Will health care reform increase emergency room overcrowding?

3694615541_515d9997ba_mA new report from RAND researchers suggests that increases in health care insurance provided by health reform efforts may increase emergency room visits. This is significant because one of the ways that insurance is supposed to reduce costs and improve quality is by allowing the newly insured to see their primary care physicians before a condition becomes so dire they are forced into the ER. Primary care is the best place to manage chronic illnesses, and while ERs do a great job of managing acute emergencies, they are lousy and overpriced places to seek care for chronic conditions.

The RAND report echoes the experience of Massachusetts, where it appears that mandating health insurance has expanded coverage, but also caused increased traffic in the ER. The underlying problems, according to health policy researchers, is that there’s a shortage of primary care docs, meaning that even when you get insurance, you may not be able to find a regular doctor. Meanwhile, now that you have insurance, you may be more likely to seek care at the ER, since you are better able to afford it.

If an initial outcome of health reform efforts is to increase ER traffic, we shouldn’t be surprised:

-Appropriate use of primary care doctors by patients, as well as robust national primary care capacity is an issue of culture and values. It would be foolish to simply think that providing more people with ability to pay for health care will suddenly boost capacity and spark health-culture change.

-The US health care system is specialist and procedure based, not primary care and outcomes based, hence the need to reform the delivery of care, not just payment and finance.

-Medical schools are currently designed to produce specialists, and insurance payment is designed to discourage entry into primary care. If we want more primary care docs, systems must train and support them.

-Finally, evidence indicates that increasing primary care physicians within the current health care system doesn’t necessarily improve population health. We need to improve care delivery process, not merely increase capacity.

Malpractice reform would also benefit from overall improvements in health system delivery and performance. Malpractice lawsuits may be motivated by poor outcomes, but are really stories about health care delivery process. A lawsuit only has teeth if you prove that a doctor practiced bad medicine, or medicine that is significantly outside the bounds of accepted standards of care. This means that if over-treatment--providing a raft of care that’s not likely to improve outcomes but makes a patient miserable while driving up costs--is part of usual care, a doc who practices a more restrained, sensible and evidenced-based approach could be said to be practicing outside the norm. Patients who feel disempowered and ill-informed are also more likely to sue. Integrating informed patient decision making into care processes is another way to ensure that patients are partners in care delivery, and expert in the potential challenges of treatment, and prepared for the possibility of poor a outcome.

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