Author Topic: Obamacare’s Next Task: Break Our Dependence On The Emergency Room  (Read 308 times)

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Offline mystery-ak

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http://talkingpointsmemo.com/cafe/obamacare-s-next-task-break-our-dependence-on-the-emergency-room

JUNE M. MCKOY – APRIL 10, 2014, 8:03 AM EDT1234

The White House was quick to tout the 7.1 million Americans who enrolled in the Affordable Care Act’s (ACA) health care benefits last week, and this week’s cover of The New Yorker depicts President Barack Obama’s revenge on Republicans now that healthcare appears to be working. Despite this messaging, Washington, the media, nor the law itself can guarantee that health care will be accessed in the intended way.

Even with the surge to sign up, the fledgling ACA faces many challenges. Perhaps the greatest is the overwhelming number of people who seek care in the Emergency Department (ED), many of whom rely on it not for emergencies but for primary care. Understanding the psychology of why so many people seek care in the Emergency Department first is key to solving the problem. Otherwise, the devastating costs of overuse could sink the ACA all together. In a 2007 report supported by a grant from the Health Resources and Services Administration, Bureau of Primary Health Care found over $18 billion is wasted annually because of avoidable ED visits. To be sure, that cost is now much higher.

For minorities and patients from lower socio-economic groups, the ED is the great equalizer. It is the place where the rich and the poor converge under one roof and receive equal attention. While most visits to the ED are neither clearly non-urgent nor clearly emergent, for those with a long-standing pattern of visiting the ED for a variety of ailments from chest pain to a stubbed toe, change in behavior will be difficult to achieve.

Overuse of the ED is predicated on several factors. Many Americans live below the poverty line and are employed in low wage positions from which they cannot take time off. For the working poor, the ED is the most convenient way to receive healthcare with 24/7 access and no appointment necessary. According to a 2012 National Health Interview Survey, approximately 80 percent of adults who visited the ED over a 12-month period did so because of a lack of access to other healthcare providers.

Simply providing people with insurance cards will not decrease use of the ED because care there is convenient. Access is therefore not a question of insurance, but more so a question of comfort, ease and trust.

For many African-American patients, the root cause of their mistrust of the healthcare system goes back to Tuskegee — a controversial 40-year study of African-American men who thought they were receiving free government healthcare while their diseases went untreated. Many African-Americans still believe that they receive lower quality care in the out-patient clinics and are wary of physicians in those settings.

Furthermore, fear of being shunted to mid-level providers in outpatient clinics, such as physician assistants and nurse practitioners, albeit highly qualified ones, is real. Many in the African-American community perceive this conveyance as second-class medical care. In reality, unlike clinic physicians, ED physicians work so quickly that they lack the time to form fixed positive or negative impressions of the patients they see.

As a physician in an urban area, I am concerned that the primary care physician shortage I see may block access for thousands of patients, both old and young, despite the fact that they are now armed with health insurance cards. Some 8,000 additional physicians — a 3 percent increase in the current workforce — are required to absorb insurance expansion according to a 2012 study in the Annals of Family Medicine.

Certainly, a systematic infusion of new medical schools focused on primary care will lead to a growth in the primary care physician population — but that will be approximately eight years from now. Americans need primary care access right now. Thus, having a health insurance card and having health insurance coverage are antithetical concepts.

Furthermore, expanding the physician workforce can only work if that group is truly diverse and can provide culturally competent care addressing ethnic, age, and racial disparities that are embedded in the health care system. Forgiving the student loans of graduating physicians in exchange for their work in medically underserved urban and rural areas is a potential solution — though a futuristic one.

An 18-month study of thousands of low income Americans in Oregon with Medicaid-based health insurance (an ACA-like program) surprisingly showed a 40 percent increase in ED use, meaning that people with insurance coverage went to the ED even more than they did before they had insurance. Published in the journal Science, the study inspired politically motivated calls to “flee from the ACA.” For me, these results do not support abandonment of the ACA. Rather, they highlight the importance of understanding why so many patients turn to the ED first. Encouraging behavioral change has to be a priority if the ACA is to achieve one of its major goals of decreasing costs and providing true access to care.

