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Science Study Latest Blow to Patient Protection and Affordable Care Act Effect on Emergency Department Use

2014; Elsevier BV; Volume: 63; Issue: 3 Linguagem: Inglês

10.1016/j.annemergmed.2014.01.011

1097-6760

Ryan L. Nave,

Healthcare Policy and Management

During the first week of the New Year, a health care bombshell dropped when a report implied that the Patient Protection and Affordable Care Act may cause more patients to go to the emergency department (ED), according to a randomized study in Oregon. The study, conducted by researchers at Harvard and published in the journal Science, found that ED use shot up by 40% among newly insured Medicaid patients compared with uninsured patients during the 18-month study period, and it touched off media frenzy of anti-Obamacare critics who seemed delighted to have fresh fodder. To opponents of the health care law, the Harvard study is just more evidence that Obamacare will not only fail to decrease costs but also will actually drive them skyward. Even the Obama administration ducked for cover. Tara McGuinness, a White House spokeswoman, told the New York Times that the study's time frame was too short to make broad assumptions about ED use. Certainly, reducing “costly ED visits” was and still is a popular mantra of the president and his supporters in pitching the law. In the run up to the passage of the federal health care overhaul, US Senate Majority Leader Harry Reid took to the floor in defense of what was then the bill that would become the Patient Protection and Affordable Care Act, which Reid said would “ensure the most vulnerable and the least prosperous among us can afford to go to the doctor when they are sick—not to the emergency room, where the rest of us pick up the bill.” During the 2012 presidential contests, the camps of both President Barack Obama and challenger Mitt Romney frequently locked horns over what was needed to fix what they called America's broken health care system. In that war of words, it was the EDs that seemed to take the most hits. The central assumptions that supporters and opponents of health reform make are that EDs are brimming with uninsured patients who aren't smart enough to realize that going to a private physician to cure that runny nose would be quicker and cheaper. After all, anyone who watches TV or goes to the movies knows EDs are bastions of anarchy. But as business and economics columnist Robert J. Samuelson wrote in a December 11, 2013 Washington Post op-ed, those media portrayals, which feed the conventional thinking about EDs, are just flat-out “make believe.” “Obamacare notwithstanding, it's doubtful that overhauling ERs would achieve huge cost savings. To be sure, the system could be run more efficiently and effectively; several studies indicate that. The trouble is that ER costs are relatively modest compared to all U.S. health spending,” Samuelson wrote. Exactly how ED costs compare to total health care spending in the United States is debatable, but estimates range between 2% and 10%—between $54 billion and $270 billion. Those are hefty sums, but compared with the $2.7 trillion spent on health care every year, ED expenses can hardly be blamed for skyrocketing costs, experts say. Alan Jones, MD, chair of the Department of Emergency Medicine at the University of Mississippi Medical Center and president of the Society for Academic Emergency Medicine, also pointed out that only 20% of people visiting EDs lack health insurance. That, coupled with the fact that EDs account for roughly half of all hospitalizations, stands as a rebuke to the idea of out-of-control abuse and costs associated with EDs. Dr. Jones puts it simply: “A majority of what we see are things that need to be seen in the ED.” The December 2013 issue of Health Affairs casts popularly held myths about EDs as urban legends. Among them are that frequent ED users are a drain on the health care system; they don't have primary care physicians and unnecessarily visit the ED for conditions that could be treated at a private physician's office or urgent care center. Presenters John Billings, MD, and Maria C. Raven, MD, MPH, noted that, in fact, ED use represents just 2.1% of all Medicaid spending and 4.6% for ultrahigh users of the ED. They also said that, contrary to popular belief, frequent ED patients in fact do access primary care. Arthur L. Kellermann, MD, MPH, dean of the Hebert School of Medicine at the Uniformed Services University of the Health Sciences and the former director of RAND Health, contributed to the Health Affairs briefing “The Future of Emergency Medicine” and wasn't quite sure why the myths are so resistant to mountains of evidence to contrary. “The accusation is more easily said than the explanation is understood,” Dr. Kellermann said. “It's a simpler argument to be made that, ‘Well, this person doesn't need to be there,’ turn them away rather than to say, ‘How do we provide people with the kind of access to care that they want and need so that they don't need to be in the emergency department in the first place?’” Dr. Kellermann traced the origins of misconceptions of the ED back nearly 3 decades to around the time Congress passed the Emergency Medical Treatment and Labor Act (EMTALA), which required hospitals to provide emergency care to anyone regardless of their immigration status or their ability to pay the bill. Dr. Kellermann believes lawmakers made the right call on EMTALA but said the legislation had a number of unintended consequences. “One of which has been to provide a ready excuse for not dealing with the problem by just blaming the patient for returning to