Medicaid Patients Use the ER Because They Have To, Not Because They Want To
It is well established that Medicaid patients use emergency rooms more than either uninsured or privately insured patients. What has been debated is whether their use of the ER is necessary or unnecessary. Well, it turns out that that depends on how you look at it. Obviously, not many people go to the ER because they enjoy the experience and have nothing better to do. However, medical problems that cause them to go to the ER could often be dealt with in a doctor’s office.
The Medicaid and CHIP Payment and Access Commission (MACPac) has just published a review of articles examining why Medicaid patients frequent the ER so much:
The majority of ED visits by non-elderly Medicaid patients are for urgent symptoms and serious medical problems that require prompt medical attention…
Non-urgent visits account for just 10 percent of all Medicaid-covered ED visits for non-elderly patients, a proportion comparable to that of privately insured patients …
A review of all studies of non-emergency ED use published between 1990 and 2010 did not find a consistent association between Medicaid and disproportionate use of the ER for non-emergency conditions.
Nevertheless, it is true that Medicaid patients have poor access to physician care:
Barriers to timely care increase the chances that individuals will use the ED (Cheung et al. 2012). Despite the fact that nearly all Medicaid enrollees report having a usual place of care other than the ED, approximately one-third of adult and 13 percent of child enrollees have reported barriers to finding a doctor or delays in getting needed care.
Delays were more frequently reported by Medicaid enrollees than by people who are privately insured, and enrollees reported that these delays often occurred for several reasons, including: trouble getting through to the practice by phone or reaching a doctor after hours, difficulty getting an appointment soon enough, language barriers, and lack of transportation.
The report also notes that “The ED is an expensive place to treat medical problems because it maintains 24-hour staff and resource availability and the hospital settings in which most EDs are based have both high overhead and fixed costs. Thus, payers and health plans have long sought to keep costs down by educating patients about appropriate use of the ED and providing timely access to care in other settings.”
Will future Medicaid patients be better “educated” to see doctors instead of going to the ER? Providers’ behavior tells us that this not what they expect. It is hospitals, not physicians, which advocate the loudest for Medicaid expansion.
“Nevertheless, it is true that Medicaid patients have poor access to physician care”
This is pretty much the reason why Medicaid recipients go to ERs. There are very little places to go to that accept Medicaid for primary care. These barriers are driving individuals to ERs.
Exactly. Unless reasonable reimbursment is passed, access will continue to be a problem.
“However, medical problems that cause them to go to the ER could often be dealt with in a doctor’s office.”
Hopefully, like discussed in a previous entry, the quick clinics being opened through Wal-Mart and CVS will help alleviate the increasing demand for care at ERs. Access should be quicker and more efficient for most visits at the minute clinics rather than at the ER.
Regardless, I am sure hospitals are enthusiastic about the increase in traffic to ERs if they are seeing significant increases in revenue from these patients.
Doctors just don’t see the point of taking on Medicaid patients because the reimbursements just aren’t worth it. In response, these individuals have used ERs as an alternative for care.
I read an article recently that suggested that lack of transportation is a factor in driving patients to the ER. Another is they are less ability to be able to take time off from work to see a specialist or go to an imaging center. Even if they have access to a primary care doctor or a community health center, they tend to see the ER as a one stop shop and they perceive the care as higher in quality than they can get in a less expensive setting.
I think the main underlying factor driving poor people to the ER for care that can be treated effectively elsewhere is poverty. Low reimbursement rates that make it more difficult to find a primary care doctor or get a timely appointment is also an issue.
Thank you. I agree with all of the above. That is one reason why I urged Paul Ryan to include Medicaid in his poverty-reduction proposal recently.
“The ED is an expensive place to treat medical problems because it maintains 24-hour staff and resource availability and the hospital settings in which most EDs are based have both high overhead and fixed costs”
This sounds like a bit of a red herring to me. Hospitals presumably maintain an emergency department for legitimate emergencies, with a fixed cost. If an emergency arrives, the case will presumably jump ahead of anyone waiting for non-emergency treatment. Therefore non-emergent patients are merely filling otherwise unused capacity and should be billed accordingly.
If hospitals could reduce costs by shunting non-emergent patients to an adjoining urgent care clinic and run the clinic at a profit, they would undoubtedly do so.