To be sure, behavioral change will not be quick. The institution of tangible changes, including night clinics (akin to night courts), week-end clinics (including Sundays), Mini-EDs, incentives for using ambulatory care practices, navigators to aid patient choices, and primary ambulatory care clinics in intimate physical proximity to EDs are all needed. Two of the fundamental pillars of the ACA are better health at lower cost.

It will require years of re-education and an army of out-patient offices willing to build flexibility into their practices to see a significant shift from ED care to office based care. No one will argue that emergency visits should only reflect true emergencies, yet indiscriminate use of the ED continues unabated. Expanding the primary care enterprise is desperately needed, but it may take years before we see if the initiatives outlined herein are good medicine for what ails the ACA.

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Online Oceander

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Re: Obamacare’s Next Task: Break Our Dependence On The Emergency Room
« Reply #1 on: April 13, 2014, 11:34:36 PM »
Hmmm, one more nascent tyrant/social engineer.

Offline truth_seeker

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Re: Obamacare’s Next Task: Break Our Dependence On The Emergency Room
« Reply #2 on: April 14, 2014, 12:23:47 AM »
Last July I went by ambulance to a top hospital Emergency Room, with a shattered shoulder, and possible head-neck injuries.

I did NOT see an MD that evening at all, but instead a PA, with the result that I go home and see an orthopedic shoulder specialist in the morning. (an issue being the need for repair, or replacement--got repair).

Throughout 8 months of follow-up treatment, I've seen the PA as much, as I've seen the MD that performed the necessary surgery.

In my household, we try to use medical services sparingly only when needed, and NOT go to the ER for every non-urgent situation.

I'm okay with that. I don't feel shortchanged or discriminated against.

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Re: Obamacare’s Next Task: Break Our Dependence On The Emergency Room
« Reply #3 on: April 14, 2014, 01:46:05 AM »
Last July I went by ambulance to a top hospital Emergency Room, with a shattered shoulder, and possible head-neck injuries.

I did NOT see an MD that evening at all, but instead a PA, with the result that I go home and see an orthopedic shoulder specialist in the morning. (an issue being the need for repair, or replacement--got repair).

Throughout 8 months of follow-up treatment, I've seen the PA as much, as I've seen the MD that performed the necessary surgery.

In my household, we try to use medical services sparingly only when needed, and NOT go to the ER for every non-urgent situation.

I'm okay with that. I don't feel shortchanged or discriminated against.

I would of checked WebMD first. They seem to have a comprehensive list of doctors in all the different parts of the country.
« Last Edit: April 14, 2014, 01:49:21 AM by SPQR »

Online Oceander

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Re: Obamacare’s Next Task: Break Our Dependence On The Emergency Room
« Reply #4 on: April 14, 2014, 08:14:57 AM »
Last July I went by ambulance to a top hospital Emergency Room, with a shattered shoulder, and possible head-neck injuries.

I did NOT see an MD that evening at all, but instead a PA, with the result that I go home and see an orthopedic shoulder specialist in the morning. (an issue being the need for repair, or replacement--got repair).

Throughout 8 months of follow-up treatment, I've seen the PA as much, as I've seen the MD that performed the necessary surgery.

In my household, we try to use medical services sparingly only when needed, and NOT go to the ER for every non-urgent situation.

I'm okay with that. I don't feel shortchanged or discriminated against.

What's a PA?  (forgive me my ignorance).

Offline aligncare

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Re: Obamacare’s Next Task: Break Our Dependence On The Emergency Room
« Reply #5 on: April 14, 2014, 08:25:48 AM »
Physician's assistant. They are more than a nurse but less than a doctor, so to speak.
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Online Oceander

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Re: Obamacare’s Next Task: Break Our Dependence On The Emergency Room
« Reply #6 on: April 14, 2014, 08:35:19 PM »
Physician's assistant. They are more than a nurse but less than a doctor, so to speak.

