Why Medicaid patients use the emergency department for primary care

A study from Science found that those on Medicaid in Oregon made 40% more visits to the emergency department.

The Oregon Health Insurance Experiment included about 90,000 low-income people and assigned 30,000 of them to Medicaid by lottery. It’s essentially a naturally-occurring randomized controlled trial.

The result seems to have caught the public policy experts by off guard:

“I suspect that the finding will be surprising to many in the policy debate,” said Katherine Baicker, an economist at Harvard University’s School of Public Health and one of the authors of the study.

But ask any practicing physician, and most would say the result is of little surprise.

Why?

The promise of insurance doesn’t guarantee access to care. Especially with Medicaid. To save money, Medicaid continually pressures physician reimbursements down, and obstructs care with a number of bureaucratic hurdles that exceed most private insurers. Cumbersome pre-authorizations and overly restrictive drug formularies, for instance.

It’s no wonder why fewer primary care doctors and specialists accept Medicaid.

Another reason is one of convenience.  Adrianna McIntyre at The Incidental Economist points to a Health Affairs study that interviewed Medicaid recipients, asking them why they chose the emergency department.

One response is telling:

For patients covered by Medicaid, the direct financial cost of an ED visit and physician office visit were similar; however, the overall cost of ambulatory care was higher because of the additional time and expense required for specialty visits or additional testing recommended by the primary care provider.

One respondent reported: “When I go to my primary, I don’t have a copay. I don’t have a copay in the ER either. But my primary may send me to 2 or 3 specialists, and sometimes there is a copay for them. Plus time off from work to go see them. It’s cheaper to just go to the ER.”

Primary care involves regular office visits to properly manage chronic diseases like hypertension and diabetes. According to McIntyre, this time cost is a greater barrier for Medicaid patients, who may have to deal with time off from work, child care, or transportation issues more frequently than their middle and upper class counterparts.

The emergency department has grown into a one-stop shop, where patients have 24/7 access to studies and consultants that would require separate visits and co-pays in the ambulatory setting.  Primary care has to evolve into a viable alternative that matches the convenience of the emergency department.  Health reform offers very little to move the needle in that direction.

The Oregon Medicaid findings highlight a central flaw in the Affordable Care Act. Expanding insurance without expanding the primary care infrastructure drives more patients to the hospital. Until that is effectively addressed, expect more newly insured patients beyond Oregon to use the emergency department for primary care.

Why Medicaid patients use the emergency department for primary careKevin Pho is an internal medicine physician and co-author of Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. He is on the editorial board of contributors, USA Today, and is founder and editor, KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • Kristy Sokoloski

    In one of the other blog entries that got posted here over a year ago someone asked the question about teaching ED doctors more about Primary Care as part of the residency programs for Emergency Medicine. My question is: would doing this help some of the problem since these Medicaid patients prefer to use the ED aka ER?

    • Kristy Sokoloski

      To the one that disliked this post the reason I asked it is because of a blog entry someone wrote suggesting the idea. I don’t know that it would be a good idea but it just made me wonder because as it is these Emergency Medicine doctors are being taken away from caring for the true emergencies but you have people who insist on not wanting to get a regular doctor to take care of the non-emergent care going to the ER for the reasons listed above. And unfortunately, a friend of mine in the UK confirms that the same things are happening over there.

      • buzzkillerjsmith

        The ueberpoint here, Kristy, is the primary care basically sucks, for all the reasons dozens of us have gone over ad nauseam at this blog.

        Primary care sucks in the UK, too, at least according to a family doc friend who married an RAF chap and then moved over there. An American moving to the UK?! Must be love.

        In any case, unless or until primary care gets a radical overhaul, unless or until they pay us much more and/or work us much less, this problem will go on and on. I am 12 years from retirement, unless that lottery thing comes through (come on baby, I’m feelin’ lucky today!) , and I expect primary care to be a worse than it is now when I get to pull the plug. I could be wrong. I hope I’m wrong.

        But you know all this.

  • Thomas D Guastavino

    Bear in mind also that access to specialty care is drying up as specialists are now doing everything they can to get out of ED coverage.

  • Kristy Sokoloski

    Then it makes sense to have a clinic for Primary Care needs built in along with ED. Of course for as much sense as that makes that won’t happen any time soon.

    • buzzkillerjsmith

      Finding docs or NPs or PAs to staff it could be hard. There’s a shortage on. Not only that, high burnout rate, crappy job. You get the picture.

      • Kristy Sokoloski

        I agree with you about the burnout. And as for the NPs and PAs it’s like I told someone not too long ago when they were of the opinion that having these others to help with Primary Care: even if you have a bunch of NPs and PAs there’s still going to be a shortage. Also, many of those NPs and PAs don’t want anything to do with Primary Care. So yes, I am starting to get some of the picture. Thanks.

