WhiteCoat

More Visits, Less Availability

A new study released in JAMA shows that the number of annual emergency department visits between 1997 and 2007 increased from 94.9 million to 116.8 million — nearly twice as much as would be expected for population growth.

Also published recently was the Department of Health and Human Services’ 2007 Emergency Department Summary (.pdf file here). Lots of interesting statistics.

Most of the increase in ED visits were due to Medicaid patients. One quarter of the 117 million visits to the emergency department in 2007 were made by patients with Medicaid or SCHIP. Seventeen percent of visits were covered by Medicare. In other words, 42% of hospital ED visits (50 million or so) are paid for by the state or federal government.

The graph to the right from the San Francisco Chronicle shows how emergency department use by Medicaid patients is now more than five times the rate of emergency department use by patients with private insurance – and since they are from 2007, these numbers don’t include the impact from the recession.

Further breakdowns in demographics from the DHHS report include high ED utilization rates for children less than 1 year old (88 visits per 100 US infants), patients older than 75 (62 visits per 100 US persons),  homeless persons (72 visits per 100 population), blacks (74.6 visits per 100 black persons), and nursing home residents.

In addition, the number of “safety net” hospitals – defined as those who treat patients regardless of the ability to pay – increased by more than 40% from 2000 to 2007.

Before you start blaming Medicaid patients for health care crisis, think about why there is a disproportionate use of emergency departments by Medicaid patients. If you or your child has a medical problem and few private physicians will accept your insurance, what are you supposed to do? You go to a place where they will accept your insurance and you get relatively timely care (as opposed to an appointment 4 months in the future). Although there are undoubtedly people that abuse the Medicaid system, in general, it isn’t the patient’s fault for having Medicaid. It is the fault of the government for failing to adequately fund and monitor the Medicaid program.

With the increase in visits, there are longer waits and less availability of medical care.

Because the JAMA study was based in California, I did a little searching and found that 61 California hospitals closed between 1998 and 2008 and 14 more California hospitals closed their emergency departments. That’s a loss of 75 emergency departments in 10 years.

The San Francisco Chronicle article notes that California hospitals are facing an additional $17 billion in payment reductions over the next 10 years. I’m sure that will translate into many more hospital closures.

Oh. And health care reform will add between 11 and 22 million additional patients to Medicaid – you know … that good insurance that all the doctors’ offices take. Then what?

I know this is another “sky is falling” post. But I think that it is important to show how health care policy changes are affecting access to medical care in this country.

26 Responses to “More Visits, Less Availability”

  1. [...] This post was mentioned on Twitter by Luis Saldana, rlbates. rlbates said: From White Coat's Call Room: More Visits, Less Availability http://bit.ly/bri689 [...]

  2. DensityDuck says:

    The obvious response is to file a lawsuit against every doctor who refuses to take Medicaid patients, every doctor who fails to run a 24-7 clinic, every doctor who doesn’t write scripts for mothers demanding placebo antibiotics or patients with 10/10 pain and allergic to everything but Vicodin…

    Because, after all, according to people like Matt, lawsuits are the grease of society. There’s no problem that can’t (or shouldn’t) be solved in court. Because, after all, court proceedings are a mere trifle–a minor niggle, solved in a single afternoon–and shouldn’t we all maintain large reserves of ready cash to defend ourselves? I mean, that’s only wise, right?

    • Matt says:

      It’s easy to make arguments when you use strawmen isn’t it? And since you really don’t know what you’re talking about, you can assume there is a cause of action for not taking Medicaid patients, right? Nice work – you beat down a made up argument with a nonexistent solution!! Does the Harvard debate team know you’re available?

      I assume your solution to this alleged California access problem is tort reform? Oh wait, California’s had it for nearly 4 decades. Damn, back to the drawing board. What next, pay physicians more? Oh wait, they’re already the highest paid profession.

      So where’s your solution? Or are we just to be content with nonsensical jabbering from you?

