Why does Medicaid increase emergency department use?

The interpretation of results of a policy study lies in the political inclination of the beholder.

If one likes the results they are “ground breaking.” If they are not in line with our world view there are “nuances” of hypothesis testing that detractors have overlooked, it’s too “premature” to draw conclusions and “further research” is needed. Statisticians, like lawyers, can be recruited to argue any point of view to meaningless insignificance.

This is natural. Instead of begrudging these biases it is best to listen to opinions on both sides as they can be instructive.

The Oregon Health Insurance Experiment (OHIE) studied the impact of Medicaid on outcomes and utilization of services. In Oregon, Medicaid was expanded by a lottery. This is as close to randomization as possible. Research in social sciences is hindered by the difficulty in randomization.

The latest results, published in Science, found that Medicaid expansion increased emergency department (ED) use by 40%.  The finding challenges an assumption: the economically disadvantaged utilize the emergency department because of lack of insurance.

This assumption is the basis of another assumption: uncompensated care by emergency department shifts costs to the insured. In turn this assumption leads to a train of assumptions: expanding insurance will keep people healthier by enabling them to visit their primary care physician (PCP), so less likely to present to the emergency department with advanced disease, and health care costs will actually decrease.

To what extent the Congressional Budget Office used these assumptions in their original models that showed the Affordable Care Act, in the long run, is budget neutral is uncertain. But there is little doubt that this assumption trail needs to be revisited.

That’s one interpretation. Here is another.

The ED is not the back office of US health care but its central headquarters. It is a system within a system. ED provides adequate, often excellent, and time-sensitive care.

Consider a shift worker straddling the federal poverty level who has abdominal pain for the past 3 months. It is 10pm on Saturday night and he has finally decided that his symptoms need to be addressed. He can walk in to the ED — no phone call, no appointment, no receptionist telling him that the PCP does not take new Medicaid patients. He will be seen, perhaps with a delay, investigated thoroughly and diagnosed or reassured. For him this is access. This is his reality.

ED is excellent not just in dealing with acute problems but in managing, at least initially, chronic problems. It takes a decent snapshot of a person’s health. It applies a decent bandage. Often a bandage is all people care about.

ED has had to reach structural soundness because of unique exposure to litigation and EMTALA, which forbids denial of emergency treatment to the uninsured. Over the years the ED has become robust because of relentless and concentrated demands placed upon it. For many it is the most reliable element, a friend in need, in this fragmented health care system.

In the UK’s National Health Service (NHS), both primary care and ED are free at point of service for all, and access to PCPs is more certain and uniform than in the US. People still throng the ED. So much so that PCPs have been asked to open shop 24/7 to take pressures off acute services which are imploding because of limited budget and manpower.

For many in the US, the ED is the 24/7 de facto primary care that the UK so craves. Perhaps the Medicaid budget should follow the patient, and spending be directed away from regulatory waste and towards the emergency department so that it morphs in to a conjoined emergency-primary care service.

OHIE confirms several things. Having insurance increases utilization. Medicaid does not provide the level of access of private insurance or Medicare. The ED is perceived to be the best access for many and this will remain so for a long time. Expanding insurance will not shift burden from ED to primary care. Expanding health insurance will not reduce health care costs (that I think we all knew, deep down).

In a sense OHIE confirms reality. As opinions on health care can be highly polarized, presenting a reality that we can all agree on is a ground-breaking achievement.

Saurabh Jha is a radiologist. He can be reached on Twitter @RogueRad.

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  • Cedric Dark

    Typo. Medicaid expansion increases ED use by *40%*

    • http://www.kevinmd.com kevinmd

      Thanks. I fixed it.

      K

  • RocK8Doc

    Why ?

    Due to misaligned Incentives. As the costs and benefits are not shared by the stakeholders/Beneficiaries, it leads to troublesome outcomes.

    When you spend your money on yourself you will economize highest value, When you Spend Someone Else’s Money(Medicaid Insurance) on Yourself(Medicaid Patient) You will not’ economize but seek highest perceived value~ER utilization.

