I heard on NPR today about a study in Oregon about Medicaid expansion. Here is the link
The study says that “Medicaid enrollees increased their emergency room visits by 40 percent over the first 15 months.” and that this was “a surprise to a lot of folks”
Why would this be a surprise? If ER care was free or low cost, why would people not take advantage of it? As the story notes, when ER care is expensive, less people go to the ER. But if it is free or low cost, why wouldn’t people use the ER more frequently, since they don’t have to pay anyway? I don’t find this surprising.
I think that the hope was that in the short term, people would use their primary care physician instead of the ER and longer term, health would improve and lessen the need for ER visits.
Why would there be a hope that people without insurance would suddenly acquire primary care physicians when they became insured? That seems like a pretty unrealistic view of both the resources of a Medicaid enrollee and of human nature.
That’s addressed in the article. The study went on for two years. The hope was that as time went on, more patients would acquire PCPs and use those instead of the ER. It didn’t work out that way - patients visited PCPs and continued to use the ER at high rates.
But your question is a good one - why would anyone expect that increasing perceived supply of something at low cost, or free, would reduce utilization of that something? “Let’s hope the laws of supply and demand don’t operate” is not a very sound basis for policy.
That’s it exactly. I was more surprised that THEY were surprised that it happened that way. Seems pretty self-evident to me - Here is something more convenient and now inexpensive or free, of course more people are going to use it
So those ER visits, increased or not, are legitimate. i.e. those that are needing treatment are getting treatment, with the added benefit that they aren’t having to shell out loads of cash to do so.
The big flaw in the whole thing of course is that it is not blinded in any way. I assume that the people who “won” the lottery (which is a bewildering concept to my ears…but anyway) knew that they’d won it, and also that it may only be a temporary situation. Any thought given to how that might affect behaviour?
ER care has never been expensive for most of the folks who qualify for Medicaid, because they simply didn’t pay, or didn’t pay anything approaching the actual cost, and the hospitals ended up writing it off. The hospitals were required (under EMTALA) to provide care, but you can’t squeeze blood from a turnip, and you can’t collect a multi-thousand-dollar debt from somebody earning less than full-time minimum wage.
True, but the study was of people who newly received Medicaid. People thought that once they had insurance, in the form of Medicaid, their ER visits would go down because they could go to a PCP or family doctor or whatever.
But of course, once the ER was low-cost or free for the newly insured, they went at a higher rate, which seems self-evident to me, but it apparently was a surprise to some people.
Bolding mine, I don’t know that you’ve gotten slash2k’s point. Prior to getting Medicaid, the ER would have *already *been low-cost or free for those folks. That’s one of the big problems with our current hodge-podge healthcare system, after all – we all end up subsidizing ER visits for people who need emergency treatment but have no money, and we do it very inefficiently by forcing hospitals to spread the cost out at their discretion.
It’s the PCP visits that would have been prohibitively expensive for those people. The idea was that once regular doctor visits are a low-cost option, people might not need as much emergency care. Personally, I’m surprised that wasn’t borne out.
I don’t understand this. People without insurance just go to the ER and don’t have to pay anything? They don’t get a bill for SOME amount? If that is the case, why does anyone NEED insurance then?
They get a bill. They just don’t bother to PAY the bill.
If they don’t pay, the hospital can take them to court and obtain a judgment, or sic a collection agency on them. However, those actions both cost the hospital money, and if the person is genuinely poor, unemployed, etc., they’ve got little or nothing for a collection agency to get. What ends up happening is the hospital writes off the bill as uncollectible bad debt. (Or the hospital makes an arrangement, such as pay us $25/month for the next 10 years against that $5,000 bill.)
You need insurance because the ER doesn’t provide all forms of medical care. For example, the ER does not provide chemo, radiation, or surgery for cancer treatment; they might diagnose the cancer, and if it’s bad enough, give you some pain medication, but after that you’re on your own, and the medical facilities that do those kinds of treatment can ask for cash upfront if you are not insured.