  3. Sarah says:

    I guess I want to know where all these clinics are that just don’t accept Medicaid. I have worked as a medical student, resident, or attending physician at several clinics, independent or system-affiliated, and ALL of them took Medicaid. There was no question about that. Don’t get me wrong, it’s a losing proposition. Maybe WI Medicaid pays more so more are willing to take it? I don’t know.

    • Gene says:

      I can tell you where they are: EVERYWHERE. I was a resident in NC and many many many clinics there were no longer accepting “new” Medicaid patients. Duke Hospital does not take new medicaid kids unless they were born at Duke OR a sibling is a current Duke patient. Move to the area and have Medicaid? Good luck finding a doc! One of my patients in my resident clinic moved about 90mi away (on the other side of a large metropolitan area) and couldn’t find a clinic to take her kids. So she drove them back to see me!

      I’ve see kids in the ER whose parents told me that they knew they should go to their PCP for the problem (ear infection, minor cold, etc) and they’ve called all the clinics in town and they are all “no longer accepting new Medicaid patients”. The few clinics that do (we had a local doc who had a private clinic that only saw Medicaid kids) are completely overrun and understaffed. The public health dept? Try getting an appointment for ANYTHING in less than one month (including ER and hospital discharge followups).

      I now live in a state where, if you take ANY insurance and are open to new patients, you are required to take Medicaid (or my state’s version of it). So almost every patient I now see has a PCP. But they still come to the ER because it is “faster”.

  4. Melvin says:

    I think the inevitable “solution” here is that physicians will be mandated to have a certain percentage of their patient base be Medicaid insured. That seems most palatable to politicians.

  5. tracy says:

    i suggest everyone read Dr. Sara’s take on the Medical crisis on her blog http://sarainisrael.blogspot.com i think she has it spot on.
    Scroll down to “Explain this: American Healthcare”

  6. Matt says:

    Before these stories can resonate, someone is going to have to tell us what the optimal amount of access is.

    Physicians play the access card for everything, and this is just another example. We’ll lose access is the cry for whatever they’re advocating. But it’s meaningless until we have an access goal.

    So physicians, what is it? What’s the US access to physician goal so we can tell when your policy prescriptions work, or when we need to try something new?

    • throckmorton says:

      Matt:

      I think the access goal should be that every patient is entitled to what they are willing to pay for and to let the free market rule. This can be done the same way it when you hire an attorney. They quote you a fee and you negotiate the arrangement.

      Our problem with medicine is that the fee that is quoted and the arrangement are dictated by someone else. Before you have said we need a sinlge payor. Right now, for the most part we have one in the Federal Government. Medicaid pays 60% of the Medicare rate. So the same single payor pays differently for different “classes” of patients. As the “single payor” decreases payments, it changes the care that is available.

      The cost to treat an acute asthma exacerbation for a child in the office is less that 10% of the cost to do the same in the ER, yet the economics of you get what you pay for means the patients will have to go to the ER instead of the office.

      I am waiting for the opportunity for physicians to have contingency fees just as lawyers do. If the patient survives, the ER doc gets 1/3 of all future earnings plus expenses. (just kidding)

    • WhiteCoat says:

      Personally, I think your argument is another bunch of hogwash. What is the optimal amount of access? Tell me how you expect anyone to make that determination. That’s like saying that attorneys shouldn’t whine about anything having to do with law until they can tell us what the optimal amount of “justice” is. Don’t claim that we’re screwing the injured until you can tell us the “optimal amount of justice.” How inane. My son can come up with better arguments than that.

      Throckmorton is right on. When something of value is without cost, there is no reason for consumers not to want as much of it as possible. The problem with medical care is that it is not without cost, but the cost is borne by the government, so the costs are not perceived by many of the people consuming the services.

      The most logical solution to the problem is to create a free market system. However, if the government continues to dictate prices (as it currently does), it is not a free market, but is instead a monopsony.

