The wait is over. The Supreme Court of the United States made its decision on the most sweeping legislation on health care since Medicare was passed: the Patient Protection and Affordable Care Act (PPACA) is not unconstitutional, according to a 5–4 decision.
Some argued, prior to the Supreme Court's ruling, that the individual mandate's penalty provisions may violate the commerce clause, and would be held unconstitutional. Somewhat unexpectedly, however, the Supreme Court held that the individual mandate is constitutional under Congress' taxing power. Those who fail to secure health insurance will be required to pay a penalty, which the Supreme Court held was a form of taxation. The legislative intent of the PPACA, which is to provide health care to the approximately 50 million uninsured, will take time to be implemented, but the early phases of implementation of the PPACA will affect emergency medicine profoundly.
Crisis Not Averted
The PPACA will exacerbate our nation's ED crowding problem by increasing the number of semiurgent and urgent Medicaid patients who visit emergency departments. Providing insurance to the uninsured takes time, and the nation's primary care physician shortage is huge problem. Unfortunately, the PPACA utilizes the same ineffective financial incentives to encourage medical students to enter into primary care training.
The newly insured Medicaid beneficiaries under the PPACA as a result will still have difficulty finding a primary care doctor. Those who already have Medicaid will experience long appointment delays for their doctor and will often succumb to the ED waiting room to seek urgent care services. Several studies have investigated this phenomenon. Cheung et al found that Medicaid patients experienced more barriers to primary care than privately insured patients, which leads to higher ED utilization. Barriers include not getting an appointment soon enough, lack of transportation, the clinic not being open at a convenient time, and long waits in the doctor's office. (Ann Emerg Med 2012;60:4.)
The Proverbial Camel's Back
The PPACA may cause hospitals to fail ED metric core measures. ED throughput times will suffer, negatively affecting those core measures. Pitts et al analyzed national trends in ED crowding from 2001 to 2008, and found that ED visits increased by 1.9 percent each year while mean ED occupancy rate increased by 3.1 percent per year. (Ann Emerg Med 2012 Jun 20 [Epub ahead of print].)
The use of IV fluids, blood tests, procedures, and CT scans and the administration of multiple medications represent a trend toward higher practice intensity, which contribute to an increased ED occupancy rate. Triage ordering, which I addressed two months ago (EMN 2012;34:6; http://bit.ly/MX3LMV), ironically contributes to ED crowding because it leads to over-ordering. The irony is that once the ED metric core measures come into effect in 2013 and 2014, the PPACA will affect ED crowding, which will cause hospitals to lose money to the federal government.
The Centers for Medicare & Medicaid Services' value-based purchasing model provides incentive payments to hospitals that perform well on core measures. The new ED metric core measures will track how fast patients are processed through the ED, and slower EDs will lose out on CMS dollars. These savings, in turn, will help fund the PPACA. Hospitals and ED groups need to prepare for ED metric core measures, along with the federal government's other cost-saving measures (RAC audits, the False Claims Act, the accountable care organization paradigm) to stay afloat financially.
The Needle in the Haystack
The PPACA will create a more challenging, high-risk environment for emergency physicians. EPs don't have it tough enough; now we have to sift through more patients to identify the truly sick ones. Like finding a needle in a haystack, adding more semiurgent patients to an ED waiting room is not as harmless as some would argue. A recent analysis by Sommers et al referring to the 2008 National Hospital Ambulatory Medical Care Survey (NHAMCS) concluded that policymakers should focus on other conditions that can be treated outside the emergency department (upper respiratory infections in pediatric patients, for example) because the majority of Medicaid visits are for urgent and more serious symptoms.
This analysis is shortsighted when one applies the analyses done by Cheung and Pitts. The NHAMCS data, in accord with Cheung's study, indicate that Medicaid beneficiaries utilize the ED more because they are sicker, suggesting that these patients experience poorer access to primary care. Medicaid beneficiaries as a result present to the ED with their medical condition in a more advanced, diseased state, which justifies the higher ED acuity.
Sommers underestimated the significance of nonelderly Medicaid beneficiaries utilizing the ED at double the rate of privately insured beneficiaries, and more often have multiple conditions, as Pitts' thought-provoking study found in identifying the root cause of rising ED occupancy rates. The problem is poor access to primary care. But the solution is not creating barriers to emergency care because that Medicaid beneficiary or that pediatric patient with a cold might have a serious illness that a policymaker might miss.
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© 2012 Lippincott Williams & Wilkins, Inc.
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