the admin said unemployment would have only gone as high as 8.8% WITHOUT the stimulus)

      Sure, I guess blaming it on Bush is getting old.

      • IVF-MD

        We have learned our lesson about trying to refute non-disprovable tenets. If unemployment goes down, the stimulus worked. If unemployment goes up, the stimulus wasn’t enough. -_-

  • ninguem

    The Mass healthcare reforms did not have to create a primary care infrastructure. If it allowed adequate payment for primary care, the docs would follow and the ER visits would drop. The elevated ER use, assuming the number accurately show this, could be a marker of success.

    IF that’s the case, you will see the ER use drop as primary care docs enter Massachusetts t fill the demand. Have we allowed enough time to see that? I don’t know.

    Not being in Mass, I don’t know. The primary care docs who are there. I assume they have more work than they can handle. Are they saying this is great, we’re doing fantastic financially, this is a great place to practice………

    Or are they saying we’re working harder, getting paid less, and this is not any good.

    • bimalc

      I actually just went to my PCP in Boston and ran into one of my old medicine professors who also attends in that practice. We talked about where I matched and my subspecialty interests and I joked that I was going the super-sub-specialized route because I’m not smart enough to manage the variety of problems seen in primary care.

      His response was depressing: The demands on his time (and the practice in general) are higher than ever, the compensation is flat at best and no one who matters (ie a party with power/money) cares. This is the same guy who, just 3 or 4 years ago was giving the med students what we jokingly called the ‘primary care pep talk’. I told him my fiance was considering primary care and he told me flat out to do anything I could to dissuade her.

      I know the pleural of anecdote is not data, but the whole exchange was just sad.

      • ninguem

        Maybe the plural of anecdote is not data, but I wonder about the exponential of anecdote. That story is repeated in every medical teaching setting in the country.

  • buzzkillersmith

    If you increase demand a lot but do not increase supply, you just might get a shortage. Not rocket science.
    I’d be willing to help out and save on ER costs by working some more precious evenings in the clinic–evenings away from my wife and children–but only if society compensates me appropriately. Society has thus far resisted the deal. So to the ER they go….

  • Steven Reznick MD FACP

    Multifactorial issues. What is required is a new mindset not just more primary care providers. Basic first aid and health evaluation and treatment need to return to middle school and high school level curriculums so that simple things can be treated simply and in the appropriate setting. That being said, Chest pain and cardiac issues, uncontrolled bleeding, acute severe and painful trauma and loss of consciousness issues along with intractable pain will still appropriately end up in an ER. We need to re educate the public as to when an ER visit is appropriate and when a call or trip to the doctor is most appropriate. We do need to restore access to health care and availability of qualifed health care personnel to provide answers to questions when patients are ill so we can care for illnesses in the proper setting. It would be nice if everyone had a primary care physician so they had someone to contact if they become ill before they self refer themselves to an ER for a non emergent issue. It would be nice if hospitals didnt treat their ERs as profit centers and encourage repititve non emergent visits. It would be great if patients used their sick leave to schedule a doctors visit rather than complain about doctor regular hours( when I kept my office hours expanded to include nights and weekends the working people never used the hours. Retirees working around their tee off times and bridge games liked the expanded hours).
    As more people obtain insurance and re-enter the health care market to be treated by an aging and understaffed provider force the ER visits may very well increase and mirror the Massachusetts experience. We killed off Public Health education in the name of saving tax money, we are killing off physician participation in primary care based on a failure to compensate the providers appropriately and we have not solved the medical malpractice liability issues and threats which encourage ER staffs to maximize their workups to reduce any liability issues. We havent even discussed the millions of senior citizens in senior facilities who are sent to the ER daily because staffing and liablity issues have replaced caring and the motto is “call 911 and copy the chart for transfer” even if the patient problem is simple and the patient has requested non aggressive treatment at the end of life.

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