      If the government wants to actually provide access to care to those who cannot otherwise afford care, it should create hospitals with open access – similar to the VA system – where all services are provided without cost to anyone who goes to those hospitals. Then let private hospitals provide value added services for those willing to pay extra for them.
      We all know that will never happen, though. Then the public would be ticked off at the government and not at the medical providers when patients couldn’t get the “optimal amount of care” – whatever that is.

      • Matt says:

        You’re not making sense. Read your posts. You claim repeatedly that we’re losing access. Ok, I believe you.

        Then you want us to do X, Y or Z to improve access. But you never tell us how we know how much access we should be shooting for. Is it X amount of various physicians per capita? A mileage distance to this or that type?

        You’re asking us to, for example, reject Obamacare because it will hurt access. Well, if we do what will access be then? Will that be a sufficient number? Or is there some magical confluence of policies you’re recommending? And if so what kind of access do we get for supporting them?

        This s pretty basic stuff. You are pushing for the free market. Putting aside tar you’re not consistent on it I support you. But are you selling it on general philosophy or on direct cost-benefi like physician access? If it’s the latter be specific on why it works. Otherwise it comes across as intellectually lazy and you’d be better off going on philosophy than empty scare tactics. Perhaps you considering every suggestion hogwash is the reason that you’re increasingly fighting an uphill battle against single payer. Your suggestion about essentially government care hospitals is a good one but your lobbying tactics aren’t working. Must be your charm.

        Offer the public a specific upside and perhaps they’ll follow you. Ironically it may be very good lawyers who create the biggest hurdle to obamacare and allow you to hold on to whatever remnants of the free market are left in medicine.

    • Matt says:

      Throck I have never advocated for single payer. I think it’s the worst idea we’ve had as a country in decades in terms of domestic policy. But when the people on the front lines, physicians, do little to stop it I think it’s inevitable.

      I read sites like this one and the focus is completely on the wrong place and the arguments lack weight when the focus is there and I don’t see how we stop it. Do you? I bet right now if you gave physicians a choice between damage caps nationwide and single payer a majority would choose the former. There’s just a total lack of political or economic savvy.

      • throckmorton says:

        Matt:

        One of the biggest hurdles we have in changing present physician payment models is federal law. We are barred from collectively bargaining. The Feds have recently used this to break up several large cardiology and orthopaedic groups that they felt “had grown too large”.

        It is presently against the law for me to call another physician in my specialty and ask how much he charges.

        You are right in the fact that we do not have the political savy. We let politicians do this to us.

        Until recently the only real option we had was to restrict services until something changed and given the mindset of most docs, no one would restrict services. Further, if you had anything to do with a hospital EMTALA would just stick you anyway. The tide is now changing. This is the change in access. We cant collectively negotiate, we cant collectively be politically savy, but we can individually en mass decide that we just aren’t going to take it.

      • Matt says:

        Hope it works. I don’t think it will, but I hope it does.

        But you’re going to have to be willing to totally divorce yourselves from the government and truly enter the free market.

        Do you think enough of your colleagues are ready to make it happen?

  7. [...] like to call it an “Emergency Department” now: At least there are fewer uninsured people showing up in the [...]

  8. It seems to me that no amount of resources taken from physicians or society as a whole will ever offset willful irresponsibility or satisfy the demand for free services. Instead of thnking about ways to force physicians to see Medicaid patients shouldn’t we be looking at what’s wrong with the Medicaid program and fix it instead?

    I don’t see many Medicaid patients who don’t have a cell phone, a watch and other jewelry, and relatively new clothes. Being unable to afford a co-pay is a choice rather than an unfortunate reality. SCHIP shouldn’t have a co-pay to protect the children from further deprivation at the hands of their irresponsible parents.

    Ron Hellstern
    rahellstern@hospitalpractice.com

    • DefendUSA says:

      Don’t open that can of worms about what the patients have! :)
      You are correct that what should be obvious, simply gets ignored.