  • Rob Burnside

    It is a good idea, though $100 is a fortune for some. A smaller fee, say $25, would be better, though care must still be provided regardless of ability to pay..

  • Deceased MD

    Does any chronic problem really get addressed in the ED? I mean they are always going to tell the pt to f/u with their PCP. So what really gets resolved? Do they just f/u in the ED in a month?

  • Elvish

    1. When do you think patients should pay their co-pays ? Before or after ?
    2. If, before, then what if someone couldn`t afford their co-pay ?
    3. What about trauma patients ? chest pain ? syncope ? change of MS ? , etc ..

    Emergency Medicine in the U.S. is one of the few great things left in “American” medicine.

    We don`t need to ruin it they way we ruined family medicine !

  • guest

    As I commented in the NYT discussion page on their article covering this study: the one aspect of ED overuse that doesn’t seem to get any official acknowledgement is how exploitation of the working poor (who comprise about 90% of Medicaid recipients) leads to their using the ED as a source of basic primary care.

    When your family is working 3-5 minimum wage, part-time jobs just to survive, you don’t have a lifestyle that allows you to schedule a daytime appointment with a PCP, and then subsequent appointments for bloodwork and other tests, or visits to specialists. For one thing, you typically don’t have time during the day to see a PCP when they have office hours, and for another, even if you do, there’s a growing culture of part-time, on-demand employment which means that your employer can call you in for a partial shift with no notice, making it hard to get to a doctor’s appointment or even see a movie, as my young adult son who works as a manager in a movie theater recently pointed out to me.

    Getting follow-up bloodwork ordered by a PCP is even more inconvenient, even for people with white-collar jobs, as I discovered when trying to take my teenaged son to a lab for bloodwork ordered by his pediatrician. Trying to go to the lab on a weekend, when I have time off from my job, involved wait times of 1-2 hours at every lab we tried over a period of weeks. Calls to the pediatrician’s office to ask about a more a workable solution produced shoulder-shrugging on the part of his office staff. My son now sees my PCP, who has a direct-pay practice and a phlebotomist on staff in his office. It is much more expensive than using our pediatrician, who accepts our (terrible) insurance,but the added convenience is worth it to me. A working class family doesn’t have this option, obviously, so it should be no surprise that using the ED is the rational solution for them.

    It used to be that if you were a low-paid worker, you had a lot of extra time and could “afford” to spend hours completing tasks related to self-care, but it seems that corporate interests have discovered a way to exploit this fact and so the working poor in a lot of cases have even less free time for things like healthcare than we white-collar workers do.

    The question in my mind is this: it’s one thing for taxpayers to pick up the tab for access to healthcare for the poor. That’s part of being an enlightened society. But why are we picking up the tab for access to healthcare through expensive ED services which is necessary as a result of exploitative labor practices that benefit only very wealthy corporate executives and shareholders?

  • buzzkillerjsmith

    I used to do a fair amount of urgent care–with insured pts. A lot would show up in the morning for a cough or something when they could have seen their own doc (or at least be seen by someone in their own doc’s group) in the afternoon or the next day. Why? More convenient.

    • Jess

      My co-pay if I go to an urgent care center is a fair bit more than if I go to my primary care doctor. For people like me, who pay our own way (at least to some extent), there’s a cost-benefit analysis that goes on in our heads at least. “Is it worth an extra $40 or $50 for me to get this cough seen to this morning rather than waiting till tomorrow?”

      For people who get a free ride all the way, if there’s no cost associated with getting immediate gratification, of course they’ll go for it every time. That’s the problem with Medicaid, there’s no price signalling whatsoever for the “clients”, everything’s just “free”.

      • buzzkillerjsmith

        Exactly. It’s the incentives. Econ 101.

    • querywoman

      They may also do it if they face serious job trouble for missing work and know they need to get to a doctor ASAP.

  • buzzkillerjsmith

    I read the NYT article and read some of the comments. One lady wrote, “Until people can be seen quickly when they are sick, the ED will remain crowded.” This is exactly right.

    Of course being seen quickly in a doc’s office is hard with the shortage on. And a lot of family and internal med docs are less than thrilled with Medicaid, for reasons that have be gone over many times at this blog and elsewhere. Maybe retail clinics and urgent care clinics will pick up a lot of the slack. I don’t know.

    An interesting point in the article is that ED costs are only a tiny bit of overall HC costs, dwarfed by hospitalization costs. So we might just be dealing with rounding error here. Maybe not, too early to tell.

    The die has been cast. Keep your eyes peeled!

    • Thomas Luedeke

      Try Urgent Care locations., extended hours, take anyone I went there after falling out of my pickup (4′ onto cement on my tailbone), and was able to get great care at substantial less cost than the ER…

      Disappointed none of you medical folks responded to my question below….

