STATES are the target of blame today for me, and the evolution of how medicine is practiced in the US. It is asserted here that the threat to a flood of patients into ERs is not greatest from those using Medicaid but from those who find themselves sick, in actual need of medical care and treatment who find themselves under-insured and facing bankruptcy in the wake of Obamacare.
Headlines for the new year abound about ER visits by Medicaid patients, and all I can think is, “News circa 1983?”
If you search, Medicaid ER use or any such jumble of words you’ll find dozens of current articles, January,2014, sprouting up from Businessweek’s, “Obamacare Medicaid Expansion to Worsen ER Burden,” to the Wall Street Journal’s, “Putting the Uninsured on Medicaid Doesn’t Cut ER Visits,” to the LA Times’, “Expanding Medicaid Increases ER Visits in Oregon Study,” all relying on a study begun in 2008 that recently appeared in the, Journal of Science.
Here’s my take. Medicaid covers ER visits and has for as long as I can remember made ER visits more popular with the Medicaid population than the general citizen population, it's not news.
This is not a “feeling,” but a fact based on reports such as the March, 1992 publication from the “Department of Health and Human Services, Office of Inspector General, Use of Emergency Rooms by Medicaid Recipients,” http://oig.hhs.gov/oei/reports/oei-06-90-00180.pdf.
Interestingly, that 1992 study cited a 1983 OIG Report entitled, “Non-emergency Use of Hospital Emergency Departments by Medicaid and Medicare Beneficiaries.”
On page 16 of the 1992 report appear recommendations including, "Increased use of managed care/pre-paid options to improve overall care access and quality, community based access to after-hours care, increased reimbursement to physicians and clinics who see Medicaid patients after hours, defining different levels of emergency room care and providing corresponding tiered pricing and reimbursement levels, triage payments to providers for screening patients not treated in the emergency room.” These were to be STATE initiatives, pre-Obamacare.
Significantly the STATES were invited to come up with programs based on the above recommendations to address the ER usage by Medicaid recipients.
While most of us are familiar with “tiered” billing and reimbursement mentioned among the recommendations, it’s less clear to me that the recommendations, especially those providing for AFTER HOURS medical care options have been created at the state level. If there are multiple places that provide such AFTER HOURS care then it’s a communication issue that requires local public service announcements informing populations through media that such options exist.
Instead, the Patient Protection and Affordable Care Act, Obamacare, which provides for the optional (as per Supreme Court) expansion of Medicaid coverage for individuals is seemingly implicated in potentially creating this problem, and that would be untrue.
Also, less clear is whether the expansion will make the problem worse through the presumption that if Medicaid users use ERs more than other patients and we expand Medicaid then ERs will be flooded by new Medicaid patients…Simplistic and seemingly “logical,” but not persuasive, at least yet.
For news to be current it has to address something new, and seemingly it is the potential for more ER use by more Medicaid patients since there will be more Medicaid patients in states that expand Medicaid coverage as per the PPACA. This assumption seems to single out Medicaid patients ignoring the key elements of Obamacare and the real risk of an uptick in ER usage created by the legislation’s flaws.
Most significantly, Obamacare has for the non-Medicaid patient pool created a system of forcing individuals to purchase health insurance without a real commitment to protecting insureds from either the ever-increasing charges by healthcare providers for health services that promises to leave significant numbers of people UNDER-INSURED, having insurance but insufficient insurance to protect individuals from financial ruin IF THEY NEED MEDICAL CARE/TREATMENT (as opposed to preventive checkups).
Under-insurance then will be the culprit for an uptick in emergency room use by non-Medicaid patients in my opinion. If you’re facing bankruptcy because you cannot pay “your share” of your medical care and treatment expenses, whether you accumulate more debt by using emergency rooms as opposed to some other location for treatment becomes irrelevant. This problem is seriously exacerbated by the bleak and total failure as far as I can tell of STATES and the Medical Profession to provide adequate alternatives to after-hours sites for needed medical care.
Emergency Rooms and Obamacare: Under-Insurance and ERs. Inadequate Insurance Coverage.
In my post of June 28, 2013, I noted that the PPACA does address the use of emergency rooms by insured individuals, (“Non-Network Emergency Rooms,” http://conoutofconsumer.blogspot.com/2013/06/non-network-emergency-rooms.html). That provision includes limited price protections for individuals who use any emergency room, even those out of their networks.
However, what is less clear is what happens to that protection if a person is admitted to the hospital as a result of the visit to the non-participating emergency room. Technically, it seems, now the person would be at a non-participating hospital liable for more of the cost of such hospitalization. It is unclear whether insurance companies will authorize a non-participating hospital’s services that result from an admission from an emergency room visit or whether we’re looking at loads of patient transfers to participating hospitals once they’re stabilized in a particular emergency room in order to try to obtain “coverage.”
Under Obamacare, we know that we can use any emergency room and receive limited cost protections. We also know that non-covered services will leave us with potentially financially crushing balance billing for provider services and tests, et cetera not covered by our insurance, whether we are in a participating hospital or not. We also know that Obamacare FAILED to significantly address the challenge of balance billing, leaving patients responsible for unreimbursed balances of non-network providers.
We also know that many plans have instituted not only co-insurance, where we’re responsible for a LARGER percentage of our hospital bill, but a co-payment that usually is required UNLESS we are admitted to the hospital.
Through its failure to address what we can be charged, balance billing, higher co-insurance percentages that we’re required to pay, reduced reimbursements, especially for non-network services and care, more hurdles to obtaining coverage including more pre-authorization required by insurance companies and bigger lists of EXCLUDED healthcare services and products that DO NOT count towards our out-of-pocket maximum in a meaningful way, Obamacare has arguably INCREASED the RISK OF FINANCIAL RUIN if you get sick.
BUT, flooding ERs because of expanded Medicaid? Obamacare is less blameworthy than the States and the Medical profession who AT LEAST have had an awareness and incentives available to address the problem since 1992.
Additionally, current news should include all provisions of Obamacare when it comes to Medicaid, including what that EXPANSION was intended to address. Here’s where a failure to understand that Obamacare is a federal plan designed to get people insured comes in.
Obamacare addressed the totally uninsured, no health insurance, private or public, and the cost of treating those uninsured that allegedly raised the costs for everyone else because healthcare providers, specifically hospitals, passed those costs onto those paying their bills, the insured in terms of higher hospital costs and the Federal government which provides money to hospitals based on the number of uninsured individuals they treat.
By expanding Medicaid, the number of totally uninsured visiting hospitals was supposed to be reduced. That’s why the PPACA also provides in section 1203, “Disproportionate Share Hospital Payments,” for the reduction of payments to hospitals treating uninsured, indigent patients.
Obviously if more people are eligible for Medicaid there should be fewer purely uninsured. In states that opted into expanded Medicaid coverage, this should be the case, more Medicaid patients but fewer purely uninsured patients. That is the number that will be relevant to Emergency Room Use as far as Obamacare goes, the number of TOTALLY UNINSURED using ERS at the time of Obamacare and after Obamacare and the number of Medicaid ER users before and after Obamacare in those regions with expanded Medicaid.
For states without expanded Medicaid, the number of Medicaid ER users should remain somewhat constant BUT those hospitals will face reduced payments from the Federal government to cover the completely uninsured since that provision was not altered by Supreme Court review.
