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Special Report: The Elephant in the ED

Scheck, Anne

doi: 10.1097/01.EEM.0000450839.09756.4c
Special Report

The ACA has helped the uninsured, and it is also validating that EDs aren't the problem. What is? You know the answer.



Considering all the arguments that have ensued since the inception of the Affordable Care Act (ACA), it seems almost inconceivable that a single study on a small population of Medicaid recipients in the Pacific Northwest could cause the debate to lurch even more drastically. But lurch it has.

The study, known simply as “The Oregon Health Insurance Experiment,” has been heavily scrutinized in the national media, resulting in impassioned pronouncements. Some publications harshly criticized the study design and conclusion, which then prompted other publications to criticize the publications that attacked the study. Katherine Baicker, PhD, one of the senior authors, put it this understated way: “There has been substantial popular press interest in the study as well as academic attention.”

Dr. Baicker, the chair and a professor of health economics in health policy and management at the Harvard School of Public Health in Boston, and her colleagues looked at newly insured Medicaid recipients in Oregon and how they accessed health care after a state lottery gave them an opportunity to enroll. Emergency department use intensified as the number of insured individuals increased. This failed to surprise many Oregonians involved in health care. One of them, Robert A. Lowe, MD, MPH, also studied the issue. (Med Care 2010;48[7]:619.)

The findings underscore pent-up demand, said Dr. Lowe, a senior scholar at the Center for Policy and Research in Emergency Medicine at the Oregon Health & Science University in Portland. “When people have been just barely making it — because it is a choice between paying the rent or getting care — they may not get care. Then, when they have the opportunity to get care, they get it,” he said, a statement that was echoed from the state's capital in Salem to the convention hall in Portland.

That's an important message to be taken from the analyses, said Heidi Allen, PhD, a co-investigator of the study, which is believed to be the first randomized trial to examine the impact of newly acquired health insurance status on uninsured U.S. adults. The ACA hadn't yet passed when Dr. Allen and the team began their studies, but she said she was still surprised by the degree to which the results have been a topic of punditry, given that they're based on one set of statistics. Even opinion pieces in the New York Times had diverging viewpoints: “The study suggests that publicly funded insurance actually benefits people who need health care,” and “No, it doesn't; it shows the potential for spending money that won't lead to better health outcomes.” (NY Times, May 2, 2013;; NY Times, May 4, 2013;

Dr. Allen said what the study actually shows is that sick people will seek needed health care when a barrier to access is removed. After all, those who received Medicaid insurance through the lottery were more likely to be diagnosed with diabetes and high blood pressure than those who were uninsured over the two-year study period, though their blood sugar and blood pressure levels didn't show significant improvement during that time. (Oregon Health Insurance Experiment;

“It can't be said that they weren't using primary care,” observed Dr. Allen, an assistant professor of social work at Columbia University in New York City. “What we don't know is if that primary care was available to them at the time they were in pain or worried and went to the ED.” Nor do some people end up in the ED because they favor it over an office-based visit. Doctors with busy practices often are difficult to see, she said, and “that provider is going to say ‘go to the ED,’” she said.

“My overall take on the study is that it is well done, and points out a major flaw [in the ACA]; that is, insurance coverage does not equal access to health care,” said Jerris Hedges, MD, the dean and a professor of emergency medicine at the John A. Burns School of Medicine at the University of Hawaii. There is a need for sufficient primary care practitioners, he said, “who are willing and available to see, evaluate, and manage care in a 24/7 manner for this vulnerable population.”

Health care often considered appropriate for family medicine is increasingly being provided in EDs by emergency physicians while politicians and others presume that the problem is the ED's availability, said Dr. Hedges, a former vice dean of the Oregon Health & Science University School of Medicine.

“Overall, when people talk about the ‘problem of ED use,’ they are just missing the point,” Dr. Lowe agreed. “This is not a problem. It is a solution.” National data from the Agency for Healthcare Research and Quality suggest that ED costs are four percent of the American health care budget, but it's a myth that the ED is often sought out inappropriately for minor complaints, he said. Is it “inappropriate” when a fever spikes or a sprained ankle occurs late at night and the only known place to seek care is the ED? “Yet we always seem to focus on these ED costs,” said Dr. Lowe, a professor of emergency medicine at Oregon Health & Science University and in the departments of medical informatics and clinical epidemiology and public health and preventive medicine.

“I never had the sense that Medicaid-insured patients were abusing the system,” said Dr. Allen, a former social worker at an ED in Portland. She said she often saw the opposite in her clinical practice as an ED social worker and in interviews with the Oregon Health Insurance Experiment participants. People who are seriously injured often decline treatment because they fear high costs, she said. “Someone got hit by a car didn't want to come in,” Dr. Allen recalled. He knew it would be a financial hardship, she said. Another patient told her he was going to patch up his punctured hand with duct tape. Dr. Allen asked him what it would take to get him to agree to be treated in the ED. “My whole arm would have to be severed,” he replied.

