You might ask why is there a dogma that universal health insurance coverage would reduce Emergency Department utilization? All the smart guys say so, all the way up to the President.
Well, in fact the consensus about ED visits and utilization has always been based on junk science analysis.
Years ago I was the Chief Medical Officer and then the CEO of a managed care company, an HMO. We provided care and insurance, but contracted for emergency department, hospital and specialty services. Our membership were enthusiastic users of emergency departments, since they had full coverage for emergency department visits as well as office visits. We paid extra though, as insurers, because they weren’t seen in the office and unless you’re a managed care entity as big as Kaiser, that has in house EDs, specialists and Hospitals, ED visits were a part of our extra costs. I was so troubled by the problem as the Chief Medical Officer and because so many of the people just had minor ambulatory illness, I spent my nights and weekends running back and forth to the office to see people, to reduce emergency department visits. My colleagues in the medical group often just sent the complaints to the ED, since it was a big inconvenience to run back and forth to the office all the time.
I have written at length about the myths that are the junk science of managed care, and that includes debunking the money saving aspects, such as reducing emergency department visits.
http://www.americanthinker.com/2010/04/the_myths_of_managing_healthca.html
www.jpands.org/jpands1504.htm
Even the Washington Post columnist Robert Samuelson, who is an economist, warned many years ago that it is delusional to think universal coverage will reduce emergency department usage. As an emergency physician I can splain it–EDs are high tech, highly capable, and always open. When you’re sick or even not so sick you don’t wanna wait for treatment, or go to an office that has to send you elsewhere for tests if they can give you a timely appointment. You can say Americans are spoiled–and impatient–well that’s part of the policy making research that should guide opinion making and promises about policy decisions.
There are approximately 130 million visits to emergency departments and the profile of visitors is consistently that the majority have insurance. Self pay is also that category of people with good health who get injured or have acute illnesses, and will expect to pay for their care or stiff the hospital and other billers. The profile for the uninsured emergency department patient is young, healthy and employed, but using their money for something other than pooring down a black hole every month for health insurance they usually don’t need. Very few uninsured are really fall through the cracks poor and the bill in Aemrica for uninsured care is less than 100 Billion because most really sick people are eligible for safety net or are already covered.
Herrick D. Crisis of the uninsured: 2007. National Center for Policy Analysis No. 95, Sep 28, 2007. Available at: www.heartland.org/policybot/
results/23202/Crisis_of_the_Uninsured_2007.html.
Levy H, Meltzer D. The impact of health insurance on health. Annu Rev Public Health 2008;29(April).
http://papers.ssrn.com/sol3/ papers.cfm?abstract_id=1142030.
That’s why government is often making decision on junk science conclusions that reasonable people would say don’t make sense.
The scientific bias is called outcome bias, or tunnel vision, borne of intellectual passion and political agendas–you assume the utopian or good outcome version will work because you are committed to the plan, want it to work. Dr. Richard Feynman would say, a scientist should be his own most severe critic and skeptic, testing hypothesis with a severe attitude. That applies to any discipline used to find reliable evidence and solutions to problems.
Why do you think I worked yesterday (Saturday) and Friday night and saw all kinds of patients who were acutely ill–well because we were open and their doctor’s office wasn’t. Pretty simple. In addition we have a full hospital lab and radiology department less than 200 feet away and a whole hospital of services. People aren’t avoiding doctors offices, they come to the ED for acute care for good reasons, and sometimes they just don’t want to wait for relief until their doc can see them. That’s true of even our fully covered military clientele.
Samuelson RJ. Obama’s illusions of cost-control. Washington Post, Mar 15,2010. Available at: www.washingtonpost.com/wpdyn/content/article/
2010/03/14/AR2010031401389_pf.html.
