Tuesday, July 13, 2010

The Coming Crisis In Emergency Care

Cross-posted from The Agenda on National Review Online.

As I wrote last week, emergency room visits in Massachusetts have increased, despite the fact that universal health care was supposed to solve that problem. PPACA is likely to nationalize the phenomenon. John Goodman has an excellent piece up on the Health Affairs blog in which he explains why this happens. It turns out that it is Medicaid patients, rather than the uninsured, who clog emergency rooms:
As we pointed out in a recent National Center for Policy Analysis (NCPA) Brief Analysis, the use of the emergency room by uninsured patients is not that much different than usage by the insured. The heaviest users of the ER (in proportion to their numbers) are Medicaid patients, probably because Medicaid rates are so low that physicians are not anxious to see them. And the reason why that is important is that more than half of the people who gain insurance under the new health reform bill will enroll in Medicaid.
Health insurance leads to more, not less, utilization of health care.
In general, people with insurance consume twice as much health care as the uninsured, all other things equal. The trouble is that the new health insurance law has no provision for increasing the number of health care providers. As a result, when people try to increase their use of physician services, many will be disappointed and a large number are likely to turn to the emergency room when they cannot get their needs met at doctors’ offices.
The conflation of health insurance with access to health care is one of the biggest epistemological problems with the progressive approach, one that the ensuing decade will lay bare.


  1. The talk I've linked to below is worth a listen as it speaks to an underlying issue with the Massachusetts example that is the distortion in our current payment incentive system has caused a 70/30 specialist/primary care MD split (90/10 in terms of graduating MDs so it's getting worse). The rest of the world has a 50/50 split.

    The Mass example shows the pent up demand for h/c coupled w/ a shortage of primary care docs. Multiply this by 50 and that's what will happen nationwide. The good news is we have enough MDs...just not the right mix. I'd argue that the primary care doc is the "quarterback" of one's h/c yet they get paid like a "special teams player" so that's a key reason why debt-ridden MD grads avoid it.

    Another fundamental issue is the extreme expense burden we have using health insurance (unlike every other type of insurance) for the day to day rather than the rare. We don't call up State Farm when we take our car in for a tune-up so why do we involve insurance for a regular checkup? Google "health insurance's bunker buster" where I go into more detail on this and my POV on the good news (in the long-term; short-term it will be painful) in the unintended consequences of the new health law.

    Here's the link to the speech ref'ed above
    Ted Epperly
    M.D., Board Chair, American Academy of Family Physicians, and Program Director and CEO, Family Medicine Residency of Idaho
    From his physician’s office in Boise to the Oval Office in Washington, D.C., Dr. Ted Epperly has been a strong voice for health care reform and Family Medicine education and research. In 1980, he joined the American Academy of Family Physicians, which represents 95,000 family physicians nationwide. Two years ago, he became AAFP president and currently serves as board chair. In this capacity, he has testified before Congress and met with President Obama on health care reform legislation. Dr. Epperly will give City Club members an insider’s view of this legislation, focusing on the delivery aspect and how Americans can make reform work.
    Ted Epperly earned his B.A. (magna cum laude) from Utah State University, graduated from the University of Washington School of Medicine in 1980, completed his residency in Family Medicine at Madigan Army Medical Center, Fort Lewis, Wash., in 1983 and held a faculty development fellowship at the University of North Carolina until 1986. He retired July 2001 as a colonel after serving 21 years in the U.S. Army. Dr. Epperly has served on the Residency Review Committee for Family Medicine, which accredits the nation’s Family Medicine Residency programs, and has published more than 40 articles and book chapters.

  2. Two pieces worth reading/listening to related to this
    1. A talk by the head of the American Academy of Family Physicians that touches on the Mass experiment http://www.cityclubofboise.org/2010/100629/
    2. Google "health insurance's bunker buster" that touches on the extreme expense burden we pay for using insurance in healthcare for the day to day rather than the rare. Do you call State Farm when you take your car for a tune-up? Then, why use insurance for a regular check-up. That adds a 40-50% cost burden that adds no value.

  3. Thanks for these. I agree with your point about comprehensive insurance and the need for more consumer-driven health care; I talk about it at the Health Tank (http://www.avikroy.org/p/health-tank.html).