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Breaking News: Health Reform and the ED: Prepare for the Surge

SoRelle, Ruth MPH

doi: 10.1097/01.EEM.0000372183.23372.93

    The health reform legislation signed by President Obama in March represents the greatest legislative change in health care since Medicare was approved in the 1960s, and emergency medicine experts said now is the time prepare for changes that will take full effect in 2014.

    Opposition and hesitancy about health reform does not reflect opposition to providing access to the health care, said Angela Gardner, MD, the president of the American College of Emergency Physicians. “It reflects a lack of trust in the process rather than that we don't need change,” she said. “People think things will not occur as promised. I agree that that is possible. We need to be ready. This is not a disaster drill.”

    The changes in the reform legislation are incremental, but by 2014, everyone will be required to have health insurance through their employers, government programs, or nonprofit member-run insurance companies. Because coverage is mandated in all 50 states and the District of Columbia, 32 million previously uninsured U.S. citizens will be brought into the system. Without preparation, that could equal a surge in demand for emergency care, experts said.

    Those who seek care will be sick and in need of urgent treatment, said Stephen Pitts, MD, MPH, an associate professor of emergency medicine at Emory University School of Medicine who completed a fellowship at the National Center for Health Statistics. “It always bothers me when people look at the emergency department waiting room, and say all these patients need primary care. You don't know which ones need primary care. A good number called their doctors, who told them to go to the emergency department.”

    He and others in the field said one way to deal with the possible surge is to start planning now.

    “Doctors don't practice as they used to. With the advent of hospitalists, they don't even go the hospital. Their practice schedules are filled with appointment patients,” said Dr. Pitts.

    That full schedule coupled with the Medicaid expansion that is expected to happen first could likely result in increased ED visits. Noting that Medicaid patients are the most frequent users of EDs by population rate, he said, once the uninsured enter Medicaid, it may lead to increased ED utilization. Some primary care physicians may be willing to accept people who were previously uninsured, meaning that “we may not get hit with the full blast,” Dr. Pitts said. He added, though, that Medicaid patients are probably sicker. “You can't expect the uninsured to seek care in the emergency department at the same rate as those who are now on in Medicaid,” he said.

    Dr. Gardner agreed that EDs can expect an increase in patients. “That's the first thing that is going to happen. Massachusetts had an average seven percent increase in volume after they covered everyone. We need to be ready, particularly for the people who may not have come in earlier.”

    Thom Mayer, MD, the chairman of the board of BestPractices, an emergency medicine outsourcing group in Virginia, said EDs will see a surge that won't diminish unless changes are made in how primary care is delivered. “Form follows finance,” he said. “What happens when you increase demand, but you don't deal with capacity? Not only do you have to deal with where and how patients get taken care of, but you also have to think of the implications for people who are already insured and treated well. Will we be able to treat them well without the ability to increase capacity?”

    Or, as Howard Blumstein, MD, the president of the American Academy of Emergency Medicine, succinctly put it: “We don't have enough facility space to care for all of the newly insured under the current system.”

    Health reform puts the need for more primary care physicians in higher profile, said Dr. Mayer. “Nothing in the plan creates more capacity or shifts the capacity. Only five percent of physicians are in primary care. The numbers of doctors created by this bill are none, zero, nada, nil. We won't have any more doctors and certainly no more primary care doctors.”

    Dr. Blumstein agreed, adding that he was hearing lots of complaints from emergency physicians about patients who cannot obtain primary care. “Patients who are discharged from the hospital sometimes end up back in the ED because they cannot get timely primary care follow-up. Primary care is becoming a less attractive option for young doctors, and at the same time, demand rises as our population both grows and ages,” he said.

    He noted that the perceived needed for more physicians, especially in primary care, has led states and medical educators to establish new medical schools and expand classes in established schools, but said he didn't know if that would be enough. “I expect that there will be an even greater increase in physician extenders providing primary care services and financial incentives for young physicians to enter primary care specialties,” he said. “All these things cost money. My guess is that, overall, the shortage will get worse.”

    Dr. Pitts said a whole new system was needed for delivering primary care. “Right now, there is every possible disadvantage to going into primary care as a medical student,” he said. “You get no respect, and there's not much money. We have got to boost primary care.”

    Dr. Blumstein warned that the population of emergency physicians must increase as well. Although academic emergency medicine has been calling for an increase in training levels for years and the number of emergency medicine training slots has been rising, growth is slow. “Estimates were that it would take many years to reach adequate numbers of board certified doctors,” he said. “If emergency department visits go up, then the time required will be even greater. In other words, if there is an increase in emergency department visits, then the manpower shortage issue will be magnified.”

    One thing to consider, said Dr. Pitts, is what brings patients to the ED. Data from 2001–2004 indicate that those with wounds and lacerations go to the ED rather than to primary care physicians or surgical specialists. “Emergency physicians represent four percent of doctors, and yet they see over half of the uninsured patients and 90 percent of lacerations and something like 75 percent of chest pain,” he said. Primary care practices meanwhile are dominated by upper respiratory complaints.

    He also said community clinics sound promising, but they have to be designed to see the truly ill. “If they saw people with wounds and those with pneumonias, they might take a bit of the burden off us. Our real crowding comes with abdominal and chest pain, imaging, and admission to the hospital. Some of these clinics have no impact on the emergency department. If they see someone sick, they send them to us,” Dr. Pitts said.

    Dr. Gardner also hopes to enlighten people, including President Obama, about the importance of emergency care. “One of the President's statements that we have had an issue with is that ‘we need to get all those people out of the expensive emergency departments.’ That's a smaller number than we think. We have to make sure as we go forward that they do not use a retrospectoscope to evaluate care. If you go the emergency department with chest pain that turn out to be gas, you still should have gone to the emergency department,” she said. That doesn't mean that patients don't need a personal physician. Many conditions such as hypertension, diabetes, and asthma are best treated in an ongoing relationship, said Dr. Gardner. “And patients need to know that the emergency department is not there just for convenience.”

    She said many EPs fear the effects of reform, but several physician groups that tested a model of having their nonpaying pay at state Medicaid rates came out ahead, she said. Still, many fear that the rates may not stay as high as they are today.

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