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  One problem with medicaid expansion so far: ER use is not declining
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Author Topic: One problem with medicaid expansion so far: ER use is not declining  (Read 191 times)
marty
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« on: July 09, 2017, 11:51:18 pm »

Note: I am not trying to use this thread to bash medicaid expansion in general (there are benefits and downsides), but rather to try to discuss why it appears that, after 2-3 years of most states expanding it, usage of the ER in place of general practices is not declining.

ER usage has long been viewed as a problem because it costs a lot more, and studies show that busier ERs are associated with negative health outcomes due to wait times, unwillingness to wait, and likelihood of contracting other diseases from others.  Medicaid expansion was, in theory, supposed to be a positive in this area because people that were previously uninsured and using the ER would not be visiting less costly doctor offices instead.

The wapo article is behind a paywall, so I'll link a few more articles on it for you to read

https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwiGypWD8_3UAhVqyoMKHd-cBiwQFggmMAA&url=https%3A%2F%2Fwww.washingtonpost.com%2Fnews%2Fwonk%2Fwp%2F2016%2F10%2F19%2Fmore-evidence-expanding-medicaid-increases-emergency-room-visits%2F&usg=AFQjCNEx1t42N-BbQjD5BCVvJq0f3sxfXA


https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&cad=rja&uact=8&ved=0ahUKEwiGypWD8_3UAhVqyoMKHd-cBiwQFggvMAI&url=https%3A%2F%2Fwww.forbes.com%2Fsites%2Ftheapothecary%2F2016%2F10%2F20%2Fmedicaid-expansion-causes-surge-in-er-visits%2F&usg=AFQjCNFYY8aWCIxOZQUBs53eOq0kPheh_w

https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=6&cad=rja&uact=8&ved=0ahUKEwiGypWD8_3UAhVqyoMKHd-cBiwQFghBMAU&url=http%3A%2F%2Fwww.modernhealthcare.com%2Farticle%2F20170616%2FNEWS%2F170619908&usg=AFQjCNFOifwVHNb6A4CshtUygCfs013gmA

My question is this: what can we do, policy-wise, do make medicaid patients less likely to use the ER?

A few possible solutions,

1) higher reimbursement rates medicaid pays to physicians and specialists: this will increase the amount of doctors that accept it, which will make it easier for medicaid patients to find a doctor they like, and less likely to resort to ER.

2) increase ER copay that medicaid patients have to pay. A friend of mine is a pharmacist and he posted this on Facebook in a conversation we were having:

Quote
Had a lady a few weeks ago come in to the Pharmacy and asked for a recommendation for her childs' fever..I said liquid Ibuprofen... she asked me to go get a bottle and wanted to know the price... It was 7 dollars or something.... she then asked " Medicaid pay for that?" I said no mam not without a prescription...

her response."I'll just take him to the ER then."

By having patients pay a larger % of the cost of ER care, it would make it less costy, relatively, to visit normal practices instead of the emergency room.

What does this board think we can do about this?

Note: please don't try to think I am coming out against or strictly in favor of m'caid expansion. I want to talk only specifically about the ER usage issue and what we can do about it.
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pbrower2a
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« Reply #1 on: July 10, 2017, 01:52:26 am »

We need to offer low-cost alternatives to ER. One is to have no-frills clinics staffed by physician's assistants (PA's). Yes, we know their limitations (clinics and PA's), but they can do much that physicians can do.

For very poor people, liquid ibuprofen at $7 for one incident could be a hardship. Poverty is a big problem in America, and it is much of our medical problem.

Who knows -- why not put something like liquid ibuprofen on a list of items eligible for food stamps? Why not also toothbrushes had toothpaste? 
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Koharu
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« Reply #2 on: July 10, 2017, 06:54:51 am »

A lot of this is just what I would call habit.

People in poverty don't realize that you're supposed to have a primary care physician. You go to your doctor for regular check ups? What?! You only go when there's something wrong! And then, because there's something wrong, you go to the ER because there's a wait to see a doctor otherwise!

This was how I grew up thinking, and it's how most low-income people I know behave. There needs to be a major education push in regards to how to use healthcare appropriately and not just for catastrophic events--and that the ER isn't for a lot of stuff. In addition, we need clinic hours outside regular business hours. Lower-income folks often struggle to make it to places that only have regular business hours.

In my home community in southern Minnesota, there are two walk-in clinics. One in a drug store and one in Wal-Mart. Their business is absolutely booming. They have hours outside of regular business hours, and while they are aimed at "urgent" care, they also deal with other issues, and refer to the local hospital when necessary. They're not perfect by any means, but they've greatly reduced the load on the local ER.
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Southern Senator North Carolina Yankee
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« Reply #3 on: July 10, 2017, 07:28:05 am »

The simple problem is that we already have the long lines and shortages that are being wailed about regarding national healthcare.

It is coming in the form of "we are sorry, we are not taking any new patients right now".


Medicaid is fundamentally flawed in this regard, and while I support the expansion, I think we would be better off phasing out Medicaid and replacing it with a 100% premium support subsidy, and with a public option in the mix among a range of competitors. Try getting that through Congress! Tongue

That being said, having the Medicaid expansion does 2 things that are beneficial, because that ER cost is now covered.

1) That cost is not being spread to other patients to cover uncovered treatment.

2) The Hospital won't be forced to close its doors because of uncompensated for care.

Because Hospitals have to take patients regardless of coverage, that means we essentially have universal "sick" care implemented in the dumbest way possible (an unfunded mandate).

It is cheaper overall, and cheaper long term to cover those patients and keep the hospitals open, then it is to let hospitals and doctors go out of business. Seeing as we already have shortages, that would only make it worse.
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