Health care reform likely to increase pressure on emergency rooms

Hartford Hospital opened an expanded emergency department this month, with new rooms and triage areas meant to keep up with an increase in patient visits.

Across town, St. Francis Hospital and Medical Center is preparing to double its emergency department space as part of a new 10-story tower set to open next spring.

UConn’s John Dempsey Hospital expanded its emergency department earlier this year in response to rising patient volume, but there are still days when patients wait in the hallways because the rooms are full.

Emergency department visits are increasing in Connecticut and across the country, and doctors say they are likely to become even busier as health reform rolls out.

Gould, Bruce 8-18-10

Dr. Bruce Gould sees patients at a free clinic in Hartford earlier this year (Michael Fiedler)

While many discussions of the health care system have focused on people without insurance crowding emergency rooms, research suggests that much of the traffic comes instead from people with Medicaid, a public insurance plan that many doctors do not accept.

Nationally, emergency room visits increased by 23 percent from 1997 to 2007 – almost double what would be expected from population growth, and the result largely of more visits by adults with Medicaid, according to an analysis published earlier this month in the Journal of the American Medical Association.

The trend holds true in Connecticut, where hospitals saw a 43 percent increase in emergency department visits from the 1997 to 2009 fiscal years. People with Medicaid were more likely to use the emergency room than those with private insurance, or without insurance, according to data from the Connecticut Hospital Association.

All of which points to an impending problem: The federal health reform law relies heavily on Medicaid to expand health insurance coverage to millions of Americans. In Connecticut, that could mean as many as 150,000 more people in the program by 2019.

For a state where primary care providers are already stretched thin, that will likely mean even more visits to the emergency room – one of the most costly ways to deliver care.

“Having health insurance does not equal having access to care,” said Dr. Gregory Shangold, an emergency room physician at Windham Hospital and president of the Connecticut College of Emergency Physicians.

Shangold and other doctors predict that emergency department visits will rise with health reform, just as they did in Massachusetts after the state enacted a health reform law in 2006. Giving people insurance coverage didn’t create more doctors to treat them, or make it easier to get an appointment quickly. Instead, it led patients to the one place that by law could not turn them away.

“The emergency room overusage is really a symptom of the fact that the rest of the health care system just doesn’t work,” said Dr. Bruce Gould, associate dean for primary care at the UConn School of Medicine and medical director for the Burgdorf Health Center in Hartford and for the city’s health department.

More Coverage, More Visits

Between 1997 and 2007, emergency room visits in the U.S. increased from 352.8 visits per 1,000 people to 390.5. Among adults with Medicaid, the rates were far higher – 693.9 visits per 1,000 Medicaid enrollees in 1999 to 947.2 visits per 1,000 in 2007, according to the JAMA article. There was no significant change for adults with private insurance or Medicare, or for those without insurance.

The authors, led by Dr. Ning Tang of the University of California, San Francisco, wrote that the increase could possibly be explained by difficulties Medicaid recipients have in accessing primary care and specialists.

They also noted that the findings suggest that emergency rooms are increasingly serving as the safety net for medically underserved patients.

Connecticut data shows a similar picture.

In fiscal-year 2006, the last year for which detailed data are available, there were 420 emergency room visits for every 1,000 residents, according to the Connecticut Hospital Association. But the rates varied dramatically by insurance coverage. People without insurance visited the emergency room at a slightly higher-than-average rate – 455 visits per 1,000 uninsured residents – while people with private insurance visited the emergency room 250 times per 1,000.

Rates were far higher for people with Medicaid – 791 per 1,000 people in the state’s Medicaid managed care program, and 1,092 per 1,000 people in the Medicaid fee-for-service program. For people receiving state administered general assistance, a program that has since been converted to Medicaid, there were 1,578 visits for every 1,000 people in the program.

People enrolled in Medicaid visited the emergency room for non-urgent care nearly five times as much as people with private insurance, according to the hospital association.

“The hospitals would all prefer that there be other options available in the community, but in many cases, there just aren’t, and those people who are using the services really have no other options in many cases available to them,” Connecticut Hospital Association spokeswoman Leslie Gianelli said.

Hartford Hospital is projecting 93,375 emergency department visits for the 2010 fiscal year, up from 82,327 two years ago. Almost a quarter of emergency department visits are for procedures classified as minimal or basic.

Dr. Lenworth Jacobs, the hospital’s director of trauma and emergency medicine, said the increase does not appear to come from people simply choosing to go to the emergency room over a doctor’s office to get lab tests faster or avoid a wait.

“I don’t see people abusing the system,” he said. “I see them using the system, and I think other parts of the system which used to be there for them are atrophying.”

Try calling primary care practices and asking for an appointment, Jacobs said – it would be difficult to find one that offers a quick appointment. For patients with Medicaid, which pays less than the cost of providing care, it can be even harder.

Already, more than a quarter of internists and family physicians do not accept new patients, according to a 2009 survey by the Connecticut State Medical Society, which warned that an influx of newly insured patients could exacerbate the problem.

Easing the Emergency

In a poll conducted by the American College of Emergency Physicians a month after the health reform law passed, 71 percent of emergency physicians said they expected emergency room visits to increase.

Shangold noted that most people who visit the emergency room have real medical needs that require attention within 24 hours. Even patients with regular access to doctors may not be able to schedule same-day appointments if they’re not feeling well, or get attention if problems arise in the evening or on weekends.

“People can’t get in to the doctors, regardless of insurance, because doctors have to see more patients on a routine basis,” Shangold said. “There’s less opportunity for sick appointments.”

Increasing the ranks of primary care doctors is a long-term project, Gould said, but a necessary one. Unlike other countries, the United States does not have a system for directing students into needed medical fields, he said. Primary care pays less than many other specialties, a disincentive for students facing debt loads that can exceed $150,000. And even those who do go into primary care might not stick with it.

“The way we look at primary care and the way we run it in the trenches often is so chaotic because the system is not well organized yet that your practitioners burn out,” said Gould, who directs the Connecticut Area Health Education Center, a program aimed at getting students interested in primary care and public service health careers.

Jacobs predicted that things will get worse before they get better. Ultimately, he said, the medical system needs fundamental changes – in the way people receive preventive care, incentives to get people into a system of routine care, adequate compensation for preventive care, and educating the public to better identify what type of care to seek for emergencies and for less urgent conditions.

“The system is struggling right now, it really is, and it will continue to struggle,” Jacobs said. “This surge of insured people coming into the system is going to make it more stressful for the next 3 to 4 to 5 years, until it accommodates, and then we can move forward. And we’re totally prepared to do that, because we’re totally committed to one standard of care, the best standard of care for everybody.”