      I believe access and quality will suffer and as others have said when you take something of value and give it away, it is neither used correctly but abused simply because it is “free”. And not by just the patients. The government also becomes the abuser to the physician who must be forced to accept a payment that is inadequate for the services rendered.
      It is a vicious cycle and my fear is that it will have to be completely broken before anyone will actually try to save it. THAT is unfortunate.

  9. girlvet says:

    I’ve had this same thought about health care reform. Who is going to take care of the influx? These people who have not had regular health care for a while and, who can blame them, now will seek all the preventive medicine all the rest of us get.

  10. Roberto says:

    I often read these discussions with a profound feeling of sadness. It’s disappointing to read and hear the most ‘educated’ members of our society (the M.D., and Ph.D.s) to show off their ignorance and bring up the free market argument so often. And it’s even worse in academia with so many people focused on writing grants and papers that only a few people will read. The sad aspect of it is of course their poor political education. Nobody teaches you this, you’ll have to do it on your own. But there’s no time since you’ve working all your life crafting your CV, i.e., your future job. Above I referred to physicians as the most ‘educated’ members of our society, but I meant the most ‘trained’. Certainly, training for performing a complex job doesn’t mean you understand politics or society or culture.

    Few other people have noted that the whole system, the whole culture is wrong, and there’s no way to fix it!!. An ever expanding, resource extracting economy that already has us indebted and at war and let me add, at the brink of extinction (viable levels of CO2 in the air are 350 ppm, we’re are currently at 385 ppm to the point that scientists are considering to cool down the Planet by spraying chemicals to deflect sunrays. But according to keen observers this program has begun already). So the best way for our healthcare system is to make it a Canadian type of single payer one so that crises don’t come as fast as they do. But they will eventually. So far I haven’t heard complaints from Canadian physicians. Single payer is not perfect but has proven to smooth out and slow down inequalities to at least make the system viable for at least one generation. That’s good for me.

    • DefendUSA says:

      Roberto,
      With all due respect, the Canadian health care system is not working! The founder/developer of that system has admittedly agreed! From my own writing…

      “Those that believe the Canadian system or even the UK’s National health care are a boon, have not been paying attention. In both places, access is pitiful, as is quality of care.

      Ask yourself why people come here for surgeries or treatments if where they live has such a wunderbar system?

      Canada made it impossible for physicians to have a private practice outside of the social system. It drove docs to other countries, but it has started to change.

      Now,doctors practice privately making it accessible to those who can afford the cost. The government care is left with the remainder and by it’s own emission on the brink of failure. Daniel Castonguay, the original architect of Canada’s system has himself said, ” “We thought we could resolve the system’s problems by RATIONING SERVICES or INJECTING MASSIVE AMOUNTS OF MONEY into it. We are proposing to give a greater role to the private sector so that people can exercise freedom of choice.”

      What does global warming or the war have to do with a social system of medicine?

      • Roberto says:

        Dear DefendUSA & Karol,

        Sorry I forgot about this post.

        Thanks DefendUSA for the tip on Daniel Castonguay, which I will follow up especially if somebody addresses the points you mention in a more extended and supported fashion (a book, a research paper, etc). I still need to look more closely at the Canadian or British systems but it’s my impression (speculation and opinion are allowed in blogs, right?) that any healthcare system will eventually get into trouble for one simple reason: our society is always EXPANDING. It’s expanding in the total number of individuals and more resources consumed per capita, demonstrable either by increased longevity or higher expectation for quality of services; more access or cheaper encounters, less error rate, etc. The ever expanding nature of our society has NOT been challenged by any of the most polarized capitalist or socialist systems, assuming any of such exist (Digression: I never talk about a society being capitalist or socialist because they don’t exist. Instead, I do talk about a specific policy being capitalist or socialist, single payer being one of the latter in a society that like the Canadian also having capitalist policies digression off). The exponential growth of our society is a topic that few people dare to talk about. So if you defend capitalist policies, you can address this problem by downsizing your enemy (wars, famine, financial collapse, epidemics, natural disaster via HAARP, etc). Or if you defend socialist policies you could address this problem like the Chinese did for example through the ‘single child policy’ or any other frugality measures which downsize everybody from a relative position of social fairness. The usual counter-argument is that elites are waived from this policy, and it’s true; elites are elites. Social inequality is impossible to eliminate but at least you can decrease it.