IANA ER doctor or a policy expert, but in most places the ER is required to provide treatment to get them stable. Rules vary by state/city, of course, plus individual hospital policies. If someone gets injured and they’re bleeding all over the place, the ER is required to stop the bleeding and close the wound, for example. They don’t ask for insurance or bank statements first, they just make sure the patient doesn’t die. Once they’ve determined they’re going to live they kick them out. They might send them a bill but most of these people just wouldn’t pay it because they don’t have any money. They obviously don’t get any follow-up visits to make sure the wound is healing properly, or for physical therapy, or for secondary surgeries that might be required. This is why the rest of us have insurance, because we want those followup treatments. If the wound gets infected, they go back to the ER, which is required to treat the infection because it might be deadly, even though the hospital probably wouldn’t be able to get paid for doing it. Treating an infection in the ER is a lot more expensive than treating it in a primary care office, which is why we want to get these people insurance.
So that was the idea – get people insurance so they can go to followup/preventive visits with a primary care doctor and stop abusing the “generosity” of emergency rooms. It seems like a sound theory. That’s why this result is surprising.
Yes, I understand all that. But I figured it like this:
“I don’t have insurance, but I’m kind of sick. I don’t want to be bogged down by any bill from the ER, just because it’s a hassle, and I might end up having to pay something someday. I guess I’ll just stick it out, and not go to the ER and try to get better”
And then, “Hey, I have Medicaid now, and I’m kind of sick. The appointment for my PCP is 2 weeks away, I’ll just go to the ER now, because my insurance will pay for it, and I don’t have to worry about a bill”
Bear in mind that a lot of newly insured people have no experience navigating doctors’ offices, insurance and medical bills. Which, free or not, is a huge mindfuck for anybody. I mean, even if you have insurance, you have no clue what your bill is going to be until weeks after you’ve been treated or seen by a doctor. And while you might be able to negotiate a $15/month repayment schedule with a hospital for ER services, good luck trying that with the guy who did your upper GI x-ray. Frankly, if I hadn’t grown up insured, I wouldn’t trust it. And a $30 copay might as well be $1000 if you can’t even pay your bills as it is.
The ER is at least a known quantity for these people. A PCP might as well be a used car salesman.
The ER will turn people away who are “kind of sick” regardless of whether or not they have insurance. It’s for emergencies only.
It sounds like you’re wondering why primary care even exists, if anyone can just go to the ER and get instant treatment. The answer is that they can’t, the ER will either turn you away, or triage you in the lowest risk category and make you sit in the waiting room all day.
No, i know why it exists, and the fact that the ER is for emergencies. But I’ve been there before and people weren’t gushing blood all over, or having a heart attack or whatever.
How would you explain the rise in ER visits after people were covered by Medicaid?
My explanation is people find it easier to go to the ER instead of waiting for a PCP appointment, especially if it is free or small co-pay. Or, as **DrCube **says, that may be all they know and/or trust.
There should have been an active attempt to get those coming to the ER who qualified to get PCPs. I mean, contacting your PCP is just a part of what they do, since there’s often a follow-up visit. So it seems natural to have that set up where they tell them about the PCPs and encourage them to use them before they get to sick that they have to go to the ER.
Heck, you could even set up partnerships with the local doctors and tell people sitting around in the ER waiting room for non-emergency care that they should go to them. If even my little city has a quick-care facility, so should these places. Send 'em there.
It’s not like the ER has to take non-emergency cases. Do triage, then send them on their way.
I have not yet seen any details about the availability of primary care physicians to Oregon Medicaid enrollees. Do any of you know how that worked?
I know that in my home state (Kansas), the fact that a given person has Medicaid coverage doesn’t mean there are doctors willing to accept them as a patient. (Case in point: a lady of my acquaintance, then in her late 50s, had to name a pediatrician as her PCP, because the pediatrician was the only one in town who would take new Medicaid patients, due to lousy reimbursements and worse payment practices.) How did that work in Oregon? Did the people being studied actually have primary doctors who were being ignored in favor of the ER, or no?
No! You can’t just get triaged and kicked out. Hospitals are required to perform a Medical Screening Exam, but that is not very well defined. For someone with abdominal pain, that might include several thousand dollars worth of labs and CT scans.