Health Policy Journal Club, Health Policy, Insurance

Health Policy Journal Club: Myths About ED Overuse By The Uninsured

Uninsured patients use the ED as often as the insured yet use other care much less.

An oft-cited argument in favor of expanding Medicaid coverage is that the uninsured consume a disproportionate share of emergency department (“ED”) resources, causing overcrowding and dangerously increased wait times. A recent article in Health Policy, however, challenges this widely-held assumption.

Researchers using large nationally representative datasets found that ED utilization rates are substantially similar among the insured and uninsured. In 2013, 13.7% of insured adults visited an ED at least once, as compared to only 12.2% of uninsured adults.  The average number of visits per capita was 0.18 for uninsured adults versus 0.20 for insured adults. When insured patients were further stratified into publicly and privately insured groups, rates of ED utilization were similar, but slightly lower, in the privately insured (11.1%) than for the uninsured (12.2%). Adults on Medicaid exhibited much higher rates of ED utilization—29.3% made at least one visit that year.

Patterns of outpatient visits, however, diverged sharply between the insured and uninsured. Only 41.8% of uninsured adults made at least one outpatient visit in 2013, versus 76.6% of privately insured adults and 74.5% of adults on Medicaid. Despite the stark difference in outpatient service utilization, uninsured and insured patients visited the ED under similar circumstances. The percent of visits categorized as nonemergent based on final diagnosis was similar between uninsured and insured adults (23.0% and 22.5%, respectively), as was the percent of visits classified as emergent but capable of being treated by primary care (33.2% and 32.8%, respectively). A similar proportion of visits were categorized as “ED care needed” based on final diagnosis in the uninsured (26.4%) and insured populations (28.9%).

A potential shortfall of this study is that it only included data up to 2013, and the ACA individual mandate did not go into effect until 2014. It is unclear whether individuals who have ignored the mandate will exhibit similar healthcare utilization patterns as previous uninsured populations. Moreover, this year’s repeal of the mandate may further alter the characteristics of the uninsured population. Additionally, this study excluded pediatric patients, whose patterns of healthcare utilization may differ. While there may be many compelling reasons to expand Medicaid, relieving ED congestion and reducing nonemergent ED usage are not among them.

PMID: 29200330

ARTICLE: Zhou, R., Baicker, K., Taubman, S. and Finkelstein, A. (2018). The Uninsured Do Not Use The Emergency Department More—They Use Other Care Less.

There is a popular perception that insurance coverage will reduce overuse of the emergency department (ED). Both opponents and advocates of expanding insurance coverage under the Affordable Care Act (ACA) have made statements to the effect that EDs have been jammed with the uninsured and that paying for the uninsured population's emergency care has burdened the health care system as a result of the expense of that care. It has therefore been surprising to many to encounter evidence that insurance coverage increases ED use instead of decreasing it. Two facts may help explain this unexpected finding. First, there is a common misperception that the uninsured use the ED more than the insured. In fact, insured and uninsured adults use the ED at very similar rates and in very similar circumstances-and the uninsured use the ED substantially less than the Medicaid population. Second, while the uninsured do not use the ED more than the insured, they do use other types of care much less than the insured.

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems.

As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula.

This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.

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