11 July 2012

Medicaid clients in the ER: emergent or not?

It's an article of faith in the Emergency Medicine community that patients on Medicaid over-use the ER; many would go further to say that they abuse the ER. I am (rarely) inclined not to be so judgmental on this point because the cause is in part rooted in inadequate access to ambulatory care. But the fact of Medicaid overuse of the ER is probably one of the very few things that most ER providers, doctors, nurses and techs would be in unanimous agreement on.
 So I was surprised to see Sarah Kliff over at WonkBlog link to the following article:

Study: Medicaid patients aren’t using the emergency department for routine care

Huh. That's counter-intuitive. But I am not sure it passes the sniff test. I'm about to go on shift, so I haven't had time to dissect the study yet. The gist is that Medicaid patients do visit the ED more, but not for less acute conditions, compared to privately funded patients. Here's a link to the study proper. A couple of quick thoughts:

1. This contradicts a reasonably robust body of research (for example) and the rule that applies to polls also applies to studies: if a given result is markedly different from the pre-existing data, it's more likely to be spurious.

2. I can't tell on first blush whether this was a scientific paper, peer reviewed, or from an advocacy organization. The study is published on a website for a policy think tank, Health System Change, which automatically makes me wonder about possible bias in the process. I am not implying shenanigans, but I don't automatically trust think tank papers, especially when they support a certain agenda.

3. The data source is the National Hospital Ambulatory Medical Care Survey of Emergency Departments, which is a great and reliable data source. However, I've previously seen its data abused to support the absurd claim that only 7% of ER patients are non-urgent. So I'm similarly skeptical of this result, especially when they seem to have dropped one of the triage categories (from a five-point to a four-point scale). F

Furthermore, triage level has at best, a poor correlation with the true urgency of a patient's condition. By which I mean that it provides a reasonable sort-order to guide which patients get seen first. But it is a poor guide to whether a patient needed to be seen in the ER or whether he or she could have been cared for in another, less resource-intensive setting. For example, a big, ugly hand lac may well be triaged as a green, since as long as the bleeding is controlled, it can wait, but it's not appropriate for an internist's office. conversely, an 9 month-old with a fever may be triaged as yellow or even orange, but would be perfectly appropriate for a pediatric clinic.

I'll review this in more detail when I have time and energy, but I would be very very cautious in accepting this as strong evidence against the conventional wisdom that Medicaid patients do over-use the ER.


  1. That cannot be right-

    About a month ago my hubby could not get into his primary Doctor. He had woken that morning with a rapidly growing abscess(size between a baseball and softball)his primary Dr. recommended he hit the ER since neither my husband or the Dr. thought it should go another 24 hours without care. His primary care Dr. was buried with double bookings all day.
    He went to the ER. This hospital is not in a low income area, but he walked into a packed room at 1pm on a Thursday in an affluent neighborhood. He figured 50 percent were elderly and the other 50 percent had little ones and based on the primarily spanish language being used he guessed medicaid or no insurance(though they their children should qualify for CHIP on a sliding scale) Snotty noses,coughs, sore throats...
    He was told the wait for him would be around 4-5 hours- at a large ER on a Thursday after lunch-
    He decided to try one of the 10 urgent care's in our area that are brightly lite with giant Neon signs far more visible from the freeway then the hospital tucked miles off the main road.
    He walked in, and they took him right back- not another soul in the waiting room. He received excellent care. He joked that they ought to put advertisements in the ER. Interesting enough, the urgent cares usually accept medicaid and medicare-so why don't the hospitals refer less then urgent patients to the zillion urgent cares?

    I think the ER's like their overloaded waiting rooms- otherwise, wouldn't they simply open urgent care's to triage patients to? I suppose it has something to do with insurance,laws and blah blah- that appears to be interfering with good patient care.

    Maybe that article is based on statistics in North Dakota- but in the rest of the US, they must have done some serious number twisting and juggling to end with their calculations- ugh.

  2. I read the article and you are right -- they are basing "emergent" on triage category. Chest pain is a 2 (at my facility) whether you are anxious and bipolar and 25 or 55, overweight with hx of CABG. That does not make those visit equally emergent. There is heavy political spin to the numbers and offering too generous of forgiveness for kids with snotty noses in the ED, in my opinion.

    Diane -- I sincerely doubt that those urgent care place accept medicaid.

  3. In my experience in labor and delivery at night, private patients often "called my doctor and he told me to come in and get checked" when there was very little going on. However, service patients, who are told to go to the hospital rather than being given an after hours phone number, are very likely to actually be in labor. There are a significant number of "She called me 3 times tonight so she's a direct admit and I'll send her home in the morning" from private attendings as well.

  4. The problem is more a lack of convenient access to ambulatory care. There are clinics and urgent cares around, but they have hours, they want you to make appointments and keep them, or if you are a walk in you have to wait. Also they do health teaching. The ER has none of the hurdles to deal with and it's free (sure they send a bill, but the folks we are talking about don't usually own homes or worry about credit ratings so the bills don't really mean anything).

    Those that go to the ER for primary care do not do so only because there are no other options. They do it because the ER is the easiest option. Unless we open so many primary care clinics that they become more convenient than the ER we won;t be getting most of those folks to change where they seek care.

    Also, I'd second the comments about triage category. It's not really a good way to measure anything, it's only value is in sorting (hence the name). I triage every chest pain as emergent and every one starts down the chest pain pathway. Most very quickly are moved off that pathway or become very soft rule outs, very few are actually having an emergency. The same is true with fevers in infants, patients that meet trauma criteria, and others. I think a much more useful metric would be discharge (or admission) diagnosis.

  5. There are some triage nurses that won't make anyone a "5" no matter what. A URI x 1 week in a 20-year-old with normal vitals is a "4" because they might need a chest XR. Also triage scores 3,4,5 are based on who the doctor is that day too. Both viral sore throats and a broken arm are "4"s.

    Chronic abdominal pain x 6 years is a "3" usually because our doctors over-order tests, etc. Triage scores 3,4,5 are based on the projected usage of resources, not really how sick they are.

    Stupid study. Yawn.

  6. Let's see....in reading the study, there seems to be a su-text that middle class insured parents know enough about health care basics to recognize that mild GI problems, green snot in an afebrile six year old, and small lacerations on the upper arm do NOT require a visit to the ER. Uninsured/Medicaid seems to indicate lack of this knowledge and/or unwillingness to deal with other treatment options in the morning.

    Oh....and the semi-valid point that most people with health insurance USUALLY do not have serious or chronic illnesses (except for pregnancy) so that the same diabetes or CP that GOT the paitent the Medicaid in the first place makes him/her sicker by definition when they do come to the ER for something else.


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