the emergency department when they don't have other options,” he said, pointing to research that shows it's often not the patient's fault for choosing the ED over other options. As recently as December 2013, researchers from the University of Colorado School of Medicine found that Medicaid patients use the ED because they have fewer alternatives, not because of the severity of their illness. Roberta Capp, MD, assistant professor of emergency medicine at the University of Colorado Denver–Anschutz Medical Campus, led that study published in the Journal of General Internal Medicine. Dr. Capp's team found that not only were adult patients with Medicaid and Medicare just as likely to go to the ED for an acuity issue as people with private insurance but also that dual-eligible adults and those with Medicaid alone were more likely to go to the ED because of “access issues” than people with private insurance. The University of Colorado survey affirms a number of previous studies with similar findings. Writing in the New England Journal of Medicine in June 2012, Dr. Kellermann and Robin Weinick, PhD, his then-colleague at RAND Health, in response to a proposal in Washington State to deny payment for unnecessary ED visits by Medicaid recipients, examined the link between EDs, Medicaid costs, and primary care access. Drs. Kellermann and Weinick, a RAND Health associate director and senior social scientist, cite research dating back to the early 1990s, including one study in 1994 in which research assistants posed as Medicaid patients and called primary care physicians and clinics at random in 10 cities, trying to schedule appointments for minor health problems so they would not have to go to the ED. In that study, “The Medicaid Access Study Group: Access of Medicaid Recipients to Outpatient Care,” callers were successful just 26% of the time. When asking for an alternative, the callers were either given no advice or told to go to the ED. Two years later, in 1996, a different set of researchers posted in 56 EDs around the United States interviewed patients during the course of 1 day and found that the majority believed they were having a medical emergency or were too sick to seek treatment elsewhere. Then, in 2005, another group of researchers posing as Medicaid patients who had been to the ED the night before tried to obtain follow-up appointments with primary care physicians; only a third of the callers were successful, the study showed. There are other unintended consequences of policymakers believing myths about EDs, said Robert Lowe, MD, MPH, a professor at Oregon Health and Science University. Dr. Lowe did some ED myth busting of his own before a joint session of the Oregon Legislature's Senate Committee on Health Care and Human Services and the House Committee on Health Care in September 2013. Besides shattering misconceptions about ED abuse and EDs being a major health care cost driver, Dr. Lowe discussed a move by Oregon Health Plan, that state's Medicaid program, to assess a $50 copay for ED visits to discourage abuse. A 2008 analysis found that although the copay did succeed in reducing EDs visits by 8%, the cost per ED visit increased by 8% and inpatient use increased by 27%, Dr. Lowe testified. “Scaring patients away from EDs carries demonstrable risks. When we discourage patients with things like copays, then patients just have to wait longer to come to the ED, and when they get there, they're sicker,” Dr. Lowe told Annals of Emergency Medicine. Dr. Lowe acknowledged that emergency physicians themselves often get sucked into believing myths about the ED. “When you're burned out from working 3 nights in a row and sending home 80% of the patients you see, it is easy to start thinking, ‘Boy, if only these patients would stop coming,’” he said. However, what physicians, policy officials, and insurers often lose sight of is that what turns out to be minor after an ED visit may not have seemed minor to the patient before the visit. And physicians sometimes also forget that EDs are the safety net when people don't know where else to go or don't have anywhere else to get treatment. “What's appealing about the idea that if we can fix ‘emergency room abuse’ that it'll just take care of all the problems is it means we don't have to deal with improving a primary care system that is badly broken. We don't have to deal with the costs of expanding hours of care or reducing the waits for primary care appointments. We don't have to deal with the lack of availability of diagnostic equipment. We don't have to deal with the cost of pharmaceuticals because all we have to do is to teach these ignorant patients to stop abusing the ER, and it'll take care of the problem,” Dr. Lowe said. “It's such an appealing solution, only if there was the slightest bit of validity in it.” Dr. Lowe said that when the ED is crowded, it's not because of the man complaining of a sore throat or the woman with a sprained ankle—physicians can treat them quickly—it's often because there aren't enough inpatient beds. And those beds are expensive, which could be one reason why people assume that EDs are a major driver of health cost. Said Dr. Kellermann, “The real impact, the big dollar drain for the health care system, is in inpatient care, not ED care…. Right now, since we're largely still in a fee-for-service world, there are many hospitals that see their EDs as a major point to pull people into the hospital.” That could change eventually as economic pressures increase to keep people healthy and out of the hospital. At that point, Dr. Kellermann believes that EDs will do a turnabout and focus more on how not to admit patients to the hospital.