Health Care Reform And Emergency Room Overcrowding

The Associated Press has an interesting story looking at what the health care law will do to the nation’s emergency rooms. Carla Johnson suggests that the expansion of coverage will actually lead more people into the emergency rooms and here’s why:

— People without insurance aren’t the ones filling up the nation’s emergency rooms. Far from it. The uninsured are no more likely to use ERs than people with private insurance, perhaps because they’re wary of huge bills.

The biggest users of emergency rooms by far are Medicaid recipients. And the new health insurance law will increase their ranks by about 16 million. Medicaid is the state and federal program for low-income families and the disabled. And many family doctors limit the number of Medicaid patients they take because of low government reimbursements.

— ERs are already crowded and hospitals are just now finding solutions.

There is little to quibble with here. The health care law expands coverage, and invests in the nation’s workforce, but on balance we’ll probably face a situation where some people will still be turning to the emergency room for care. The law has already begun making important initial investments in workforce expansion.

On June 16, (in addition to other provisions in the new law) Sebelius announced $250 million from ACA to increase the number of primary care providers. The money would create 1,700 new primary care clinicians, expand more primary care clinics in underserved areas and provide money to states to plan and implement innovative strategies to expand their primary care workforce by 10 to 25 percent. And, two days ago George Washington University released a study showing that the ACA investment in primary care though Community Health Centers will ultimately provide care for an additional 17.5 million people over the next ten years while saving the health care system $181 billion by eliminating unnecessary ED visits and hospital admissions.

We’ll have to invest more dollars in training primary care physicians and paying more for Medicaid services, but more can also be done with the money we’re already spending. Ellen-Marie Whelan, our in-house workforce expert, tells me that Medicare and Medicaid spend about $12 billion dollars funding Graduate Medical Education (GME) in hospital based residency programs. But rather than appropriating those dollars towards primary care, or other priories, we simply give hospitals the check in a lump sum and then they spend it however they like. Surprisingly, “states are not required to regularly report on Medicaid spending to support resident education,” even though experts estimate that 2/3 is spent on hospital administration and 1/3 goes towards residency salaries. But if we’re really interested in dealing with the emergency room crunch wouldn’t it make sense to deliberately funnel that money toward primary care doctors or training doctors in community settings? For more recommendations, see the most recent MedPAC report here.

So we can begin to address emergency room overcrowding by reorienting the existing workforce resources towards primary care and the new expansion of coverage can serve as the inspiration and motivator.