Increased emergency room visits can be an improvement

1/02/2014 03:42:00 PM
Only You can prevent healthcare waste.
...but it probably isn't optimal.

Aaron Carroll points our attention to a study using the data from the Oregon Health Insurance Experiment that showed that gaining Medicaid coverage causes individuals to visit emergency rooms more frequently--to the tune of 0.41 more visits per person over 18 months. That's a substantial increase that, as Carroll notes, we probably should have expected. "Increased coverage increases care" isn't exactly a ground breaking result. But then, I suppose that's the point of this study--a lot of people were hoping we'd find the counter-intuitive result that increased access reduces emergency room visits. Turns out, the intuitive result was the right one.

What I like about Carroll's semi-rant on this is his overall point: increased emergency room use could quite possibly be an improvement over the status quo in which people are going without treatment because they lack coverage. Carroll says:
"until someone proves to me that the increased ED use was unnecessary, I don’t know why anyone would assume it’s a bad thing. If our goal is to increase people’s access to the health care system, getting more people insurance (like Medicaid) is a good tool for that."
Cost/benefit studies generally show that the treatments we administer really do generate more social value than they cost--usually many times more. Hence, increased emergency use probably is an improvement over the status quo.

But that's entirely different than saying that the increase in emergency room visits was socially optimal, and I think that's where Carroll goes astray. There is a well developed literature showing that for things that could be treated by primary care physicians, emergency rooms are vastly more expensive and generally lower quality. Emergency rooms are set up to treat trauma victims, and unless you are hemoragging large volumes of blood, that probably does not include you. They are not set up for routine treatment, which means that they won't manage chronic conditions or follow up with patients very well. Moreover, there's an extensive literature, to which Carroll alluded, showing that despite these costly shortcommings, a lot of people end up using emergency rooms for things that could be more effectively treated elsewhere--the reason being simply that people want urgent care even though they don't necessarily have an actual emergency (as an aside: patients with very serious chronic conditions are poorly served by the exisiting system--their condition can easily turn into an emergency, but emergency rooms aren't set up to manage chronic conditions).

Now, we can't really tell from this data whether the 0.41 extra visits per person to the emergency room were true emergencies, but they probably weren't. Like I said, emergency rooms are for trauma--life-or-death situations where you don't have the ability to decide whether or not you think you can afford the bill. That increasing medicaid access increased emergency room visits can only mean three things:
  1. People with life-threatening emergencies were not going to emergency rooms because they lacked Medicaid coverage
  2. People had more emergencies as a result of gaining medicaid coverage
  3. People started going to the emergency rooms for non-emergencies
Each of these may have some truth to it, but only (1) represents a move towards optimality. Clearly, if (2) is right, then expanding medicaid is highly problematic, while if (3) is right, we may have improved overall healthcare access, but we also caused some degree of inefficient waste.