    • saurabh jha

      Nice table! But do you believe that charging Medicaid patients a co-payment (reasonable) for ED use will shift care to PCP to a meaningful extent?

      • RocK8Doc

        Saurabh; It’s not just what I believe, it’s the rational human behavior. Ownership of cost or benefit is such a powerful motive. Most of us will use resources in ways that maximize our own best interest. We inherently care more about protecting our own resources ($, time, effort…) than someone else’s.

        We can ask any number of our friends that ravel using corporate credit card vs their own credit card.

        A reasonable co pay in the ER vs significantly less co pay in the clinics and incentives for clinic appointments will solve the ER utilization to a significant extent.

        • saurabh jha

          It’s hard to disagree with the theory (and empirical evidence) behind your prescription. Enacting as policy is a whole different matter.

        • SarahJ89

          And will charging a low-income person a fee somehow make the reality they can’t leave work during normal office hours go away?

  • Thomas D Guastavino

    I am going to be blunt. The survival of the ER as a means of providing care to the non and burgeoning under insured population has been dependent upon the indentured servitude of health care providers. EMTALA along with the requirement of most hospital active staff physicians to be on the “on call” roster has made this happen. Years ago this was not a problem but it has now reached critical mass. The trends are clear. More and more hospitals have been forced to pay for on call coverage as the number of physicians willing to take call has been dwindling. Those physicians who do take call are shying away from the more difficult cases. This is going to continue to get worse as physicians in training continue to opt for more sub-specialties that do not involve ER call.

    • Deceased MD

      My sentiments as well Dr. G. I got tired of working for “free” as well. It is really deflating. There is so much money in HC and yet they expect physicians to work for free in the ED? Give me a break. And this is a free market?

      • SarahJ89

        Thank you both for sharing this information. Are you saying you are not paid for on-call shifts? I’ve worked in hospitals and had no idea. Most people I’ve known on call were paid when they got a call at least. Some got a pittance for the disruption of one’s life that on call entails.

  • PamelaWibleMD

    Got a email from an uninsured 57 yo patient (and friend). Subject line: $624 cat bite. He went to the ER. I told him he could have saved 100s of dollars had he gone to urgent care. Even more had he called me. He considers himself a well-educated man. He has lived in the US his entire life. He had no idea that the cost of care would be so different between these facilities. Obviously, even educated patients need more education. By the way, I’m in Oregon. I’m a primary care doc. And I am pretty much available 24/7.

    • Kristy Sokoloski

      Dr. Wibble,
      I am curious to know where in Oregon you are. The reason I ask is because I lived in Oregon as a teenager in the town of Florence.

      • PamelaWibleMD

        Eugene. :)

        • Kristy Sokoloski

          Very cool. We used to go to Eugene quite a bit. It was always a fun trip. One of the doctors I had when I was growing up was Sharon Catlin. Did you know her?

        • SarahJ89

          Eugene, Oregon. I live in New England. In the seventies my friends and I decided that if you worked in any form of education or human services and you were very, very good… when you died you got to go to Eugene. Much better than heaven for anyone who really cared about actually helping people in a meaningful way. One friend actually did move to Eugene for a position as a day care director. She was dileriously happy. (Can’t spell today, have the flu.)

          • PamelaWibleMD

            So true! I am deliriously happy too!

      • PamelaWibleMD

        A bit about my clinic here: http://www.idealmedicalcare.org

    • Bob

      For free?

    • http://hautuconsulting.com/ Shane Irving

      Good points Dr. Wible. There are many good Urgent Cares in Oregon around at 1/3 the price of a simple ED visit. Maybe ED’s should be required to tell patients they could use an Urgent Care facility once they are triaged (similar to the CT/MR notices large clinics are required to use when ordering imaging studies)

      With Oregon Medicaid the ED utilization has been steadily increasing. I think part of the problem is with the Medicaid CCO’s pushing conditions onto the PCP’s that they aren’t necessarily comfortable handling and that they would usually refer to a specialist for management. The CCO Pre Authorization processes can be so slow and onerous that having patients go through the ED jumps the authorization process. The CCO’s have to start trusting the PCP’s to manage their patients because all they are doing now is shooting themselves in the foot.