  • Jess

    It’s pretty much heresy in the new “progressive” America to expect anyone to have to pay any of their own money towards their own health care and maintenance. Unless they’re the evil “rich”, then they’re supposed to pick up the tab for everyone’s.

  • Jess

    Copay if you’re on welfare/Medicaid, $0.

    This article is “Why Medicaid patients use the emergency department for primary care”.

    And Obama is bragging about adding 17 million or so more Americans to the welfare/Medicaid pool.

    I don’t see what could possibly go wrong.

    • buzzkillerjsmith

      The thing that makes me shake my head about all this is not so much the ER stuff as it is the well-known fact that Medicaid payments are a slap in the face to us primary care docs.

      The deal we are offered is this: “We know there is a shortage of you all and that a lot of you have more well-paying pts than you can handle, so how about we offer you a bunch more difficult pts and pay you a lot less to see them?”

      Their reasoning always brings me a little smile. But what do I know?

      • NewMexicoRam

        I wonder if the government does that to Boeing and McDonnell Douglass?
        “Well, you know military planes cost too much, and we really need those planes for the safety of our country. How about if we pay you 30% less than what it costs you to manufacture the planes, knowing the necessity the country has and you can still make money from selling planes to American and United.”
        What a joke. And we physicians just eat the slop.

        • Deceased MD

          I think unfortunately to the govt ., poor people with medicaid are not worth much to them.Anything to do with military is. so if you have the job of taking care of the poor, they are letting us know that they do not value them or us docs. Insulting but I think rings true. If one does not bring economic value to the big business of HC. they are not interested.

          It is probably worse than that. In the sense that. Look at all teh medicaid states that refuse billions of govt money to help their state and the poor. Prime example.

          • NewMexicoRam

            They sure value those votes, as Medicaid patients vote, too.

      • buzzkillerjsmith

        Decision makers in this country often don’t even lay eyes on the poor and lower-middle class. Out of sight, out of mind.

        In addition, of course, there is the “fair-world” hypothesis, the common idea that people pretty much get what they deserve in life.

        Curious also that people who are a paycheck or two from poverty also often don’t think much of the really poor. I suspect talk radio is a factor.

        I remember a VA urology professor talking to us med students about this in 1983. His wife was a corporate lawyer. Apparently when he talked with her about his world and the world of his pts it was hard for her to understand. Nice lunches with people who had good teeth and new clothes were more her reality. I can’t blame her too much. Very common really, the rule rather than the exception. It’s hard to mentally move people from “them” to “us,” especially when things are good for us.

        • rbthe4th2

          Very true. Thank you for the post.

  • NewMexicoRam

    I volunteered at a mission hospital compound in Haiti in the early 80′s. They served the poorest of the poor in the Western hemisphere. They did not give away their care for free, because they knew they would soon be overwhelmed with the increased demand. So, they charged a measly one gourd in cash for visits, which wasn’t a lot, but many of their patients only made 500-1000 gourd per year, so it did mean something. They were still busy, but not overwhelmed, and the patients shared in the cost somewhat.
    That’s what needs to happen with Medicaid. It needs to cost something to the patient.

  • Suzi Q 38

    I knew a popular dermatologist in Los Angeles who would have his receptionist ask for the money up front. This was because this particular individual was very slow in paying.

  • Suzi Q 38

    Good Luck collecting the money.

    • querywoman

      Spot on once again, Suzi Q!

  • guest

    Where I live the doc in the boxes all close at 8 pm and a couple of times I have had the experience of going there at 7:30 with something they didn’t want to deal with and getting directed to go to the ED instead.

  • Elvish

    “”If they can’t pay, then they get to play phone tag with collector’s”"
    That is why, despite of our financial and military strength, we will never be as civilised as other countries.
    Oh boy, I am so glad I am leaving !

  • NewMexicoRam

    It works that way with Medicaid contractors. Not every insurance company contracts with Medicaid.

  • buzzkillerjsmith

    Nice matrix. I like the smiley and sad faces.

  • Thomas Luedeke

    So how does the advent of the urgent care walk-in clinic (i.e. open long hours, no appointment needed, no fuss) ameliorate this situation? Or does it?

  • medicontheedge

    Yep. No surprise here… in my state, medicaid recipients have no co-pays, and seemingly no throttles or oversight whatsoever.. This is where we see the most “frequent flyers”… We also have become primary care for many, especially kids… Child have a fever? Don’t spend your own money on tylenol! Take the $800. “taxi” (ambulance) to the ED for the $1,200. tylenol. No ride home? Medicaid pays for that, too.No appointment, no hassle, and it’s “free”!
    Do the math! As long as medicaid recipients have no responsibility for their own actions, no “skin in the game”, why wouldn’t they use the ED?

