A few thoughts on the latest Oregon Medicaid results

  • If you don’t know which results I’m talking about, you should read Adrianna’s post and Harold Pollack’s. See also the WSJ article by Melinda Beck, in which I am quoted.
  • My feeling is that we should interpret the patterns of health system use as — more or less — reflections of individual assessments of costs and benefits. An individual may rationally opt to visit the emergency department (ED) when a less intensive, ambulatory setting would suffice for many reasons of convenience, culture, and/or ignorance. (I do not mean that pejoratively.)
  • Using other settings also incurs (possibly higher) costs in time, as well as in resources to become educated in how to access them.
  • It may also be the case that the ED is less interested in the “whole patient,” treating just the symptoms as presented. Some consumers may view this as an advantage. In contrast, a primary care practitioner may attempt to provide more care than the individual wants, including gentle (or not so gentle) inquires about potentially sensitive lifestyle issues (sexual activity, nutrition, substance use among them), recommendations for return visits, and referrals to specialists. Not all of this will be pleasant to all consumers.
  • Ultimately, my view is that “overuse” of the ED reflects the broader problem that the health system is not very responsive to consumer demand or sensitive to all types of consumers. (The disparities literature is relevant here.) In other words, it’s not consumers making “bad” choices, but the system offering poor ones.
  • A standard proposal to address this problem is to have consumers pay more out-of-pocket. When it’s their money, they’ll seek and demand better options, and the market should respond. But this is a study of Medicaid patients, so one cannot expect them to pay very much.
  • Bradley Flansbaum points out that privately insured patients exhibit similar patterns of ED overuse, suggesting that the problem is not Medicaid but something broader.
  • More outreach and education might help, if it can be delivered in ways that are attractive to Medicaid beneficiaries, as well as better non-ED options.
  • Greater support for and use of community health workers warrants consideration, as do changes in scope-of-practice laws to increase the supply of practitioners who can provide primary care.

UPDATE: I added the bullet on privately inured patients.


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