Thanks!  I am in agreement that people like PAs and RNs should start providing a lot more of the frontline care than they do now.  It seems to me that one of the things nurses are good at (amongst many, many other things) is triage:  making quick decisions about who desperately needs a doctor's undivided attention, who should be examined by a doctor in fairly short order, who has injuries that don't require primary examination by a doctor, but examination and diagnosis by a PA or RN, followed by a review of the proposed treatment by a doctor, and who really just needs some TLC:  a little hand-holding, some antiseptic cleaning, removing a little grit from a skinned knee, a couple of bandages, and a lollipop.

One of the things that I've noticed have just begun sprouting up around LI are the "urgent care" clinics.  We took my daughter to one last fall when she said she could barely hear out of one ear after she had a short but strong cold.  We walked into the clinic, waited for half an hour, and were then seen by someone - in this case a doctor - who did a quick examination, made a diagnosis, and suggested that we follow up with her pediatrician when we could but without a lot of delay.  I was very impressed because it was exactly the sort of care we needed in that situation:  we needed to be seen by someone quickly, in case there was some real damage to her hearing, which wouldn't happen if we had tried to schedule a visit with the pediatrician, but we didn't need the full-bore examination we would have gotten in the emergency room and, in any event, we would have spent half the day, or more, waiting for her to be seen if we'd gone to the emergency room.  We saw her pediatrician a week and a half later and she confirmed the urgent care doctor's diagnosis and his prescribed treatment.

It seems to me that this sort of clinic should be the first place almost all ambulatory patients go to first because I think they would be very good at triaging the patients, deciding who needs to go to the emergency room to get the full exam treatment, and who can be safely treated at the clinic, either with or without a prescribed follow-up with the patient's own doctor.  Not only would that reduce costs tremendously, it would get more practical care more quickly to a greater number of people, and it would take a lot of the pressure off the emergency rooms, freeing them up to treat the serious cases more efficiently and more quickly.

How we get to there from here, however, I'm not so sure of.  However, I think that a very aggressive advertising campaign - and some of them are advertising aggressively on their own - would start to put them into peoples' consciousness as a resource they would generally look to in the first instance.  I would prefer to avoid trying to force people into them, like having the law require insurance policies force their clients to go to an urgent care clinic first in order to have any of their expenses covered, not only for the individual liberty concerns but also to prevent creating an artificial distortion in the market that could be arbitraged by bad-faith clinic operators to extract uneconomic payments out of the system.

Offline truth_seeker

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Re: Obamacare’s Next Task: Break Our Dependence On The Emergency Room
« Reply #7 on: April 14, 2014, 08:43:29 PM »
One of the things that I've noticed have just begun sprouting up around LI are the "urgent care" clinics. 

My wife and I have been self-insured, until the last year. We have therefore used what we call "walk-in clinics" for the most part.

Since we are known to be cash customers from the start, they give you their diagnosis, quick and cheap, including recommended drugs, and other follow up treatments.

Now that we have insurance, with different companies for now, we need to know the "walk ins" and nearby ERs that our doctor groups use, etc.

As a well informed medical consumer, why should I take up space in an expensive ER for every sniffle and bruise, when that space can be kept available for uninsured, illiterate, illegal immigrants--and other Obama voters?

Offline sinkspur

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Re: Obamacare’s Next Task: Break Our Dependence On The Emergency Room
« Reply #8 on: April 14, 2014, 08:50:25 PM »
I haven't seen our primary care physician in two years, even for physicals.  The PA does it.

I can get in to see the PA, if urgent, the same day.  I like this arrangement .  Doctors are for very sick people, not for earaches or joint issues that will require off-site X-rays or a visit to an Orthopedist anyway.
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