The research “also highlights the need for all involved — ED staff, community-based health professionals, insurance companies, and social services — to educate newly insured patients about their plan's benefits and the best locations for using those benefits,” said Reid Blackwelder, MD, the president of the American Academy of Family Physicians. This increased utilization of services and EDs also reflects the critical need for payment reform, he said.

A key purpose of Medicaid expansion nationally — and the Medicaid-Medicare parity provision of the ACA — was to improve access for these patients and to shift costs from the inappropriate utilization of EDs to primary care physician offices, said Dr. Blackwelder, who practices family medicine in Kingsport, TN. “Unfortunately, partisan politics have negatively impacted this needed outcome,” he said, noting that parity is only guaranteed to continue through the end of 2014. “So far it has not significantly resulted in physicians accepting more Medicaid patients, mainly because doing so would create real difficulties when Medicaid payments returned to pre-parity levels,” he said.

Research by the Patient-Centered Primary Care Collaborative, a multi-interest stakeholder organization focused on primary care, is showing how the concept of patient-centered medical homes can succeed, Dr. Blackwelder said. Among Vermont Medicaid patients, for example, there were 31 percent fewer emergency department visits. Even more dramatic results can be seen in other health plans.

“Such settings might need some restructuring to increase same-day availability to Medicaid recipients,” Dr. Allen said. Longer hours, particularly evening coverage and expanded services, such as minor surgery and lab-test capability, may decrease the use of the ED, Dr. Lowe agreed.

In fact, 18 months after receiving insurance coverage, a majority of the patients tracked by Dr. Allen and her co-authors had connected with a primary care physician and had identified a primary care clinic for their care. A 2010 study by researchers for the National Bureau of Economic Research found that reductions in medical care are related to the degree to which individuals must pay for it. (

The need is “ever-growing” as more chronically ill patients are identified, Dr. Hedges said. A team approach, known as the Ho'okele concept, has been proven effective in Hawaii, and it goes far beyond reduction of ED visits. The Ho'okele team is part of Hawaii's Beacon Project, a government-funded program for innovation in health care delivery. Coordinated care organizations in Oregon have been formed to meet that same team-based, patient-outreach need.

Some research suggests the ED is very appealing to a lot of people, despite a general reputation as a place of long waits in crowded surroundings. (Health Aff 2013;32[7]:1196.) “This isn't just always a case of ‘I know the ED is there, so that's where I'm going,’” Dr. Lowe said. “It's also a preference for some, for those who say things like ‘I can go there, and I can get everything taken care of at once.’”

Another study suggested that increased co-payments for visits may be a safe and effective strategy for reducing ED use in a middle-class population, but the more vulnerable beneficiaries of Medicaid, such co-pays, along with other measures intended to cut costs, led to an eight percent drop in ED visits but an eight percent increase in the average cost for an ED visit, including a huge increase in inpatient services. (Health Serv Res 2008;43[2]:515.) “I suspect that the co-payments did discourage ED use, but people waited till they were sicker, at which point they needed more costly services,” Dr. Lowe said.

“The inescapable conclusion is that the health care system — patients, payers, and policymakers — must value and invest in creating a robust primary care-based health care system. Health care systems only work for patients if they have a strong emphasis on primary care,” said Rick Kellerman, MD, the chair and a professor of family and community medicine at the University of Kansas School of Medicine in Wichita. As a family physician who has worked in various emergency medicine facilities during his career, Dr. Kellerman, a former AAFP president, likened the Oregon Health Insurance Experiment to one piece of a larger puzzle that isn't yet representative of the entire jigsaw image.

In fact, this spring, another puzzle piece seemed to fall into place, from a study on a five-year period of increasing insurance coverage in Massachusetts by means of state health reform. The period was associated with a small but consistently higher use of the ED. Was this increase because financial barriers were eliminated? A persistent shortage of access to primary care for those with insurance? Some other cause that is not entirely clear? Like the Oregon Health Insurance Experiment, the study appears to be raising as many questions as answers. (Ann Emerg Med 24 March 2014 [ePub Ahead of Print];

“There has been much national interest in our findings given that the results have direct implications for states preparing for the full implementation of the ACA,” said lead author Peter Smulowitz, MD, an emergency physician and instructor in medicine at Harvard Medical School. “It's quite clear to me, given our findings and the recent study out of Oregon, that states should be prepared for equal or greater increases in use of the ED compared with what we witnessed here in Massachusetts,” he said.

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The Intersection of PC and EM

Where does primary care meet emergency medicine? Read about Hawaii's Ho'okele Program and other concepts for post-ACA in our iPad app on June 5 and in the Breaking News blog on June 12, both available at

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