by Dr. Tyeese Gaines
The proposed changes to Medicaid and Medicare by Congressman, and Republican Vice Presidential candidate, Paul Ryan will undoubtedly change the landscape of 24/7 emergency care. U.S. emergency rooms, with 123.8 million visits per year, are a staple in many communities, especially inner city and rural areas.
As ER physicians, we are the relative safety net for certain aspects of health care, so anything and everything that affects health care, affects us in the ER. That rolls over to our patients, including how long they wait to be seen and the services we can offer.
A Medicare proposal of premium support — a government payment to each Medicare recipient to cover health care expenses — seems on first glance promising, but leaves holes.
Many seniors can barely afford their daily expenses on a fixed income; so keeping up with additional costs if their health expenses exceed the payment will be challenging.
“Ryan’s Medicare vision would shift the burden of cost from the federal government to seniors, which for African-Americans could be deadly,” says Dr. Cedric Dark, an emergency medicine physician at Saint Agnes Hospital, an urban, community, teaching hospital.
“Eventually, health care inflation will outpace the [premium] support and thus, seniors will have to dip into their savings to make up the difference if they opt for a private plan,” he says.
Dark, who also runs a health policy website called Policy Prescriptions, stresses how important Medicare and Medicaid are for many of his African-American patients.
Changes to Medicaid — the health program which insures persons and families under the poverty line — will include capping grants to a certain amount per Medicaid patient, regardless of services provided, leaving each state to fill in the gap or make cuts. This potentially means even less healthcare services for Medicaid patients.
“Ryan basically proposes to turn Medicaid over to the states and let states decide what to do for low-income people,” says Dr. Wes Fields, an emergency physician and chairman of the Emergency Medicine Action Fund. “You have to wonder what states like Texas would do. Look at their uninsured rate. It doesn’t bother them. Their biggest priority is to hold down costs and hold down taxes.”
Dr. Alden Landry is frustrated with the present system.
“It’s hard to practice medicine in an environment where hospitals and physicians see patients as dollar signs as opposed to individuals with needs,” says Landry, who is director of community outreach in the department of emergency medicine at Beth Israel Deaconess Medical Center in Boston.
“I see my career evolving beyond practicing medicine because I know more work will need to be done in health policy.”
Outside of the ER, Medicaid yields many woes. We often see the patients who cannot find follow-up for months, so they return to the ER looking for help. We also see the family who can’t afford Medicaid co-pays to see outpatient physicians. Worse, because of how little Medicaid pays doctors, fewer and fewer doctors accept the insurance plan now.
However, without Medicaid, the number of insured would have been much more than the nearly 50 million that existed before the Affordable Care Act. Medicare, as opposed to Medicaid, insures the oldest, sickest patients, especially of those seen in the emergency room.
Even without Ryan’s cuts, “seniors end up sitting around the emergency department longer [than other patients],” Fields says. “One effect [of the changes] for Medicare beneficiaries is that they’re likely to wait even longer to get an inpatient bed if they require hospitalization,” he continues. “Hospitals feel like they lose money on them.”
Regardless, the emergency room is still the portal for healthcare for many patients, especially those with nowhere else to turn.
“[The ER] is the only place in the health system where you have a right to health care,” says Fields.
Lower income, non-Hispanic black patients and those aged 75 and over are seen in U.S. emergency rooms more than other groups, according to a CDC report. In the same report, as family income increased, the number of emergency room visits went down.
“Hospitals would never have been able to subsidize 24/7 care for the poor and the elderly without the federal programs [Medicare and Medicaid] to cover the costs of their care.”
He adds that the 1986 mandate requiring that no patient can be turned away, regardless of their insurance status, is also tied to participation in Medicare and Medicaid. That mandate, EMTALA, established that as a right, without respect to the patient’s ability to pay.
“Working in the Emergency Department every day you can feel how desperate people are for health care coverage,” Dark says. “Even people with regular physicians come into the ER once they lose insurance because their primary care doctors refuse to see them once they become uninsured. Coverage is key to accessing health care.”