        Karol, I favor single payer health system (socialist policy) because is more stable, there’s more peace, fewer crises and a large segment of the society benefits at large. Capitalist policies led to concentration of power in a few despotic hands and therefore is less stable, it’s the rule of the strongest, and more inequality, etc. But anyway the nicest things in our society are in fact socialist in nature; see the NIH, the interstate highways, public schooling, libraries, Clean Water Act; Clean Air Act, etc, in short, most of the nice stuff paid by the State. But socialist policies have a major drawback: they are harder to defend because they require a strong popular consensus. Capitalist policies don’t need people to defend them. They are so powerfull that only a few well positioned businessmen can push them real hard with no trouble whatsoever (see for example the $700 billion bailout just spun off by a few Federal Reserve and Goldman Sachs guys). It actually amazes me why people like you who work very hard in their jobs defend capitalism. Capitalism doesn’t need to be defended. It’s so efficient in its momentum that doesn’t need grassroots participation. On the contrary, socialist policies are very hard to move them through Congress or to advocate them. That’s why I defend them because they do need popular support. I invite you to think about it, and to find why ‘capitalism needs to be defended’ is a myth.

        DefendUSA, now to your question ‘What does global warming or the war have to do with a social system of medicine?’. I can tell you both have A LOT to do with it. In fact, both are the result of the same variable I referred to above: the ever expanding nature of our combined capitalist/socialist that infringe upon our homeland, Planet Earth. Please take a look at this paper http://www.ejsd.org/docs/The_Population_Bomb_Revisited.pdf . Now, if you want to enjoy a marvelous and fascinating book please read Daniel Quinn’s ISHMAEL.

      • DensityDuck says:

        …natural disaster via HAARP?

        Sorry, my ability to take you seriously has just suffered a major failure. Discussion over, thanks for playing, try the server, tip your veal.

    • Karol says:

      “Free market” is not the problem. The problem is punitive taxes on the risk-takers, and redistribution from the producers to those who produce nothing. Socialism/Marxism kills.

      You said: Single payer is not perfect but has proven to smooth out and slow down inequalities to at least make the system viable for at least one generation. That’s good for me

      That is the problem with socialist/Marxist thinking. So very short-sighted. You will get yours, that is all that matters. Socialist economic thinking is nothing more than a pyramid scheme, the early investors get rich and the ones who get in at the tail end lose everything.

  11. Roberto says:

    The Quebecquian report that led DefendUSA to mention Claude Castonguay is called GETTING OUR MONEY’S WORTH and can be found as a full report or summary here. http://www.financementsante.gouv.qc.ca/en/rapport/index.asp

    I’m reading through it. But the questions are:

    -Is the problem of access?
    -Is it cost?
    -Is it quality?
    -Can be demonstrated with numbers?

    While I read the report I’ll venture to post my hypothesis so I can get opposing views from other readers of the report:

    The social policy of single payer healthcare is better suited for a frugal society. However, if this society is continously growing and inputs don’t match outputs, then at some point it’s going to either downsize or outpour. Rich canadians are the ones called to go shopping in their neirgborhood and purchase medical services just any other commodity from doctors in America who will be glad to offer them especially since they have been starved by managed care.

    So my hypothesis is not the single payer system is bad. Rather, an ever expanding society in a limited Planet is what is bad. And will break down any so-called ‘system’.

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