During the debate over the Affordable Care Act, one issue that kept coming up was emergency room visits. One key element to reducing health care costs is providing care more efficiently. Often times, the same illness treated for the same person can have radically different costs depending on where they’re accessing the care. And nowhere is that care more costly than your local ER.
Fewer Uninsured Americans Means Fewer ER Visits?
One crux of Obamacare was always the idea that, by expanding insurance coverage, care could be delivered more efficiently. This took many forms, from improving the quality of the care given by conducting new research on the efficacy of different drugs and treatments to focusing more on preventive care to keep people well and avoid costly treatment for preventable chronic conditions.
However, one other major consideration was the ability to avoid unnecessary emergency room visits. The hope was that, once insured, people would start kicking their habit of heading to the ER for every illness and start going to a primary care physician for non-emergency care. This alone could have a major effect on costs. A 2010 study by the Rand Corporation came to the conclusion that 17 percent of all ER visits could have been handled outside the ER and cost an extra $4.4 billion because they weren’t.
New Study Shows Medicaid Patients Actually More Likely to Visit ER
Unfortunately for the law’s proponents, a study in the journal Science released on Thursday indicated that simply getting insurance might not be enough to deter people from going to the ER. The study, conducted in Oregon and comparing those patients who won a chance to go onto Medicare in a 2008 lottery to those who missed out, showed that there was actually a 40 percent increase in ER visits by those on Medicaid as opposed to those who were still uninsured.
Certainly, the source of this divide isn’t immediately clear, and precisely what is driving this behavior isn’t clear just from the study. However, it has to be a troubling result for those proponents of Obamacare counting on improving efficiency to arrest ballooning health care costs.
Emergency Rooms Increase Costs
But for what’s ostensibly the same care, why are primary care physicians so much less expensive? The answer probably lies in the basic organization of the two locations.
Emergency rooms have to stay open 24-7 and keep a staff constantly at the ready. They also need to be prepared for almost any conceivable medical emergency, keeping large amounts of medical equipment and expertise in a single location. As a result, emergency rooms are expensive. The goal is not efficiency; the goal is being ready for anything and hospitals will sacrifice as much efficiency as is necessary to ensure that they can save the lives of those gravely ill or seriously injured people coming through their doors.
Meanwhile, primary care doctors can work specific hours, schedule visits, schedule staff based on a predictable patient inflow, and don’t need to purchase and maintain expensive equipment. As such, they can see and treat patients for a variety of conditions at a much lower cost, not to mention refer patients with illnesses they can’t treat to the most efficient other options.
ER Represents Easier Route to More Care for Many
Part of the issue is that, while unnecessary ER visits are the bane of administrators and policy wonks alike, they’re really a better way to access care for many people. While long waits are often in the cards, many individuals’ decision to head to the ER for non-emergencies (including many people with insurance, primary care doctors, and plenty of other options) is a rational one.
One trip to the ER can allow someone to visit a variety of specialists in one visit to a single location and for a single copay. And with hospitals, insurance plans, and government shouldering the costs, why wouldn’t someone take this route? You can get all your care at once rather than having to wait weeks while you schedule visits to a primary care physician and any subsequent specialists, shelling out a copay each and every time.
In short, if you spend a lot of money on building single locations that offers the best possible treatments for every conceivable condition and have to be conveniently located to population centers, you shouldn’t be all that surprised when lots of people want to use them.
Incentivizing Not So Easy
So the answer’s clear, right? One simply increases the copay for an ER visit, or starts issuing financial penalties to frequent ER users and the issue sorts itself out.
Unfortunately, the nature of this issue, like most things in health care, is not so black and white.
For starters, while the consequences of someone visiting the ER when they don’t need to are outweighed by the consequences of someone not visiting the ER when they do need to. In short, you’ll take a few hundred people coming to the ER with chest pains that turn out to be heart burn to prevent one person from ignoring those chest pains that turn out to be a heart attack.
If even a handful of people fail to visit an emergency room when they should because of these disincentives, it could outweigh any cost benefits due to costly emergency care. More importantly, the human cost of lives lost or ruined would be impossible to ignore.
What's more, convincing medical professionals to tell patients not to visit the ER could prove difficult. In a profession that's fairly risk-averse (and probably should be), the addition of considerable legal liabilities associated with advising people against care are considerable. Telling one person they don't need to go to the ER the next time they have certain symptoms can create the phallanx of angry family members that could ruin a doctor or nurse's career. As such, correcting patient and caregiver behavior over time could prove difficult.
No Easy Solution
Drawing too much from the study of Oregon residents might be a mistake. The sort of behavioral changes in question can take some time, and it’s entirely possible that newly insured people are likely to pursue more care than they previously did while using the same methods they used to. What’s more, uninsured individuals may have been forgoing treatment for certain conditions only to increase their utilization once they had health coverage.
However, it’s clear that, of the many health care cost-drivers out there, reducing unnecessary emergency care visits is a complicated one that may require some difficult decisions to address.
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