I agree. It feels good to know we’re taking care of any and all patients, especially those in need, but it can still be overwhelming. Many reports show that overcrowding in ERs across the country has increased. Yet, despite the rumors that uninsured patients are the reason for these long waits, recent data shows that that’s not true.
Those with Medicaid – of which one in five are black – were found to use ERs more than both the uninsured and those with private insurance. Among those under 65, more than one in four children and nearly two in five adults with Medicaid had at least one ER visit, sometimes more.
“Better access doesn’t necessarily reduce the number of people that come to the emergency department,” says Fields. “Look at what happened in Massachusetts.”
Some say that Medicaid — and the Affordable Care Act’s expansion of it — will parallel Massachusetts. After the state extended health coverage to the uninsured, which included increasing patients’ access to primary doctors and preventative care, emergency room visits still increased by nine percent between 2004 and 2008.
Fields adds that earlier Medicaid data created a misnomer of the misuse of the health care system by Medicaid patients, or as he says, the notion that “everyone who has Medicaid in the ED has a hangnail.”
This concept was, in fact, proven to be false. In the CDC report, the reasons for ED visits were at the same urgency regardless of whether the patient was uninsured, privately insured, or had Medicaid.
This suggests that Medicaid patients really do need the care, but raises the possibility that other groups are misusing the ER for their so-called “hangnails” as well.
The fact that emergency care is available 24/7 and often has access to tests and x-rays that primary care doctors do not, leads to some ER visits being based on convenience, rather than necessity.
This is also a convenience that with cuts, may not exist moving forward, if more become uninsured or underinsured. With the unique availability that emergency departments provide, Dark resents the “demonizing” of ERs by policymakers who characterize ERs as a negative part of health care and the most expensive places to get care.
In response to this claim, the American College of Emergency Physicians — an organization representing more than 28,000 emergency physicians, residents and medical students — actually reports that spending on emergency care only makes up 2 percent of total health care spending.
While Dark admits that ER visits come at a premium, he adds, “That’s why things cost more: convenience for patients, for referring physicians and for the uninsured. Who else works 24/7, 366 days a year?” (It’s a leap year).
More challenges are to come for ER physicians and hospitals by way of Medicare.
In October, some hospitals will have their Medicare payments reduced for readmitting recently discharged patients into the hospital. Nearly one in five Medicare beneficiaries are readmitted within a month.
The penalty, under the ACA, is a new effort to get hospitals to ensure that patients have a good plan once discharged. Since decisions on admitting patients often falls on the ER doctor, this is an added weight, and, in many cases, leads to a feeling that our hands are tied.
The question becomes: where should these sick patients go? Hospitals can’t control whether seniors have prescription coverage, allowing them to purchase the medications that will keep them from returning to the hospital. Hospitals also can’t control the availability of the patients’ primary doctors for appropriate follow-up.
“[The issue is] these are patients that no one is going to make money off of — those with diabetes, end-stage kidney disease, chronically ill, elderly, and medically or economically indigent,” says Fields.
“There’s a very high likelihood of those patients showing up in the [emergency department] between dialysis visits, for example, and private plans aren’t going to crawl all over each other [for them] either.”
The overarching concern is not only to Medicaid and Medicare recipients, but to all patients who utilize the ER for their care.
It is suspected that overcrowding would only get worse if cuts are made. For each patient’s care that is delayed, there’s more of a chance of dangerous outcomes, not to mention the delays in care when ambulances have to bypass certain hospitals due to overcrowding.
The problems of the ER and health care are not isolated to one doctor or one patient, one type of insurance, or one patient without. What happens to one group will certainly affect us all.
Dr. Tyeese Gaines is a physician-journalist with over 10 years of print and broadcast experience, now serving as health editor for theGrio.com. Dr. Ty is also a practicing emergency medicine physician in New Jersey. Follow her on twitter at @doctorty.
July 17, 2015 //
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