      Thanks,
      Breitenbush fan from Central Oregon

      • PamelaWibleMD

        You have an Oregon’s insider’s perspective fo sure! Impressive.

    • querywoman

      If he’s your pre-existing patient, I hope you worked harder to convince him that you are available 24/7 (most of the time).
      You do need time for the bathroom, to be sick yourself, and an occasional mental health day.
      Maybe he didn’t want to bother you and thought you didn’t have the right supplies.

  • buzzkillerjsmith

    The idea that expanding HI would decrease ED visits was merely a political talking-point to fool regular folks who were half-way paying attention to this on the nightly news while eating dinner. No one at this blog ever really believed it.

    Most of us here expect more of this kind of stuff. I would submit that, in time, studies will likely show that this whole EHR craze has been a colossal waste of time and money. Of course I could be wrong.

    • saurabh jha

      TBH, I was one of those fools, and I am likely to be fooled twice or thrice.

      The trouble with an observation and a plausible theory (if people don’t have insurance they will go to the ED), is that the opposite is also considered true (if people have insurance they won’t go to the ED). As it is quite evident from this study, these things tend not to be so symmetric.

    • Bob

      The differences between wishing, hoping and truth are sometimes basically dishonest as is ObamaCare and why it will kill healthcare in America.
      ER’s get patients for many reasons and in large metropolitan areas they are hangouts for the local populations. Why take care of your health or go through the expense of finding a doctor, unless you need one, and when you do everybody knows they can find a lot of them at the local ER.
      And nights are real fun for that is most likely to have the victims of crimes to appear as well as the local drunks and “crazies” frequent visitors to ER’s.
      The best acute care at no cost? Who needs insurance that costs money and time, and you don’t even have to pay he bills.
      And January 1, 2014 when millions joined as they were deemed Medicaid or tax payers would subsidize their insurance, not a single physician, nurse, or ER was added for the millions of “new customers”, so where will the overflow go? The only place open 24/7 and free, even in states that do not accept ObamaCare’s New 100% Medicaid patients, who will just die on the vine or get rid of Medicaid frauds.
      That is the only silver lining in ObamaCare.

      • saurabh jha

        It seems that social correlates of health and health-seeking behaviour are difficult to overcome in any system. The ACA, of course, is not alone in failing to deal with these. One could say, at least it tried (trying).

        • Bob

          They who know not that they know not are very dangerous. How patient will new Medicaid patients be, for they weren’t told they could keep their doctor, they were promised one and won’t be able to find them!
          Ironically they will end up in ER’s, in droves and in states without new Medicaid they’ll cause real problems; financial and otherwise.

          • saurabh jha

            On a philosophical note you may well be correct. However, it is as much human nature to want to make a difference as it is to err. Policymakers will be confronted with this question: what should we do about people making < FPL? The answer can't be "do nothing".

          • Bob

            Philosophically my foot!
            1 doctor can’t care for 2 patients at the same time and hospitals not being able to pay them on top of that isn’t theoretical, philosophical, or metaphysical, its simply reality!
            You can’t put 3 pound of rice in a paper bag w/o the bag splitting and spilling the rice!

          • saurabh jha

            What’s your solution? Do nothing is not on the menu.

          • Bob

            The only two solutions are: less patients, which can be done in many ways, and better care which includes training more and using personnel better and more efficiently.
            Money isn’t the problem even though $1 trillion a year can be released by ending waste, fraud and abuse, $1 out if every $3 spent; but all the money in the World can’t give any care: only well intentioned and trained humans.

          • saurabh jha

            Not many will oppose strengthening primary care. It would also help paying the PCP on par with Medicare. But for the PCP to be effective there has to be social stability. As some have pointed out, people < FPL are more in flux than many of us imagine.

            My point is that there is an element of inevitability in their use of the ED.

  • JR

    Here’s a case study of two people I know on Medicaid:

    1. Female, late 20′s. No children (only qualifies for Medicaid 2014). Has a low-income job even with a college degree. Lives with parents and has a good support system. Has had a long term relationship with a PCP, goes to PCP for care.

