11 June 2012

Medicaid and the power of a relationship

Arthur Kellerman on the Washington State Medicaid ER ban, in the NEJM.

Key graf:

The genesis for the idea of denying payment for nonemergency ED visits is frequently traced to the research of John Billings, a professor of health policy at New York University. In the early 2000s, he developed an algorithm that used discharge diagnoses to identify ED visits that are “ambulatory care sensitive.” In his view, ambulatory care–sensitive visits fall into one of two groups: those that are “primary care treatable,” meaning that the problem could safely be managed in a doctor's office, and those that are “primary care preventable,” meaning that the visit might have been averted if care had been provided sooner. An uncomplicated lower urinary tract infection would be considered “primary care treatable.” An asthma flare-up would be categorized as “primary care preventable.”
Unfortunately, policymakers have generally misinterpreted Billings's findings. The fact that many ED visits could be managed in primary care settings does not mean that such care is available. In fact, Billings himself asserted that high rates of ED use for ambulatory care–sensitive conditions are a strong indicator of poor access to care — not poor judgment on the part of patients.

I couldn't have said it better myself. Which, I suppose is why I'm writing here and he's writing in NEJM. One other nugget I wanted to expand on — Kellerman writes:
Perhaps the Authority's actions will encourage Medicaid beneficiaries to forgo nonemergency ED visits and instead forge enduring relationships with primary care providers.
This is an important point that goes beyond access to care — note the words "enduring relationships." That's a pretty huge element of primary care. I've been with my PCP for a dozen years. (Oddly he was medicine chief resident in my university when I was a 3rd year med student, in a university 2500 miles away. Life is weird.) The family practitioner who delivered me was still my doctor when I got accepted to medical school. These relationships are enduring and that's a big part of why they are so valuable. They are also a big part of why med students go into primary care.

Now our community has decent access to primary care. It's not great, but I am sure it's better than some places. We have a large and reasonably well-funded network of Community Health Centers (many of which were funded by Obama's ARRA and ACA, but that's another topic). They're overburdened; the demand exceeds their capacity, but they do good work with limited resources. Unfortunately, the doctors there are not well paid, many are doing public service to get loan forgiveness, and they tend to come and go pretty frequently. They have decent access for acute care, again, they do their best, but most urgent visits get shunted to an urgent care area staffed by mid-level providers, not the regular medical staff.

Commonly enough, I see CHC patients in the ER with, as Dr Kellerman calls them, "ambulatory care sensitive conditions." Cutting the BS, these are trivial things to go to an ER for. Cough/URI. UTI. Flu. Medicine refills. A rash. Back pain. We all know the non-emergency crap that fills our ERs, and despite ACEP's dishonest PR claims, it's a hell of a lot more than 7% of ER cases.

So why do these patients come to the ER instead of accessing their established primacy care doctor? They do have them, so what's the issue? Well, I make it a point to ask them, politely and non-judgmentally. Part of it is my curiosity, and part is to encourage them to actually go there in the future. The answers I get generally fall into about three distinct categories:

  • Anxiety
  • Access
  • Absence of Relationship

Anxiety is straightforward enough: "My baby (18 months old) had a fever and a cough and I'm an 18 year old single mother and I was worried." Fair enough. Access is also a common issue: "I called the clinic but they didn't have any openings." Again, I can't argue with that. But I have been surprised at how often the reason patients give for bypassing their PCP and coming to the ER is that they don't feel like they have a relationship with an actual person: "Every time I go there I see someone different."

This is actually huge, and commonly overlooked. I go to see my doctor because I like him and trust him, and he knows me. If I had to go to a clinic where I'd never see the same person twice, well, the added value of that over an ER is nil, and on top of that you have to call and get and appointment and wait for the appointment, while the ER is just "drop in convenience." From the perspective of the patient, especially a medicaid, "cost-insensitive" patient, I can see why they come to the ER.

I don't know what the solution is. I don't see more money coming into the care-for-the-indigent tier of our two-tier health care system, and as more patients come onto medicaid in coming years, I can only assume the access barriers and the depersonalization of the CHC system will worsen before it gets better.

We'll be here to see them in the ER. Hopefully the state won't punish us by refusing to pay.


  1. I would add that part of the problem is also the fact that to go to a primary care doctor you have to make and keep appointments and many of the folks that come in, especially at night, either can not or will not do that.

    The ER is there 24/7, you can go whenever you want, it's free (so long as you don;t care about credit rating), and it's historically quite generous with the opiates.

    THere are a whole lot of folks out there who have no motivation at all to go to a primary care doctor. To them the ER is a much better deal.

    Nothing in Obama Care or in the ridiculous measures that our state is taking will do anything to change that.

    Those same people are going to continue to go to the ER for all their health needs unless we turn them away at the door, which despite the current changes is policy is unlikely. Even then they are likely to try another ER, and another before going to a primary care doctor.

    I have no idea what the solution is, or even if there is one, but I don't think the current measures will make a dent in the problem.

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  3. I agree with Vince...in my ER it seems that people choose the ER over the clinic out of convenience: no appointment to make and keep, no having to pay a sliding-scale amount prior to being seen, can usually get some sweet meds, etc.

    As for the government not paying for non-emergent ER visits...how does that work with EMTALA in the picture?

  4. Most of the patients I see call their doctors and they tell them to go to the ER. That is why Monday is historically our busiest day. We see 3 days worth of sick. Patients who get sick over the weekend wait until monday morning, call their doctor and get told "go to the ER" no matter how minor or routine their complaint is. 20 year old kids with chest pain, oh no go to the ER! Or else if their doctors do see them in the office, then they send them to us to do their workup. And then they call up the triage nurse and say "they need to go right back, I told them they shouldn't have to wait." Excuse me, but their are 30 patients in my lobby and I'm doing triage and you don't get to decide the order they go back in.


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