Emergency Room Use Under the ACA: An Opportunity for Appropriate Care
As the results of the Oregon Medicaid study ultimately showed, many newly insureds will be interested in preventative care when it is available. But the fact remains that, as some predicted, ER usage did go up in Oregon in accordance with the influx of new healthcare consumers.
How can we account for those numbers?
The problem isn’t just that ER usage goes up with the expansion of coverage — the problem lies in what kind of ER usage increases, and how that increase is addressed.
Understanding Consumer Behaviors that Drive ER Utilization
ER waste is predominantly driven by two types of consumers: those who use the ER as a clinic of convenience and those who do not pay attention to their health until minor problems become major illnesses. The Oregon data bear this assertion out, showing that usage increased for visits classified “non-emergent,” “primary care treatable” and “emergent, preventable.”
So why are these consumers not going to primary care providers?
First and foremost, America has a primary care provider shortage and given the increasing difficulty of getting into (and paying for) medical school, perceptions of decreasing status among physicians and increasing workloads, that shortage isn’t likely to reverse itself.
As a country, we need to make real strides in training and producing more primary care providers.
Second, “emergencies” are subjective. Many consumers who will gain coverage through Medicaid expansion, or via subsidized exchange-based plans, have little to no understanding of what meaningful coverage can be used to accomplish.
Some do not value primary care and preventative medicine because they have not grown up in households that valued it. A significant portion of the population who use ERs as clinics of convenience come from disadvantaged backgrounds. Health care consumers who grew up among the working poor and didn’t have the means to make regular doctor visits, may not understand the full implications of the ability to do so now.
Additionally, c2b solutions research has found that the uninsured are heavily weighted toward the Willful Endurer segment, a psychographic patient type that live “in the moment” and are not hard-wired toward advance planning when it comes to health and wellness (e.g., scheduling, and waiting for, a doctor appointment days, weeks, or months in advance).
Years living with no coverage — and under a system in which EMTALA guidelines forced ERs to treat non-emergent conditions — have resulted in a disconnect, in the consciousness of many American consumers, between what a doctor would consider an “emergency” and what a patient considers an “emergency.”
Is a minor burn or non-displaced fracture a true medical emergency? Probably not. But it certainly is painful. Is a sinus infection an emergency? Of course not. But it’s miserable. Yet to the patient, these are conditions that simply cannot wait until an appointment next week, or even the next business day.
And for years we have operated under a consequence-free system. ERs had to see these patients under the law, regardless of ability to pay. For a poor patient with bad credit, walking away from a hospital bill is no skin off his back.
Of course ER visits will increase for an insured population that knows little else of healthcare beyond the emergency room.
It is the burden of health care providers to educate consumers who, for years, lacked coverage under this system, didn’t have (or was unwilling to pay) $75 to $100 to visit a proper primary care doctor, and was simultaneously incentivized to use ERs under a consequence-free system, on the benefits of benefits of primary care and preventative maintenance.
Therefore health care reform must be paired with patient remodeling— which leads us back to the free-standing ERs of last week’s article.
Getting to the Root of the Problem
With passage of the ACA, many health care providers assumed that all of the dire predictions would immediately come to pass. Increased ER usage seemed like an easy enough problem to address, so off-site centers were created where consumers could conveniently receive these services.
Building these facilities, however, further reinforces consumers’ misunderstanding of “medical emergency” and increases the likelihood that they will not seek out primary care.
24-hour primary care, urgent care centers and retail clinics can help reframe the issue for consumers. These facilities have experienced much growth in the last decade and will continue to do so under the ACA. Delineating the role of urgent care vs. ER will take education for many consumers, but will be a meaningful effort.
Providers can engage in responsible ways of changing patient behaviors by developing and implementing education programs to show patients the gains that can be realized — both in episodic illness and in the aggregate over a lifetime — through the recognition of appropriate care.