12 July 2010

Annals of Crappy Journalism, part 27

This article was sent to me by no fewer than a dozen people, including ACEP and my wife.  So I thought it was worth a response.  It's an AP article with the splashy headline:

Health overhaul may mean longer ER waits, crowding

Interestingly, the article itself is mostly accurate and well-written.  It quotes a friend of mine, Dr Eli Berg, and also Dr Arthur Kellerman, who is rightly highly respected in the field, and it accurately lays out the stresses and challenges in running an efficient ER and trends leading to overcrowding. So on the article itself, I have little quarrel.  With one exception: the headline is misleading and not factually supported by the article itself.

The central thesis of the piece is that the healthcare law will increase ER overcrowding.  While the article nicely describes the causes and problems related to overcrowding, it fails to provide any basis for its suggestion that health care reform will cause further overcrowding, nor does it compare the future-more-overcrowded ERs to the case in which healthcare reform had not passed.

The sole support for the central thesis is the vague reference that Medicaid patients are more likely to use the ER, and also that the Massachusetts experience shows ED volume growth "a bit" ahead of national trends.  Moreover, the author ignores the provisions of the health care law which would alleviate the ER burden (increased training slots for primary care and increased investment in community health clinics, for example).  This is particularly relevant given the implication that the expansion of Medicaid will drive ER use. Medicaid patient overuse ERs (in part) because they have limited access to primary care physicians' offices -- an expansion of Community Health Clinics would be expected to directly mitigate that driver of volumes.  Similarly, the author never examines the revenue effects that the healthcare reform law will have on ERs. Increased volumes combined with improved payer mixes should provide facilities more ability to invest in their ERs, which are by and large chronically undercapitalized, in order to meet current and future demands.  Which effect will be greater is an interesting question that has not been tested to my knowledge, but the honesty of the article is compromised by the fact that the author cherry-picks facts to support a predetermined conclusion.

It would be wrong, of course, to deny the reality that ER visits will continue to increase in coming years. It was pointed out by many during the reform debate that numerous aspects of this bill did not go far enough and that it would be only a "first step" in addressing the problems we have in health care.  My cynical side suggests that if reform opponents had engaged with something more constructive than "death panels" the final product might have been better.  That, however, is water under the bridge.

My issue here, however, is with the misleading headline, which smacks of an agenda to undermine support for the still-contentious reforms.  It's a newsworthy piece, since the fact that the ER crowding crisis is not going away and that more reforms are needed is important. A more accurate headline would have been:

Despite health overhaul, ER crowding to worsen

Which would have dovetailed nicely with suggestions from policy-makers and leaders like Dr Kellerman of things that the government should do to improve the problems facing the nation's ERs.  Instead readers are left with the false impression that the reform bill somehow is making things worse, and no idea how things could be improved.

It's disappointing, because you don't often see such good reporting on the ER crowding crisis in the the lay media, and this otherwise-excellent article will have readers take away exactly the wrong conclusion.


  1. A better headline might be "Health overhaul not actually a health overhaul...it's just paying more to cover more people...all the talk about driving costs down and giving people more coverage for less was pure BS...looks like the critics that said this was a crock were right"

    Kind of tough to fit, but it's accurate.

  2. Respectfully disagree with your take, SF.
    What the "overhaul" will result in is more people in government healthcare programs, mostly Medicaid. In most states, some or most docs will not take Medicaid patients cause they lose on each visit, so where else will these patients go?

    The article does note funding for 16K more "providers." Doubtful that funding more providers will help. The reason for the shortage of primary care docs is that laws and regulations make it very unsatisfying to provide primary care, and difficult to make a reasonable living. Generating more providers does not deal with that problem.

    As an ER physician, you may not want to see an increase in the number of people in the waiting room whose problems are nowhere near emergent or urgent- problems that can and should be managed in the office of a Family Physician- but if that FP continues to lose $5 or $10 on every one of these patient visits, her door will not exactly be wide open for them. They will (continue to) show up at the nearest walk-in clinic aka Emergency Department.

  3. Anon 9:53 -- yeah, there should have been better cost controls in the bill, but the "death panels" line of argument and the town hall hecklers put an end to that, didn't they?

    jb -- Of course, the health reform act does provide for medicaid primary care services to be paid at medicare levels, so that may alleviate the access problem that medicaid patients suffer. Of course medicare rates are also problematic.


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