By Sandhya V. Shimoga, Ph.D., M.S., M.Sc.
One of the main arguments behind the Medicaid expansion is the premise that increased access to insurance, and thus to primary care, would entice people with low-acuity conditions to seek care from PCPs rather than emergency departments (EDs). A counterpoint is the moral hazard argument that lowering costs to the patient can increase the use of ED services. Despite the political rancor and policy discourse in this area, the actual evidence base is mixed and sparse. A recent and much discussed Oregon Health Insurance study shows increased ED use among the newly insured, even for conditions that could be treated in outpatient primary care settings. On the other hand, a study of California’s Low Income Health Program suggests that the increase in ED use right after acquiring insurance can be temporary and decreases after a year. The main difference between the Oregon expansion and the California program is that the latter included a mandatory assignment of patients to a medical home, the availability of care coordinators, and easier access to specialty services. These results make us wonder whether this medical home model was the mediating factor that seemingly reversed the results in these examples.
Adding to the growing body of literature in this area, a recently published study by Capp et al. (Medical Care, June 2015) explores what percentage of Medicaid enrollees prefer to use EDs rather than PCPs for low-acuity conditions and the potential reasons behind choosing ED over their PCPs. This exploratory study, conducted in a large, urban academic ED in 2012, combines survey data with claims data for adult Medicaid enrollees who had a PCP. The study results indicate that among the 95 adults who met inclusion criteria, less than half (43.5%) would have preferred to go to their PCP if they had an appointment available, and 11.6% of participants were not satisfied with their PCP. The main reason (for about 48% of the patients) for using the ED turned out be the technology or specialty care that is readily available in the ED setting. Other notable reasons included being in pain (15%) and the perception of receiving better care in ED than in their PCP offices (12%).
While this study had a small sample size and is an exploratory study conducted in an academic medical center setting, it reveals that about half the patients using ED would benefit from PCP services delivered in an integrated setting, with some specialty care and services such as labs and basic radiology services. A considerable portion (11.6%) of the survey participants expressed dissatisfaction with their PCPs, including feeling neglected or not cared about by their PCP, which points to poor quality of primary care. The results magnify the concern that the perceived benefits from having access to insurance might be drowned out by the lack of quality PCP care, resulting in overall higher healthcare spending that might not result in any better health outcomes.
The number of Medicaid enrollees has increased in the past two years, with overall Medicaid enrollment growth of 8.3% in FY 2014 and 13.2% in FY 2015 across all states, according to an issue brief from Kaiser Family Foundation. This growth is even more pronounced in states that have expanded their Medicaid coverage under the ACA. To counter the potential demand surge due to coverage expansion, the ACA has authorized the Medicaid Health Home State Plan, which provides enhanced federal funding for states to design medical homes to provide integrated comprehensive care for Medicaid beneficiaries with chronic conditions. As of May 2015, 19 states have had 26 approved medical homes that are in various stages of development and implementation. While this emerging model is certainly encouraging, it is not yet adopted in all the states, including ones that have enthusiastically taken up Medicaid expansion (e.g., California and Nevada). This difference in Medicaid enrollment growth and potential lack of comprehensive services does not bode well for utilization of ED services. Going forward, it will be of interest to policy makers and researchers alike to figure out whether the areas serviced by these medical homes see lower ED use for low-acuity conditions and whether patient outcomes improve as a result of change of care patterns in these areas.
Sandhya V. Shimoga is an Assistant Professor in the Department of Health Care Administration at California State University, Long Beach.