Why the Oregon Medicaid study ultimately won’t matter

2014 has dawned, and with it more than 2.1 million people have new health insurance under the Affordable Care Act. This, as they say, is where the rubber meets the road. But a new study out of Oregon is challenging a key argument for extending health insurance to millions: that doing so will reduce costly emergency room visits.

The study in question showed that when health insurance was extended to Oregon residents who didn’t previously have it, they actually used the emergency room more — not less. This is the exact opposite of what many had predicted.

As the leader of an emergency medicine physicians group, this question of whether ER volume will increase or decrease as more people gain health insurance is absolutely essential for us. It’s also essential for hospital leaders, who are making decisions about where to invest in expansion of services and where to plan for a retrenchment.

The Oregon Medicaid study suggests an answer, but for my money, I’m betting on a slight bump in ER volume, followed by a general and persistent decline.

The truth is that the Oregon study — i.e. the importance of newly insured patients as it pertains to ER volume — may not be as determinative as you’d think. In Oregon, the expansion of Medicaid at the state level encouraged people who formerly had no access to care to seek that care as quickly as possible. I fully expect this result to be replicated in other states in the near future, particularly the ones that have expanded Medicaid.

Meanwhile, newly insured patients facing high deductibles will face an opposing incentive to actually seek lower cost care. The rise of high-deductible plans that incentivize patients to shop around for their care and consider their care decisions more carefully has already been impacting the market for years. Which incentive is more powerful may depend on the availability alternatives to the ER, such as access to primary care.

This is likely a good thing for our health care system. A patient should think twice about the need for any care, including emergency care. Can I wait a day or two to see if this fever resolves and cough goes away or do I need to go, right now, to be seen? These are decisions that informed patients make when their dollars are at risk.

In the long run, I predict this shift along with others, including changing incentive structures for hospitals, will mean lower emergency room volume. In other words, the Oregon study may accurately predict a bump in ER use, but ultimately larger forces will combine to drive down ER volume.

2014 brings a brave new world to our health care system. And as the Chinese proverb says, “May you live in interesting times.”

Angelo Falcone is chief executive officer, Medical Emergency Professionals (MEP).  He blogs at The Shift.

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  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I actually thing ER utilization will increase by leaps and bounds, unless the powers to be explicitly bar poor people from the ER, and in today’s atmosphere, this is entirely possible (They’ll probably call it the Emergency Access Improvement Act, or something similarly callous).
    Anyway, a fairly recent Health Affairs study found two reasons for why the poor prefer ERs to office practice. Everybody is concentrating on access to ambulatory care, mainly primary care, but there was another reason why Medicaid members go to the ER – they perceive the ER to provide better quality care.
    Considering what our planners have in mind for providing “care” to the “indigent”, such as retail clinic, technicians in mobile vans, “trained” community workers, optometrists, etc., I think poor people will go to the ER even more. Being poor, doesn’t necessarily imply being stupid.

    • guest

      Certainly the ER provides the most efficient care delivery system available, which if you’re part of the increasingly “productive” workforce these days i.e. working more hours for less money, which kind of describes all of us except the leisure class. For folks like us the ED really makes the most sense in a lot of situations….

  • buzzkillersmith

    Just did a quick Google search on this and came up with a web page at Boston.com that said studies differed on ER use when MA got near-universal care. Who knows what will happen in the longer run? I sure don’t.

  • Eric Thompson

    They are poor and probably won’t make the co-pays anyway. So why not use the ER?

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