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Medicaid patients use ER for emergencies
Contrary to commonly repeated assertions, most Medicaid patients use hospital emergency departments for emergencies, and not for routine care, according to a national study by the Center for Studying Health System Change.

“Policy makers and providers frequently point to Medicaid patients’ heavy reliance on hospital emergency departments as a problem that contributes to crowded emergency departments, long wait times and high costs, as well as poor management of chronic conditions. Recent research has dispelled misconceptions linking ED use to crowding, finding that most crowding results from emergency patients admitted to the hospital but waiting for an inpatient bed – so-called ED boarding – not a high volume of non-urgent ED visits,” the center reported.

It added that various studies have challenged the mistaken belief that most ED users have Medicaid coverage, are uninsured, or do not have a usual source of care. “In fact, people with private insurance account for most ED use, and people with higher incomes and a private physician as their usual source of care are driving ED visit increases over time,” the center added.

Other misconceptions about Medicaid patients’ ED use continue to drive policy, the center said. “In response to state budget crises, some Medicaid programs have sought to cut ED use by denying payment for emergency care viewed as unnecessary, increasing patient cost sharing to discourage visits and penalizing patients for too many ED visits – all based on the assumption that Medicaid patients commonly use EDs to evaluate symptoms that could wait for a primary care clinician to treat,” it said.

“Media coverage of so-called frequent flyers – a small number of people with hundreds of ED visits – may have contributed to commonly held views that Medicaid and uninsured patients often use emergency departments inappropriately,” the center added.

Only 10% or so of emergency department visits by non-elderly Medicaid patients in 2008 were for non-urgent symptoms, compared with about 7% for privately insured non-elderly people, according to the study funded by the Robert Wood Johnson Foundation. Researchers found that more than half of Medicaid and private insurance visits were categorized as emergent or urgent, i.e. needing immediate attention or needing attention within an hour.

The study was based on the most recent available data from the National Hospital Ambulatory Medical Care Survey conducted by the Centers for Disease Control and Prevention. “This certainly goes against conventional wisdom that Medicaid patients are using the ED for more routine-type visits,” Dr. David Seaberg, president of the American College of Emergency Physicians, commented to American Medical News.

The findings indicate an access problem, reinforcing the impression that Medicaid payments are too low to attract many providers. Only 53% of specialists in the United States were accepting all or most new Medicaid patients in 2008, compared to the 87% accepting all or most new privately insured patients.

Adults with Medicaid coverage have difficulty accessing many medical specialties, especially orthopedics, gastroenterology, neurology, and dermatology. Barriers to specialty care could contribute to high ED use by leaving no alternative source of care other than emergency departments for acute and ongoing symptoms related to chronic conditions.

“Even though these patients have Medicaid as insurance, the program still doesn’t provide them great access to primary care and specialty care,” Dr. Seaberg added. Compounding the difficulties, Medicaid patients often can’t afford co-payments, or don’t have the ability or time to get to doctors’ offices, “and consequently they have poorer health, so when they get sick they have higher acuity,” Dr. Seaberg said.

It is not only the poor who are having a difficult time seeing a physician. American Medical News quotes a recent study from the Annals of Internal Medicine which found that the total time patients spent in the ED jumped nearly 30% from 2001 to 2008, increasing from 330 million to 417 million hours. The number of high-acuity patients also grew by 23% during this period.

Non-elderly Medicaid patients do use emergency departments at higher rates than non-elderly privately insured patients. In 2008, people aged 0 to 64 covered by Medicaid had 45.8 ED visits per 100 enrollees compared with 24.0 visits per 100 non-elderly privately insured people.

“Most of the difference in emergency department use between non-elderly Medicaid and privately insured patients results from more ED use by Medicaid patients for urgent and semi-urgent symptoms that need prompt medical attention,” said Emily Carrier, MD, M.C.S.I., an emergency physician and coauthor of the recent study from the Center for Studying Health System Change.