Despite expanded health coverage, expensive ER visits are on the rise

Despite the implementation of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), 75 percent of emergency physicians indicate that emergency room (ER) visits are on the rise. When the American College of Emergency Physicians (ACEP) conducted this poll one year before, less than half of physicians reported increases. ACEP’s president, Dr. Michael Gerardi, stated that emergency care remains a valuable model of care, pointing out that the ER is the only place that remains open at all hours and that no one is ever refused care.

Polling results

Poll respondents reported that the availability of alternative models of care, such as urgent care centers and triage lines conducted by telephone, has not reduced the volume of ER visits. The large majority said that the severity of illnesses among these patients is either the same or has increased, compared to the past. Over half of respondents also said that the number of Medicaid patients is rising, as well.

ACA

The ACA’s goal of seeing more people covered by health insurance was furthered by the individual mandate, requiring people to have health care coverage or pay a penalty. ACEP reports that the rise in ER visits comes after the date that the individual mandate went into effect. The ACA also provided an opportunity for states to expand Medicaid programs to cover those who were previously ineligible, with additional financial contributions from the federal government. ACEP notes that a Health Policy Alternatives report also indicates that efforts to direct Medicaid enrollees away from ERs to primary care is failing.

More patients, no providers

Despite Medicaid expansion covering more patients, providers cannot be forced to see these patients. Medicaid reimburses providers at the lowest rate, although the ACA includes a provision to offer a slightly higher rate to primary care physicians willing to treat Medicaid enrollees. However, since the ACA resulted in more coverage by private insurance that typically pays providers at much higher rates, providers are even more interested in boosting their bottom line with those patients. Even providers listed on Medicaid managed care plans are busy, with median wait times for appointments at two weeks and a quarter of providers forcing patients to wait over a month.

This problem is exacerbated by the shortage of providers overall, particularly primary care providers. A 2014 report from the Association of American Medical Colleges (AAMC) indicated that the primary care physician shortage would reach 45,000 by 2020. This shortage is explained by aging physicians, Medicaid expansion, and more people newly insured through the ACA. In 2015, these projections were updated through 2025, indicating that the shortfall of primary care physicians would be somewhere between 12,600 and 31,100. The lower numbers will require aggressive changes to payment and delivery models, such as accountable care organizations (ACOs). ACOs unite providers and coordinate patient care in an effort to save government funding. However, provider participation is voluntary.

Emergency model of care

According to Dr. Orlee Panitch, an ACEP fellow, access to both primary and specialty care for Medicaid patients is not timely, resulting in ER visits as the last, or only, resort. Panitch is also concerned by some state policies that discourage Medicaid patients from seeking emergency care, noting that it could have dangerous results. Gerardi points out that this polling offers evidence that the emergency care model is valuable and desirable. There is evidence that this model is evolving. The Mayo Clinic offers a joint Emergency and Urgent Care Center, where triage evaluates the seriousness of a patient’s condition and determines the appropriate level of care. Directing patients to urgent, rather than emergency care, in situations that are not life-threatening or do not warrant immediate attention may result in cost savings. Although information is available from places such as Blue Cross Blue Shield to help patients determine where to seek care, a possible emergency or even urgent situation might not allow a patient to take precious time to make these decisions.