  • medicontheedge

    Bingo Many, mine included, are actively marketing to non-emergency customers.

  • Jess

    Obama, the Democrats and the author4 all use the term “insurance” to describe Medicaid. Medicaid does not have a high deductible for emergency room care. Medicaid is, as I pointed out, completely “free”. There is no moral hazard to the 17 million extra Americans Obama wants to put on welfare (and call it “health insurance”) going to the ER every time they have the sniffles rather than drearily making an appointment with their PCP like the rest of us schmucks have to do unless we want to be out hundreds of dollars.

    I blame Obama and the Democrats for ever conflating Medicaid with “health insurance” in the first place. It’s not health insurance, it’s welfare. But there you go. Putting an extra 17 million Americans on welfare and telling them they’re now going to get all the free ER visits they want, is absolutely going to increase the number of ER visits they make. People like free stuff, in case you never noticed, and giving more people more access to more free stuff is quite obviously going to lead more people to take advantage of the increased levels of free stuff you’re offering them.

    • MentalPatient

      I know you folks probably don’t mean this group of patients, but some of this discussion infuriates me because virtually everyone I know who is on Medicaid is on that program because they were seriously disabled due to birth defects or other health problems that developed in childhood. Therefore, they never could work enough to get Medicare or regular insurance. Woe to them, they are on WELFARE.

      I have an extremely sick relative on Medicaid and I wonder sometimes if doctors aren’t trying to ditch him because he’s a mental patient with severe, complex physical health problems and also on Medicaid. Probably both are strikes against him. BTW, he ALWAYS pays his copays and buys his own Tylenol. Many of his medical supplies are not covered by Medicaid. It is not his fault that he is so sick that he must go to the ER from time to time. I signed him up for a medical home program, and call his primary if it’s extremely urgent but not a true emergency, and the primary care physician always says he has to go to the ER at a top notch hospital that’s 60 miles away because his problems are just too complex for anywhere else.

      Most of these extremely sick people I have known feel terrible and deeply ashamed about their situation, and they watch the news and read the bashing about Medicaid patients and people on SSI. Perhaps doctors shouldn’t have saved those babies with severe birth defects, eh? Just to kick ‘em around later because they never get well enough to become a taxpayer.

      As I said before, folks probably don’t mean to bash the severely disabled, but a lot of posts about this topic are not carefully worded, as if everyone on Medicaid abuses the system. I suspect there is a percentage of frequent flyers without serious medical problems who are making everyone look bad.

      Finally, I’m not on Medicaid, but I am on Medicare, and when I have had to go inpatient for mental illness, I was required to go to the ER. My psychiatrist could not call ahead and get me admitted. What a waste that was! I have hooked up with a doc who does hospital work, so maybe if that comes up again he can direct admit me (the issue hasn’t come up). Many mental patients are on Medicaid, so there’s some serious waste for you.

  • querywoman

    I researched this more and see that’s in an old study. In the last 2 years, Medicaid ER visits have declined in Oregon. It’s possible those Medicaid patients got themselves more stable and got their acts together better.
    Nevertheless, when I worked in public welfare, I could see that many lower income people cannot plan their lives well, have short fuses, and seek immediate gratification. If they got two or three thousand bucks, like from a legal settlement, and they were always filing personal injury type lawsuits, they’d blow the money fast.
    I always say the average life of an Earned Income Credit refund is 2 weeks. Middle-middle class and higher middle class people often don’t have a good conception of the EIC because it doesn’t effect them. Lower income working people get back more than they pay in income taxes. It’s like a kickback for working. The ones with children probably get can get up to 4 or 5 thousand back now. They usually file as soon as possible, and then they can blow their EIC’s in two weeks. And no, they do not want to pay their own doc visits and meds with it either. Folks, it does stimulate the economy.

    Getting back to subject of increasing medical care for the low income, I saw once that offering primary clinics in poorer areas actually drives up costs. In theory, for example, blood pressure pills save money on heart attacks. It actually costs more to have a clinic to do the tests and treat people who weren’t getting it.
    It must be extremely difficult to evaluate the cost of spending on medical care as opposed to costly hospitalizations and/or early deaths.
    Medicine is a never-ending sinkhole. You will never spend enough. The more care you provide, the more needs pop up.
    For those of who are Christians, Jesus said the poor you have always with you. You can extend that to say the sick you have always with you. That’s the way it is in the only world we know.

  • querywoman

    People with Medicaid are a step above the uninsured also. The uninsured, like the insurance, can get urgent care at the 24 hour clinics for a price!
    If the county and the VA had 24 hour urgent care clinics, the need would soar! Wonder how many they would need?
    Hospital ER’s are the de factor urgent care centers now.