Earlier this month many of us received a news release from the American College of Emergency Physicians about a survey that indicates emergency department visits are rising along with coverage expansion under the Affordable Care Act. This was happening even though one important goal of the health law is to connect people with primary care physicians so they wouldn’t feel compelled to go to the ED for primary care.
While many of us ignored the release or, at most, wrote a brief; some large news outlets did give the survey big play, even linking the increase to expanded Medicaid coverage. The tone of that coverage, at least in a few pieces I saw, was that this was a negative development.
Sarah Kliff, in an article for Vox, does a good job of explaining why she gave the story a pass even though ED visits may well be rising, at least in some places. In a 2014 blog post for The Washington Post, Kliff reported on an Oregon study that appeared to find a link, although that study actually was based on a 2008 Medicaid expansion effort prior to the ACA and in a different context. The new ACEP survey doesn’t convince her.
“This study is about perception and not actual visits. ACEP asked their members whether since January 2014 they thought visits to their emergency department had increased greatly, increased a little, remained the same, or decreased. About three-quarters of respondents said visits had increased to some degree. Is this an accurate representation of whether visits have actually increased? I have no idea — but I’m skeptical of relying on doctors’ memories of the past year and the whirlwind of patients they saw. If you asked me whether I wrote more or fewer stories this year than last year, I’d probably say more — the recent stories I wrote were a lot of work, and I remember them better! Am I a reliable estimator? I have no idea.”
She also noted that ER use was going up before the ACA – it’s hard to know if this reported increase is because of, or despite, the new federal law and coverage expansion.
Likewise, research analyst Matt Broaddus at the Center on Budget and Policy Priorities in a blog post also points out the limits of the survey, provides more information about the earlier Oregon study and sums up what some states are doing to direct Medicaid beneficiaries to the most appropriate point of care.
I’d make a few additional points beyond the good ones Kliff makes:
- The survey says, “More than one-quarter (28 percent) report significant increases in all emergency patients since the requirement to have health insurance took effect. In addition, more than half (56 percent) say the number of Medicaid patients is increasing.” I’d wonder how accurately doctors remember how many of their patients are Medicare, Medicaid, uninsured, commercially insured. Maybe they are great at it .But this is based on memory, not claims or data, and the Medicaid expansion/no expansion state divide is not clear.
- It was an online survey emailed to ACEP members.
- While the headlines tended to say things like three quarters of doctors saw an increase, the actual breakdown was 47 percent who thought they saw a “slight” increases, and 28 percent who saw visits “increased greatly”
Finally, consider why the survey was done and the goal of the association’s press release. ACEP wasn’t focusing on crowding, quality or resources. No, its goal was to emphasize the value of emergency departments and how policymakers shouldn’t do anything to block patient access. That’s in contrast to many other delivery system experiments and care quality metrics that in fact are aimed at reducing ED use as well as improve community-based care.
The release quotes the association’s head:
“The reliance on emergency care remains stronger than ever,” said Michael Gerardi, MD, FAAP, FACEP, president of the ACEP. “It’s the only place that’s open 24/7, and we never turn anyone away. Rather than trying to put a moat around us to keep people out, it’s time to recognize the incredible value of this model of medicine that people need.”