Health Reform and the ED: Prepare for the Surge

Posted by BestPractices on April 1 2010

In the May 2010 edition of Emergency Medicine News, Ruth SoRelle asks Dr. Mayer and other experts about health reform and the impact it will have in the emergency department.

Health Reform and the ED: Prepare for the Surge

By Ruth SoRelle, MPH

The health reform legislation signed by President Obama in March represents the greatest legislative change in health care since Medicare was approved in the 1960s, and emergency medicine experts said now is the time prepare for changes that will take full effect in 2014.

Opposition and hesitancy about health reform does not reflect opposition to providing access to the health care, said Angela Gardner, MD, the president of the American College of Emergency Physicians. “It reflects a lack of trust in the process rather than that we don’t need change,” she said. “People think things will not occur as promised. I agree that that is possible. We need to be ready. This is not a disaster drill.”

The changes in the reform legislation are incremental, but by 2014, everyone will be required to have health insurance through their employers, government programs, or nonprofit member-run insurance companies. Because coverage is mandated in all 50 states and the District of Columbia, 32 million previously uninsured U.S. citizens will be brought into the system. Without preparation, that could equal a surge in demand for emergency care, experts said.

Those who seek care will be sick and in need of urgent treatment, said Stephen Pitts, MD, MPH, an associate professor of emergency medicine at Emory University School of Medicine who completed a fellowship at the National Center for Health Statistics. “It always bothers me when people look at the emergency department waiting room, and say all these patients need primary care. You don’t know which ones need primary care. A good number called their doctors, who told them to go to the emergency department.”

He and others in the field said one way to deal with the possible surge is to start planning now.
“Doctors don’t practice as they used to. With the advent of hospitalists, they don’t even go the hospital. Their practice schedules are filled with appointment patients,” said Dr. Pitts.

That full schedule coupled with the Medicaid expansion that is expected to happen first could likely result in increased ED visits. Noting that Medicaid patients are the most frequent users of EDs by population rate, he said, once the uninsured enter Medicaid, it may lead to increased ED utilization. Some primary care physicians may be willing to accept people who were previously uninsured, meaning that “we may not get hit with the full blast,” Dr. Pitts said. He added, though, that Medicaid patients are probably sicker. “You can’t expect the uninsured to seek care in the emergency department at the same rate as those who are now on in Medicaid,” he said.

Dr. Gardner agreed that EDs can expect an increase in patients. “That’s the first thing that is going to happen. Massachusetts had an average seven percent increase in volume after they covered everyone. We need to be ready, particularly for the people who may not have come in earlier.”

Thom Mayer, MD, the chairman of the board of BestPractices, an emergency medicine outsourcing group in Virginia, said EDs will see a surge that won’t diminish unless changes are made in how primary care is delivered. “Form follows finance,” he said. “What happens when you increase demand, but you don’t deal with capacity? Not only do you have to deal with where and how patients get taken care of, but you also have to think of the implications for people who are already insured and treated well. Will we be able to treat them well without the ability to increase capacity?”

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