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I Hate To Say I Told You So…

… but I told you so.

On KevinMD, we find a story that Oregon Medicaid recipients are 40% more likely to go to the ED – far more expensive care -than their primary care physician:

The Oregon Medicaid findings highlight a central flaw in the Affordable Care Act. Expanding insurance without expanding the primary care infrastructure drives more patients to the hospital. Until that is effectively addressed, expect more newly insured patients beyond Oregon to use the emergency department for primary care.

I’ve been saying all along that this is one reason the ACA will further destabilize the system and drive up costs. You cannot add 30 million people to the Medicaid rolls, people with no financial stake in using the resources appropriately, and expect that they will utilize it less.

With accepting Medicaid a money-losing proposition and little worth the bureaucratic hassle, and primary care physicians being reimbursed so poorly already, fewer med school graduates are choosing primary care over more lucrative specialties, and many of those that do are adopting cash-only, concierge practices.

And an ever-growing number of practicing primary care physicians are refusing to take new Medicaid patients.

So what good is having health care coverage, if nobody in your city accepts it?

Medicaid recipients are going to do what they’ve always done; treat the ED as their default primary care clinic. That’s the most expensive, fragmented type of care, and a substantial portion of them will rely upon the EMS system to get them there.

When it comes to healthcare, your choices are quality care, easy access, and low cost.

Pick any two, because having all three ain’t possible. Anyone who says otherwise is either a liar or a politician.

But then, I repeat myself.

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Comments - Add Yours

  • Granimore

    I am seeing nothing at all “affordable” concerning the ACA. At a combined salary, my wife and I are not even halfway to six-figures, yet our lowest cost marketplace plan would be $557 per month for both of us, with a $12,600 dollar deductible. Every story I read talks about subsidies for the middle class, yet apparently my massive income puts me in the elite realm of the 1%. I had no idea I was so fabulously wealthy!

  • Too Old To Work

    There is a way to fix this, but the politicians will never implement it. Change Medicaid so that there are deductibles and co pays for recipients who use EDs and EMS when there is no need. Just like my insurance, and I’d guess your insurance.

    If Medicaid recipients had some skin in the game, they’d have an incentive to use their primary care providers just as you and I do.

    As I said, it will never happen, but it would put a huge dent in the problem.

    • MerlinMedic

      Medicaid recipients won’t pay the co-pays; this is a trend we are seeing with Medicare now.

    • Garrett Kajmowicz

      In Ontario, the pt. is responsible for the cost of the ambulance ride unless the ER doctor decides that it was medically necessary. Not based on dispatch, but on ER presentation.
      This results in a lot of people not wanting to take an ambulance unless things are really, really bad.

      • Ambulance_Driver

        Which is how it should be here.

        And if they’re unwilling to fork over a Medicaid copay, then deduct it electronically from any other government benefits they may receive.

  • Old_NFO

    Agree with TOTW… Sigh

  • Peter

    What about versions of Medicaid like the Healthy Indiana Plan, that are structured like health savings accounts? That at least theoretically gives people a financial stake in using their healthcare resources.

  • Jake

    AD, what would you say to proponents of Canada or Australia’s systems, which provide generally equal quality of care with relatively easy access and low cost?

    • Mari

      Be prepared to wait for a long time for a lot of things.

      • Christopher

        Sort of. My fiancee is Canadian and loves her health care and is dreading coming under my US health insurance (did you catch how I didn’t call it “health care”).

        Considering as a country they pay less as a percentage of their GDP than we do, perhaps if we used their model with our spending we could have those “shorter wait times” you speak of; that is, if you feel that the wait times are actually long…

      • Jake

        Yeah, not so much. I’ve lived in all three and the ONLY thing I’d wait longer for in Australia is elective surgery. For, say, primary care visits, it’s next day service in Australia (with easy access to same-day walk-in clinics like an urgent care if I’m willing to see a different GP) compared to the two weeks I waited in NY. For specialists, it’s longer, but the 6-10 weeks you’d wait for cardiology here is comparable to the regional American city where I lived as well.

        Knee replacements, now, that’ll run you 8-12 months on a wait list, and that’s a lot longer than in any US hospital I’m familiar with…. but you’ve always got the option of going private and having them done in 2 weeks, you just have to pay for private insurance (still cheaper than my COBRA ever was)! It’s even cheaper for foreigners like me because the cash price of the same procedure procedure is a fraction of what it would cost back home – the local orthopaedic guy does them for $12k, compared to ~40k at the facility nearest me in NY.