Well the subject has now become a rage because a study on Oregon shows no reduction in emergency department use.
http://www.washingtonpost.com/blogs/wonkblog/wp/2014/01/02/study-expanding-medicaid-doesnt-reduce-er-trips-it-increases-them/
Here is a link to an overview essay by Kaminsky,
http://spectator.org/blog/57327/medicaid-patients-use-emergency-room-more
and the more in depth discussion by John Goodman, Healthcare Policy Expert at National Center for Policy Analysis, the boss/daddy of health savings accounts and
promotion of market based health insurance.
http://healthblog.ncpa.org/too-many-emergency-room-visits/
So, bottom line, it’s a non problem that’s being elevated to the status of national emergency for the purposes of politics and doom and gloom media. I suspected as much.
I was the chair of the American College of Emergency Physicians Medico Legal Committee when the ant dumping law was passed in 1986, subsequently amended and titled Emergency Medical Treatment and Active Labor Act. (EMTALA) found at 42 US Code 1395dd, which requires a screening exam to determine if a person presenting to the ED has an emergency condtion, then treatment or transfer to a higher level of care if an emergency medical condition or active labor are identified.
You be right in your comments. I was an investigator for the gubberment on the request of the Texas Medical Association because the state inspection teams were perceived to be made up of nurses with a need to hang scalps. I visited many hospitals in Texas unannounced to respond to complaints. Did it for 3 years, and my job was medico legal emergency physician expert on ED cases. Teaching the investigators with blood in their eye that docs don’t get up in the morning to hurt patients and get in trouble with the law.
I was subsequently asked to study the act, learn it and I even followed the Jurisprudence at the trial and appellate level for 15 years.
The law is not so bad, it is intended to prevent turning away seriously ill or injured people, which would be the obligation of a licensed hospital with an emergency department open to the public anyway, but the obligation to screen and treat is used by people to force access.
I would say the net effect is not as bad as it might be perceived, and that there is widespread referral to ambulatory care for the ones determined not to be really sick, but they do get care, and, as I said in the original post, it is timely, convenient with good access and if you go to the emergency department they can do tests that may not be available at an office.
most important to know. the cost of emergency dept care is pocket change for our medical system. 130 million visits, billed out at 1000 per, let’s say and that’s billed, not the expense of care, which is less.
So that’s 130 billion in a system that costs 2.5 trillion. A majority of the billed is paid at a discount by insurance.
We end up with less than 100 billion so that’s less than 5% of the total healthcare costs in America annually. 1 x 10 to the 9th over 2.5 x 10 to the 12th (100 billion/2500 billions= 4%
Believe it or not that is approximately the amount that the system needs to absorb for uninsureds who don’t qualify for safety net, and can’t pay, according to studies done by Kaiser and Blue Cross Blue Shield about 5 years ago.
Now the insurers are protected by provisions in the ACA for insolvency, so the whole thing is being driven by a strange form of crony capitalism. No telling what a mess we will have but you can count on collectivism producing mediocre professional services and generally bad and inefficient administration. That’s why socialism doesn’t work well except for the oligarchs.
So it is not the burden or the drain on the healthcare budget claimed.
John Dale Dunn MD JD Consultant Emergency Services/Peer Review Civilian Faculty, Emergency Medicine Residency Carl R. Darnall Army Med Center Fort Hood, Texas Medical Officer, Sheriff Bobby Grubbs Brown County, Texas 325 784 6697 (h) 642 5073 (c)
One of the downsides of democracy is the need for politicians to avoid ever being a “bad guy”. Realistically, the only way to reduce unnecessary emergency room utilization is to start turning people away en masse. Unfortunately, current laws, and subsequent law suits, have hospitals scared to death of turning away a kid with the sniffles for fear that they’ll be ruined in the exceedingly rare case the kid dies of some strange disease afterwards. In the best case, howls of discrimination and corporate money grubbing are inevitable.
Tort reform, and other actions designed to protect doctors form the lawyers of “victims” whose family member sadly couldn’t be saved will never pass because no legislator wants to be seen as being on the side opposing the crying mother.