One of the primary expectations from the passage of the Affordable Care Act was that fewer people would go to the nation’s emergency departments rather than their primary physicians, thereby reducing the overall cost of health care. The reasoning was that since emergency departments are more expensive than primary care offices, and the reason patients aren’t going to private offices is that they don’t have insurance, providing insurance will shunt people away from the ED, thereby saving millions while unclogging the nation’s emergency departments. Conversely, it was argued that if the ACA was not passed – or now, repealed – there would be more patients forced to go to the ED. Two recent studies, published in the Archives of Internal Medicine, suggest that both scenarios, upholding the Affordable Care Act or repealing it, will result in increased visits to the ED.
The first, a study by Tara Bishop, MD, et al, published in the June issue of the Archives, looked at the number of physicians who accept Medicare, Medicaid, private insurance and no insurance. This report was a reflection of the saturation of most medical practices. When a practice becomes full or near full, the physician typically restricts his or her practice to certain payor categories. So, while the number of practices that continue to accept patients with Medicare and Medicaid remain relatively high, the declining number of practices accepting new patients is worrisome because those patients usually end up in the ED. Bishop’s study noted that the percentage of physicians who reported that they were accepting new patients didn’t vary much between 2005 and 2008 (94.2% to 95.3% respectively – a slight increase). This reflected the fact that most medical practices are operating at or near capacity. But the percentage of physicians accepting new Medicare patients dropped from 95.5% in 2005 to 92.9% in 2008 (P = .01). However, according to Bishop, the number of doctors taking new private noncapitated insured patients dropped even further, from 93.3% in 2005 to 87.8% in 2008. The most worrisome was the fact that the rate of acceptance of new Medicaid patients was the lowest of all and continued to fall over the study period. The surprise was that self paying patients were accepted into practices at a rate of 96% and this rate did not fall.
How does one explain these changes and what impact will they have on the ED? First, as Medicare compensation continues to fall, there is a natural winnowing of a private physician’s practice that occurs. Although the number of practices declining to accept new Medicare patients is not great, this number will be combined with the ever increasing numbers of total Medicare recipients. This “perfect storm” of rising need and declining access will result in a predictable rise in the number of Medicare patients being seen in the ED. And worse, everything that is true for Medicare is doubly true for Medicaid. Medicaid reimbursement rates are the lowest of all categories and half of the new patients insured as a result of the ACA will be through mandated state Medicaid programs. This will undoubtedly swell the already high numbers of ED Medicaid patients.
But why would practices be declining new privately insured patients? One suggestion that is often heard is the increased administrative burden of complying with the various plans. But this has not be studied definitively. What about self paying patients? Why would practices continue to accept them? This appears to have everything to do with cost shifting. While some self pay patients are clearly ‘no pay’ patients, many who pay out of their pockets are not. And by selecting the patients properly, the practices actually increase their reimbursement above the totals allowed by Medicare, insurance, and Medicaid.
But now the Affordable Care Act hopes to move 16 million of these non-insured patients onto the rolls of private insurance and another 16 million onto Medicaid. And these are the two categories least likely to be enrolled as new patients in a private practice.
Moreover, as the mandated coverage provisions of the ACA become active, insurance companies have increased their premiums to cover their risk. This, in turn, has made paying the IRS fine and going without insurance altogether a more viable option for some cash strapped employers. The result is that uninsured patients might find it easier to get into a private practice than if they’d kept their previous policy. Then again, will that mean that they are less likely to go to the ED? Probably not.
A new study by researchers at University of Colorado School of Medicine and Oregon Health Sciences University, published also in the Archives, suggests that any change in insurance status makes a patient more likely to utilize the ED. This study found that 20.7% of insured and 20% of uninsured adults had at least one visit to the ED in the previous year. But when a patient was newly insured, he or she had visited the ED 29.5% of the time. As the previous study suggested, simply having insurance doesn’t mean that you have a doctor. Actually, a smaller percentage – 25.7% – of the newly uninsured patients had visited the ED in the previous year. The suggestion was that it was the change in status that made a person more likely to visit the ED – only 18.6% of the continuously insured visited the ED.
So what do these studies suggest for the potential for increasing or decreasing he number of ED patients? For one, they suggest that simply having insurance is no guarantee that patients will have access to primary care. Limited physician office hours, wait times for appointments, difficulty with getting in touch with a primary care physician’s office to make an appointment, and transportation issues all are reported barriers to using a primary care physician. And these barriers have all increased in recent years. When Massachusetts enacted legislation similar to the Affordable Care Act, there was no drop in ED visits. Gaining insurance makes patients less likely to get into a private practice and more likely to go the ED. And if you get on Medicaid, you are the least likely to get into a private practice, and most likely to go to the ED. Those two factors alone suggest that when 16 million Americans are moved to either private insurance or Medicaid, the nation’s ED will see an increase, not decrease, in annual patient volumes. Douglas Holtz-Eakin, a health care economist, has estimated that this shift will generate 68 million new ED visits at a cost of $36 billion to the nation’s health care bill. It’s simply the Law of Unintended Consequences.