    • Garrett Kajmowicz

      I grew up in Canada, now live in the US and volunteer as a part of EMS here.
      I would generally agree that the medical outcomes are similar, but the experience is drastically different. Unless you have an acute emergency, you can expect to wait a long time to see anybody. To get in to see my family doctor for a routine check-up was a 2-4 month wait. In the US, if I need to, I can see my PCP for something routine on a 1-2 week schedule.
      Things may have changed in the past decade, but it used to be that if you were hospitalized, you were only guaranteed a ward bed. If you wanted a private or semi-private room you needed to pay out-of-pocket (or have private supplemental insurance).
      My Dad, as a mill manager, had a way of dealing with employees who he thought were faking minor illness in order to go home early (eg. to watch a major hockey game): I’d tell them that to be sure, he was going to call them an ambulance and have them sent to the ER just to make sure that it wasn’t work related, and that the company would pick up all associated costs. Knowing that they’d probably spend 6 hours+ waiting to be seen for something so minor, they’d almost always change their mind as it would be faster to wait for the end of their shift. Yup – the perception was that the ER was so slow was so pervasive that it could be used as a legal threat.

      • Christopher

        My fiancee has similar waits to me for PCP visits, so perhaps Ontario handles it different than your area of Canada.

        • Garrett Kajmowicz

          I grew up in Ontario as well. I grew up in Thunder Bay, Ontario, so my guess is that there were large regional differences.

          • Jake

            That’s surprising, Garrett, but fair enough – I lived in Ontario for a couple of years and had wait times for primary care of 1-2 weeks, about the same as in NY. In regional Australia, where I am now, I can usually get in the next day, but I suppose geographic differences or practice policies might account for it…

            Definitely true that admission doesn’t guarantee you a private room, but that’s true in lots of US hospitals too, and having spent 3 years in EMS in the US I can guarantee that the wait time is not a significant deterrent to most of the folks driving up the system’s cost.

  • lelnet

    Of course, if we don’t kill this thing, we’ll end up with the worst of all worlds…substandard care that’s hard to get and costs extortionate prices.

  • mr618

    70,000 people in Maine were dropped by MaineCare (the local name) as the ACA kicked in. The Governor felt that since they now had the option of buying on the open market, state support was no longer required. One problem, though, is cost: an unemployed person cannot afford $450+ per month for insurance. Hence, that person is going to put off getting help as long as possible, and will tend to be much sicker when he or she finally bites the bullet and calls EMS. At that point, the ER becomes the PCP, and the patient is a dead loss on the hospital’s bottom line, as there is NO reimbursement, crappy or otherwise, yet the treatment costs will probably tend to be much higher than if the patient had been able to get preventative care.

    For instance, a woman here in town requires medications that run close to $1,000 per month. Her husband is unemployed (and has been for a couple of years, so now he’s virtually unemployable, according to Forbes and Business Week). Without insurance, she will be unable to get the meds she needs. She will likely die in less than a year. They’re both decent people that got caught in a crappy economy and medical problems out of their control.

    This is because Governor LePage declined to accept the Federal funding to expand Medicare.

    TOTW and Old NFO have valid points, and I’m sure there are plenty of people who abuse the current system, just as there will abusers in any other system. But the way things are in Maine now, INNOCENT PEOPLE WILL DIE. Is that really what we want?

  • Joseph from IL

    Lessee. Where did AD get his information about Medicaid (pays 33% of all billed charges, least of private insurance, Medicare, and FFS at 58%, 36%, and 34% respecively)

    What is Annals of Emergency Medicine from 2008?

    I’ll take properly sourced studies for $200, AD.

    • Ambulance_Driver

      Hey, it’s MY blog rant.

      If I meant to write a properly sourced paper, I’d submit it to one of the magazines that pays me for this stuff.

  • Old_NFO

    Actually, isn’t it pick ONE???

  • MerlinMedic

    Anyone with a half an ounce of brains has been saying this since 2009.

  • Chris

    I bet even if the ER wait time was short, if workers were (as your dad suspected) faking illness to get off early to watch a hockey game, they would be reluctant to visit the ER and have their illness (or lack thereof) documented by a doctor.

    If they turned down the ambulance, were these folks required to visit their primary care doctor after work? If not, this story probably says more about people faking illness to get off work early than it does about ER wait times.

  • Garrett Kajmowicz

    No co-pay, no ER treatment. Either way, the problem is resolved.

  • Ambulance_Driver

    I can get behind that, with a caveat:

    If the complaint does not meet emergent criteria, either collect before treatment, or debit the co-pay electronically from any other government benefits they receive.

    If people who pay for insurance have to decide between a co-pay and some other bill, so should people who pay nothing for their insurance.