    2. Female, late 20′s. 1 child who is chronically ill. Has low-income job. Lives with boyfriend and doesn’t have a good support system.
    -Looses housing, moves to a different state closer to family (can’t continue with PCP).
    -Breaks up with boyfriend, temporarily moves in with un-supportive, highly critical parent (can’t continue with PCP)
    -Finally moves on her own again. Finally locates a new PCP.
    In between, she went to the ER. Why? Because she doesn’t have a PCP, doesn’t have much time to search for one, and she had a toddler with constantly re-occuring ear infections. She had to call in sick for work, is out of sick days, and has to get a doctor’s note. She can’t get on FMLA because she needs a PCP.

    I was a middle-class kid in a school full of kids living in poverty. I was the only one in my class who paid for school lunches. These kids were smart. But they did poorly in school. Kids living in poverty move. and move. and move. and move. In and out of different schools; in and out of different districts. This school is ahead so they try to catch up… that school is behind so they get bored.

    Do ER rooms have social service workers who can help connect patients with PCPs who take Medicaid for follow up? Should the ER not dismiss the patient until they’ve confirmed a follow up appointment is scheduled with a PCP? If not, could hospitals provide office space to non-profits who provide social services; so after caring for a patient they can walk straight over there and get help? It seems that a lot of patients in ERs need social services more than the ER.

    • saurabh jha

      Excellent points.

    • SarahJ89

      My family moved 17 times in one year, 28 times by the time I was ten years old. I was in my mid-twenties before I learned one could actually unpack and not live out of cardboard boxes. It took me a long time to learn how to settle down and expect life to not be a moving target.

      • SarahJ89

        My sweetie and I cling to the bottom rungs of the middle class now, living in a four-room cottage on piers and saving like demented squirrels for our retirement.

        I recently had occasion to be in or pass through areas of extreme poverty. It all came back to me in an unpleasant rush just how incredibly depressing poverty is. It’s hidden in the US, isolated in little geographic pockets. Middle class people often think they see it, think they understand, but we don’t.

        I realized as I sat with my friend with no teeth, as I passed through dreary, depressing landscape dotted with shacks and ramshackle trailers (and no work), that I had managed to forget its reality. It’s really depressing in a way that saps your life force.

        And for those of you who think it’s easy to “just move to where the work is,” I’ve seen the results of people landing in their car with small children in a place where they know no one and run out of money for gas before they find work. It’s not pretty. But the rest of us do get to criticize them for making that desperate move. After all, we would have done it so much better.

        I am so glad I am not there any more, never want to be there again. But make no mistake, “there” is a different place from where most of us here now live.

    • querywoman

      There are PCP’s that take Medicaid. Where I live, there are public clinics that specialize in them and also clinics at the large church hospitals.
      The first woman you cite is a responsible person with familial support who probably knows how to find things. She was responsible enough and persistent enough to get a college degree.
      The second woman may or may not be responsible and persistent herself, but she was in a time of transition. Plus, it would be child abuse not to take her child to the ER when sick! That is being responsible.

  • Milly Landers

    Normally individuals that are on Medicaid have either no personal transportation and therefore utilize public transportation. Many cities will not operate public transportation after 10 p.m. I’m not talking about NYC or Washington, DC! If a person on Medicaid does have a personal vehicle, it is an impossible decision to use the weekly gas allowance to drive to the burb minor emergency clinic or the ER down the street. I am talking about how the rest of us Americans live. People on Medicaid don’t have a computer which requires access to internet. $$$. How does an individual on Medicaid without a cell phone, computer and working a job “defined” as “working poor” find a PCP? Do you guys advertise? Wait, people on Medicaid don’t have cable either! If a single mother has a sick child at 10:30 p..m., where is that mother to go? Poverty sucks and I am so glad the medical community gets to complain about how Medicaid increases ER visits!

