...is what people in Oregon are thinking. Oh no...a policy nightmare!
A recent study published in the Journal Science followed a group of newly insured, low-income residents in the Portland area, and focused on their utilization of ER services. The randomly selected group of people had entered a lottery to gain Medicaid coverage in 2008. What the researchers found goes against the conventional wisdom that gaining healthcare coverage can reduce the use of Emergency Room visits because people now have access to primary care services and other outpatient specialists. This is a particularly important concept, since the ER is a much higher cost setting than physician offices or outpatient centers. Instead, the study discovered that the newly insured visited the ER 40% more than their uninsured counterparts. "The pattern was so strong that it held true across most demographic groups, times of day, and types of visits, including for conditions that were treatable in primary care settings," reports the New York Times.
While the study followed the "gold standard" in study design, critics claim that the time horizon is not long enough to establish a definitive pattern of behaviour. I think what this highlights is Access to healthcare is not just about getting people insured, albeit that is a very important first step. But this reminds me of Penchansky & Thomas' "5 A's to Access" (Afforadability, Availability, Accessibility, Accommodation, Acceptability). While insurance helps with the first "A", afforadability, it does not address the others. This study highlights the importance of Availability, Accessbility, and Accommodation:
1) Availability / Accessbility: The ER is the first place people think to go to when they have minor injuries, headaches, pains, etc - things that can be easily addressed in different care settings, such as Urgent Care Centers, Ambulatory Care Centers, Physician Offices, Minute Clinics. The Availability of these ambulatory settings of care are increasing, but still not as prevalent as your local hospital's ER. This supply-side factor is just as important a consideration as patient demand.
2) Accommodation: This may be stretching the definition a bit, but it has to do with the patient actually understanding the difference between when and when not to use the ER. Especially the newly insured, who are probably not familiar with their own health and haven't had preventive services for most of their lives.
Once the system can figure out ways to address the issues of availability, accessibility, and accommodation, perhaps we can finally see a reduction in the use of costly ER services.
