Considering how many pieces were published yesterday on the latest from the Oregon Medicaid experiment (gated), I’m guessing I don’t need to rehash its findings. In case I do: coverage increased. So did emergency department visits, including those for non-emergent care, despite self-reported access to primary care. This wasn’t a huge surprise to many people who study health policy, but I saw the results characterized as “counterintuitive”.
Well, not really.
Last summer, a Health Affairs paper by Kangovi et al examined possible reasons that low-SES patient are disproportionately inclined to use acute hospital care instead of the more cost-effective ambulatory care we want (and, when patients have insurance, might expect) them to use. The study’s methodology has limitations; it’s based on interviews with forty low-income patients in the Philadelphia area. But the findings are quite relevant to understanding why patients covered by Medicaid might opt to visit the emergency department, even in cases where primary care would suffice—and they’re pretty intuitive, if you give it a little thought.
First, low-income individuals are likely to attach a high “time cost” to primary care visits. Relative to their middle- and high-income counterparts, these patients face greater barriers when it comes to taking time off of work for a scheduled appointment, arranging transportation, child care, and the like. The hospital might offer easier access than outpatient clinics, and, in the emergency department, it’s less likely that they’ll be asked to return for follow-up visits.
For patients covered by Medicaid, the direct financial cost of an ED visit and physician office visit were similar; however, the overall cost of ambulatory care was higher because of the additional time and expense required for specialty visits or additional testing recommended by the primary care provider. One respondent reported: “When I go to my primary, I don’t have a copay. I don’t have a copay in the ER either. But my primary may send me to 2 or 3 specialists, and sometimes there is a copay for them. Plus time off from work to go see them. It’s cheaper to just go to the ER.”
The authors also found that patients sometimes harbored a belief that hospital care is superior to services provided in a primary care setting.
[P]referential use of hospital instead of ambulatory care may be driven in part by perceptions that hospitals offer better access and technical quality. Therefore, efforts to reduce preventable hospital use, such as unplanned hospital readmissions, solely by improving hospital quality may have the paradoxical effect of increasing readmissions. Equalizing access and perceived quality across inpatient and ambulatory settings may be more effective.
The Affordable Care Act expands insurance coverage, but insurance reform is not health care delivery reform. Until now, Medicaid beneficiaries have always been a narrow constituency of patients in a system largely designed around those with private insurance or Medicare. That’s changing, at least in the states expanding the program.
Individuals of different socioeconomic statuses have heterogeneous needs, priorities, beliefs, and limitations when it comes to accessing health care—so rational behavior is going to be similarly varied. With expanded coverage, a central challenge on the health policy scene is making the delivery system adapt to meet the needs of a more diverse patient population. That’s something insurance alone can’t do.