By Joseph Ginejko, DO
In many ways, the lead-up to full implementation of the Affordable Care Act (ACA) in January 2014 felt a bit like the countdown to Y2K. Some pundits were convinced that our healthcare system would collapse on New Years Day when the newly insured stormed the emergency department (ED) doors demanding their Obamacare.
I'm therefore pleased (though not terribly surprised) to report that Reform Realtime ED data for January and February 2014 shows no significant difference from years past in terms of average volume, acuity mix or top diagnoses. (The 2014 data covers about 700,000 patient visits at 90 sites across the country.)
One trend the data does show is a significant uptick in the proportion of patients paying for their own care. This points toward some issues that are often overlooked by politicians, pundits and the media — yet are very real for the patients involved. So that's the trend I'd like to address today.
First, I'd like to point out that the Refrom Realtime data paints a somewhat different picture than what I see in my own ED (part of a medium-sized hospital in California's Central Valley). For us, there's been a noticeable shift in acuity mix with more patients presenting for routine nonemergency care. (A similar pattern occurred in Oregon and parts of Massachusetts when these states expanded healthcare coverage.)
Since Jan. 1, we've been treating more patients for chronic conditions like diabetes and hypertension that could easily be managed in the outpatient setting. Some are almost apologetic about showing up to the ED, but say they had nowhere else to go.
"I applied to the exchange in February," they say, "but I'm still waiting for my card."
Unfortunately that slow-to-arrive-card has become a crucial key to healthcare access. Due to limited coverage provided by some lower-end exchange plans, primary care providers (PCPs) have been hesitant to take on exchange patients.
At the very least, they want to verify coverage and check the plan's reimbursement rate before adding a new patient to their packed caseload.
And it's not over once the coveted card finally arrives. Here in the Central Valley, patients on low-cost exchange plans have been told they may need to wait 6–8 months for an appointment.
It's important to note that all of this is playing out against the backdrop of a severe PCP shortage. Even before January 2014, there weren't enough providers in the Central Valley to meet our community's needs. An expansion of our local clinic system (which was originally designed to care for the indigent) hasn't been able to keep pace with our expanded insured population.
So who's feeling the brunt of this? In many cases, it's the newly insured. I've met many patients who say they put off needed care until the exchanges opened. They thought that as soon as they signed up, they'd get assigned a PCP and go in for a visit. Now they find themselves facing delays of up to a year.
We're also seeing a fair number of previously insured patients whose health plans were canceled effective Jan. 1. They signed up for the exchanges and found themselves in the same long line for primary care as their newly insured peers. The same is true for people who switched from private insurance to an exchange plan and lost their primary care physician in the process.
So with no other options for these insureds, the ED becomes a safety net. In addition to getting needed care, they also hope we'll connect them with needed primary care. We do our best, but we can't always deliver miracles when the resources just aren't there.
This brings us to an unpalatable truth. Despite the rhetoric about coverage for all, it seems not all exchange plans are created equal. When it comes to access, you mostly get what you can afford. This is bad news for people who are struggling financially — who may in fact be living in poverty — but who earn too much to qualify for Medicaid.
It also drives home the point that physicians have been making for years: Simply enrolling people in an exchange won't guarantee meaningful access to care.
So will this trend of increased self-pay continue? In the short-term, probably. I do think access will slowly improve as hospitals transition from volume-based providers to managers of population health. This shift will provide incentives to invest in primary care clinics and ensure greater access to preventative care.
However, in the Central Valley, we're still years away from achieving this. It wasn't until this year, when local clinic volumes soared, that hospitals started talking seriously about population health. So for the foreseeable future, it will be up to our EDs to provide a much-needed safety net for insured patients who will continue to have limited options — even once their long-overdue cards arrive.
Joseph Ginejko, DO, joined CEP America in 2007 and currently practices clinically at Clovis Community Medical Center where he also serves as department chair. In addition, he is the physician lead for the Sepsis Committee and is a representative on the Quality Council and Executive Committee. Dr. Ginejko has served within CEP America as an assistant medical director at Adventist Medical Center, Hanford and medical director at both Madera Community Hospital and Clovis Community Medical Center. Originally from the Chicago area, he completed his undergraduate degree in molecular biology at Benedictine University in Lisle, Ill. Dr. Ginejko then attended the University of Health Sciences in Kansas City to complete his osteopathic medical education. This was followed by an internship and residency in emergency medicine at Botsford General Hospital in Farmington Hills, Mich., where he served as chief resident. Dr. Ginejko is board-certified by the American Board of Osteopathic Emergency Medicine.