    • querywoman

      I don’t drive either. I’m on Medicare, not Medicaid.
      Yesterday I had nausea and fast heartbeat. I called 911 around 9:30 PM and went to the ER. I was treated in the ER for dehydration with IV’s and released around 1 PM.
      I called a cab home, and it was a little under $15. I haven’t taken a cab in over half a year, but at least I can afford it. It beats car payments and insurance.
      A really poor or cheap person would have had to hang around till about 5 AM when the buses start running again.
      That doesn’t exactly respond to you, though, Milly.
      The crummy amount Medicaid pays for the ER is more than having to totally eat the expenses for an uninsured person.
      I think the Medicaid recipients probably feel comfy going to the ER because they know Medicaid will pay.
      As a long-time Texas welfare worker, I can assure you that that many of the poor are impulse driven and can’t plan their lives very well.

    • querywoman

      I’m rereading your post and digesting it more.
      Medicaid does provide medical transportation with advance notice, maybe 24 to 48 hours.
      For planned visits, it’s available. I don’t know if Medicaid will pay for ER transportation home or after hospital release.

  • querywoman

    Many of the lower paying jobs don’t follow FMLA or any labor law closely. You have to be at a job a certain amount of time first to be qualified for FMLA.

  • querywoman

    Yes, I read it, and I just researched FMLA law. Right off the offical US government site, “have worked 1,250 hours during the 12 months prior to the start of leave.”
    There are a few other requirements.
    My experience when I worked in welfare is that a lot of the clients don’t stay in jobs very long, and there is a lot of turnover. I had a lot of women who worked for public schools as cafeteria workers and the schools fix it so they can’t get unemployment comp in the summer.
    That doesn’t rule out that there are many people who have stable long-term jobs who qualify for Medicaid for their children. I’m not talking about this in terms of them not getting legally qualified FMLA, but many of those more stable jobs do hassle people for taking off. I have written up “excuses” for employed people that stated when they were in my office.
    Getting fired for missing work is concerns me more than the loss of wages for lower income workers who go to docs. I have seen so many survive loss of a few hours’ wages, but job loss is harder.
    I’m used to people getting hurt on the job. In Texas, employers are not required to have worker’s comp insurance, but are required to pay out of their own pockets if they don’t have it. Sometimes they do.
    Just as an aside here, I’ve seen lots of people fall off ladders at dollar stores and get hurt. I’m not referring to any name brand dollar stores here, doesn’t stick out in my mind, but we have lots of lots of dollar stores.
    Low wage employers like Dollar General, Family Dollar, and Walmart have a big corporation behind them, who is supposed to be making them adhere to laws.
    It’s well-known that Walmart hassles their employees.

  • querywoman

    I don’t understand why you think I don’t read you properly. We are probably on the same wavelength, anyway.
    I attend a church that is very concerned with Jobs for Justice. Working conditions are getting worse all the time.
    Most laws work best for people been on a job for a while.
    I was beat out on overtime on almost every job I had till I went to work for a government agency.

  • SarahJ89

    And it *is* disrupting, whether you get called or not.

    • Deceased MD

      so true. the anticipation is unpleasant to deal with. thanks for your empathy.

      I also grow weary of a system that exploits. thinking of hospitals and data bases/privacy–the list goes on, when i say this

      • SarahJ89

        Oh, I am SO sick of Corporate Medicine. It’s destroyed what used to be medicine. I miss having a doctor on my side as a resource instead of someone whose main focus is appeasing the computer gods of her avaricious hospital employer. In our area it’s really bad because the hospital is the prime employer in the one city here. They’ve bought up every practice in a 30-mile radius. The city gives them whatever they want–roads, highway access, you name it–and the taxpayers pay for it. The CEO pulls down almost a million a year in an area in which the median salary is $47K.

        Thank you for listening (if you did). I feel better now.

  • SarahJ89

    I’m in northern New England. I live near the state capital, a town of about 40,000. The hospital in question is absolutely brilliant in marketing. It’s also the chief employer in the area. It bills itself as a “regional medical center,” despite the fact it has no affiliation with any medical school or *real* regional medical center. It’s just an overgrown suburban hospital. With a snazzy, shiny cancer center and cardiac surgical unit. We live 90 minutes from Boston. I used to work as a hospital social worker in another overblown suburban hospital in the Boston area so I’m aware big places frequently fail to meet their reputation. But I really cannot understand why someone with cancer wouldn’t at least go for a second opinion instead of staying in East Podunk. I’d mortgage my house if I had to.

