By Matt Sartain, MBA
In the countdown to January 2014, there was a lot of speculation (and trepidation) about how newly insured patients might use (or overuse) the emergency department (ED).
Perhaps the most common prediction was an influx of less serious and lower-acuity complaints that could be better handled in primary or urgent care settings (assuming patients had access to one). Such a scenario was supported by the experience of states like Oregon, which has been tracking healthcare utilization of its expanded Medicaid population since 2008.
The prospect of an influx of newly insured patients at the height of flu season actually had some care providers quite worried.
So what actually happened? Well, the January data is in, so let's have our first look at how January 2014 diagnoses, volume and acuity stack up against previous years.
Some familiar numbers
The top five diagnoses for January 2014 across all CEP America emergency care sites were:
- Abdominal pain (15% of all visits)
- Chest pain (7%)
- Other upper respiratory infection (6%)
- Other lower respiratory infection (5%)
- Sprain (5%)
Emergency care providers, do those numbers sound familiar? If so, maybe it's because they're no different (statistically speaking) from the top 5 diagnoses in January 2013 and January 2012.
In addition, acuity mix and average ED volume were statistically indistinguishable from Januaries past.
Why no change yet?
A few factors might explain these similarities:
- Timing. January 2014 is still relatively early in the game to see newly insured patients making an impact. At that point, exchanges were still plagued by significant technical difficulties, and many people who attempted to sign up were unsure of their coverage status. So they might have been hesitant to seek care.
- These patients were already coming to the ED — just as uninsured. As the healthcare marketplace is flooded with the newly insured, there is still the same primary care access (or lack thereof) that was available in 2012 and 2013. The emergency department served and continues to serve as the safety net for primary care in many underserved communities. The ED also serves as a convenience for both the insured and uninsured.
- Relatively few "newly insured?" Of the millions of folks who'd signed up for exchanges by January, how many simply transitioned from another form of coverage? That's a number no one really seems to know, and given new changes in the US Census questionnaire, we may never actually find out. But I think it's fair to assume that folks who simply switched from another policy to an exchange (perhaps to take advantage of subsidized premiums or lower deductibles) wouldn't show much change in their utilization patterns.
Trends to Watch
Of course, these numbers might look much different in six months once the kinks in the system have been worked out and patients are more confident about using their coverage. In addition, because the January data becomes more robust with time, we might notice trends that we are unable to pick up on now.
So might we see then? With all the complexity involved, I think it's hard to call. But here are two possible scenarios:
1. Less emergent diagnoses, lower acuity. Coverage doesn't guarantee access to care. Maybe patients live in an area of severe physician shortage. Or maybe the doctors in their area aren't accepting Medicaid or exchange patients, or there's a long wait for appointments. In these cases, insured patients might have no choice but to take their coverage — and their sore throats, coughing babies and ear infections — to healthcare's true safety net: the local emergency department.
As a fairly well insured individual, I guiltily admit showing up to one of our CEP America emergency departments last winter with a complaint of influenza-like illness lasting seven days. I was unable to get into my primary care physician that day, so I headed to my nearest ED. This was a convenient way for me to be seen the same day. After a quick evaluation by one of our excellent physician assistants (and some TLC with the promise to get some rest and drink fluids), I was sent home and received my "superbill" of about $800 on the hospital side and $300 in provider charges.
Among states that opted to expand coverage early, this pattern seems to be the case in rural areas (but not necessarily in cities like Boston).
2. More emergent diagnoses, higher acuity. This, of course, is the end goal of healthcare reform. I see it evolving through two stages.
In the short-term, expanded coverage would increase patients' access to regular primary care to treat less serious conditions and help them manage chronic illnesses. For example, an insured diabetic patient can afford insulin and supplies and work with his primary care provider to monitor his glucose/insulin levels. Careful management greatly reduces his risk of emergency complications, which keeps him out of the ED.
Meanwhile, as reform marches forward, hospitals are gearing up to manage population health. This requires an enormous shift in delivery model, with a focus on prevention and investments in primary and urgent/ambulatory care clinics. But in the long-term, it would greatly increase patients' access to preventative care and disease management — services that work to keep them out of EDs.
Emergency departments will always be needed to handle heart attacks, strokes, trauma and other critical care events. But the day may be coming when high-acuity cases are all they handle.
Other factors driving ED use
So how soon might we see evidence of scenario No. 2 above? The answer depends on a number of factors:
- Service integration. Care coordination requires seamless transitions from one care setting to another. An example might be a hospitalist group that rounds at both a hospital and an affiliated skilled nursing facility. This allows physicians to follow their patients across settings for increased continuity. Other examples might include use of a transitional care manager or integrated home health service.
- Patient compliance. An emergency physician I know likes to joke, "There are three M's that keep us in business: McDonalds, Marlboro and Michelob." To effectively manage population health, hospitals need to find ways to incentivize patients to take responsibility for their own well-being.
- Solving the provider shortage. Much of reform's success hangs on access. We need enough providers to care for both our newly insured and our rapidly aging population. Midlevel providers like physician assistants and nurse practitioners will likely play a crucial role in meeting this challenge, but individual states are still hammering out the details and there is little movement on the federal level.
So that's what I see in this January's diagnosis data. But what about you? Share your thoughts about diagnoses, acuity and the future of hospitals by commenting below.
Matt Sartain, MBA, director of healthcare consulting for CEP America/MedAmerica, has over 20 years of experience in consulting with an emphasis in acute care settings. He has developed and implemented several programs that have greatly improved the financial and operational performance of clients' emergency departments, inpatient hospitalist practices and urgent and post-acute care centers. Matt's background includes hospital administration, regulation, quality/risk management and multi-specialty medical group management.