About 8 years ago, I became ill with what felt like the flu. Days after my symptoms appeared, though, they got worse. On a Sunday, I called my primary care provider’s office and heard back from the physician on call. She suggested I go to the emergency department (ED).
But I felt so awful that the prospect of sitting in an ED waiting room was more than I could bear. I live in New York City, where ED waits can be painfully long (a recent ProPublica analysis shows that the city’s average ED wait to see a clinician ranges from 40 to 105 minutes). Also, I was keenly aware that preventable medical errors at hospitals constituted the fifth leading cause of US deaths at that time (it’s now estimated to be third).
Why would anyone want to go to an ED if there were an alternative?
That’s the question I asked myself when reports emerged that decreasing the ranks of the uninsured actually increased ED visits. These findings are of particular concern to those who supported the Affordable Care Act’s (ACA) mandate for coverage, arguing that it would decrease health care expenses overall by providing the uninsured with nonemergency options for care, including access to primary care and preventive services.
The Data Are Equivocal
Because EDs are required by law to provide care of an emergency nature regardless of the patient’s ability to pay, many assumed that was the reason that uninsured individuals use the ED more often than people with insurance. But a 2007 Kaiser Family Foundation analysis found that uninsured people were less likely to use the ED than those covered by Medicare and Medicaid. In concert with this finding, the National Center for Policy Analysis predicted in 2010 that ED use would increase under the ACA as more people enrolled in Medicaid or other insurance plans.
Early reports from Massachusetts indicated that ER usage increased by 6% as people obtained coverage. “Preventable” or “avoidable” ED visits increased the most. In fact, half of all ED 2004-2008 visits were deemed avoidable, regardless of insurance coverage. But some have argued that an overall increase in ED use predates the Massachusetts health reform law and the growth rate in ED use was lower than in prior years.
Other studies have found that the onset of universal coverage in Massachusetts is associated with ED use that is unchanged or actually decreased. But last month, the only study to use a randomized controlled design found that ED use increased among new Medicaid users in Oregon, where a lottery system was used to expand coverage of poor adults. The new Medicaid users made 40% more ED visits than those in the control group (those on the lottery list who remained uninsured). Critics have argued that this study covered only an 18-month period and that Oregon is engaged in a proactive strategy for improving care coordination among Medicaid recipients. Indeed, a recent report by the Oregon Health Authority of the first 6 months of 2013 noted that ED use decreased by 9% compared with 2011 and ED spending declined by 18% among Medicaid recipients managed by coordinated care organizations.
So the data are equivocal, but if the ACA actually does reduce ED use, will that result in reduced health care costs? The 2007 Kaiser Family Foundation study found that the high-ED users (4 or more ED visits every 2 years) were more likely than low users to be “elderly, the poor, and persons living with chronic conditions [84% of high-ED users], all of whom are more likely to be in poor health.” They were also more likely than low-ED users to have both physical and mental health problems and to use outpatient services. The high-ED users constituted 1% of the population but accounted for 18% of ED visits and about 16% of ED expenditures. So even small reductions in ED use by Medicaid recipients are likely to reduce ED spending.
Why Use the ED if You Don’t Have To?
Doing what we can to reduce ED use is an important aim, given the cost factor and the likelihood that ED care will not help people prevent or manage chronic illnesses. So why would anyone use the ED if an alternative were available?
One prevailing argument is that insurance coverage doesn’t guarantee access to primary care—especially if there’s a shortage of clinicians. Avik Roy, of the Manhattan Institute for Policy Research has argued that Massachusetts and the nation have not adequately addressed the supply of primary care clinicians and that Medicaid payment rates for primary care physicians are so low that many will not accept Medicaid patients. The US Health Resources and Services Administration has projected that the shortage of primary care physicians will continue into 2020 but could be ameliorated by an expected 30% and 58% increase, respectively, in primary care nurse practitioners and physician assistants. The ACA authorizes focused investments in the education of all primary care clinicians.
But a study of nonurgent ED users at 2 sites in an academic health system found that being unable to find a primary care clinician was identified as a reason for not using primary care less than 7% of the time. They were more likely to say they were using the ED instead of primary care because of financials factors, wait time for an appointment, and constraints in their ability to access primary care during conventional office hours.
What can be done to decrease ED visits among the newly insured?
First, we must expand the number of primary care clinicians, including physician assistants and nurse practitioners, and use them more efficiently. Jeffrey Traczynski, PhD, and Victoria Udalova, MS, analyzed data on nurse practitioners practicing without mandated physician supervision or collaboration and found that ED use decreases, primary care visits increase, and some quality measures improve.
Second, attention must be paid to improving the infrastructure of primary care services. This includes easy scheduling of appointments, extended office hours, and same-day visits. Retail clinics in stores like Walgreens and CVS Caremark are on the rise and the evidence to date indicates that they provide high-quality, affordable care—including preventive care—with satisfaction by users. Some of these clinics are offering disease management and are interfacing with health systems to help with care coordination.
Finally, a primary care clinician ought to talk with a newly insured patient about when to use an urgent care center, what symptoms ought to lead to an immediate ED visit, and how to access the provider off-hours.
I didn’t go to the ED when the physician on call said to do so. I waited until the next morning and saw my primary care clinician. But, as a nurse, I know when I need an ED and when I can wait. Can we do a better job helping patients to understand the value of both primary and emergency care and when to use the ED?
About the author: Diana J. Mason, PhD, RN, is the Rudin Professor of Nursing and Codirector of the Center for Health, Media, and Policy at the Hunter College; Professor at the City University of New York; and President of the American Academy of Nursing.
About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.