    In answer to your question, most people around here are regular Kook-Aid drinkers. The handful of us who’ve nearly died or have loved ones who did die or are permanently maimed know better. We talk in whispers.

    I will say the nurses in that place are great. The problem is the administration, graduates of the 1984 School of Business at Stepford University.

    • Deceased MD

      you have a good sense of humor, but I’m afraid there is a lot of truth in what you say. I think they could be Kool Aid or Kook-aid drinkers. (i know a typo but I think you’d have to be nuts to believe all that. The sad part is that anyone who is business minded can make a killing in HC now.
      I agree with your comment on second opinions. they see the shiny new building with slogans and think that has to be the best??

      i often wonder if people are still not getting what is going on. They just know HC is expensive but don’t question it and believe it is the best. I really have no clue. It is refreshing to chat with you since you seem very aware. I guess in your area, people care more about employment than HC. Actually would say that’s true everywhere of course.

      • SarahJ89

        Yes, we all mostly care more about employment than health. I learned that as a young woman when I moved into the nearest Big City (population 10K), a paper mill town. Within three days I realized what would happen to that community if the pollution-belching mill shut down. I kiss my sinuses good-bye and started my new job. Since then the mill has shut down. I’m sure everyone is healthier, but I cry whenever I go there to see the poverty.

        Part of the problem for patients is that the information we need in order to make rational decisions is systematically withheld from us. Good luck finding out anything about how many operations a surgeon does of a particular type per year, how long the team has been together, what sort (if any) charges have been brought against the hospital or doctors, how things are sterilized, what kind of safeguards are in place (and used) for infection prevention. Nope. All we have to go on is that shiny sign, the doc’s personality and my, what nice curtains you have. That’s a thin broth, I tell you.

        Another problem is insurance. My sweetie’s insurance is written so he can only go to the hospital in which his PCP has privileges. When we were younger your PCP made a diagnosis, then helped you find the right fit in choosing a place for treatment. Now most of them are tied to one hospital, which owns their practice. In our case, this would be the local hospital we don’t trust.

        We decided we simply had to play the odds. We figured at his age the most likely thing that would require hospitalization would be cancer or heart issues. So we found a good PCP with privileges at two hospitals, one of which is good with heart. My niece works in a nationally known hospital instate that has a good cancer center and that’s where he’d go for that (god forbid).

        The PCP is 35 miles away, but sweetie is basically healthy so he doesn’t need much at this point. He sees him once a year. He appears to be burning out (the PCP, not the sweetie.)

        Ironically, sweetie had a medical emergency that ended up in installation of a pacemaker 18 months ago. We were on vacation in another state. He was taken to a small hospital we’d never heard of. Niece came over, loaded for bear. Only to find out the cardiologist there had trained the cardios she lunches with at Big Famous Medical Center. Turns out the small hospital is in an area where very wealthy people vacation. They go to Florida for the winter, then come back up to Small Hospital to have their pacemakers checked. We lucked out.

        • Deceased MD

          well that is very fortunate. But you have outlined the problem nicely. I am not sure how many people actually realize this, but it is a crime. Many people die bc of these sorts of things and no one even realizes. or at least morbidity and mortality. so glad things worked out for both of you. But one should not have to struggle like that. It’s 1 thing to make your own choice to drive far for a doc but another when dictated. so we have now that dilemma plus folks being forced to pay for unaffordable insurance–at least the middle class. years ago people worked on the railroads to help the rich. Now we just support them by buying health insurance.

          • SarahJ89

            ” years ago people worked on the railroads to help the rich. Now we just support them by buying health insurance.”
            Perfect. I’m the daughter of a gandy dancer, who later became an award-winning news photographer.

          • Deceased MD

            seriously? how weird is that!

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