Blogging Doctors Just Don’t Get It
With states now allowed to make changes on eligibility requirements for Medicaid, West Virginia will be requiring many beneficiaries to sign a contract in which they promise to use the ER only for emergencies and to keep their doctors’ appointments. Failure to do so will result in loss of benefits. And why not?
Medicaid spending is out of control and is squeezing state budgets. ER visits for non-urgent conditions are hundreds of dollars more expensive than an office visit so that seems like a good place to start to try and control costs.
He goes on to note that low-income people disproportionately make up a good percentage of ER visits, and goes on to say that “only about 16% of ER visits among all patients are considered to be true emergencies so the potential exists for a substantial reduction in unnecessary ER visits among Medicaid beneficiaries.” In the comments, another doctor, Flea, agrees.
I’ll throw another mess into the pot here before drawing my conclusions. A retired orthopod, Dr. Thompson, frequently comments on my blog, and left this zinger today: “I personally see nothing wrong with health savings accounts and allowing patients to be in charge of their health care decisions.” Wha-wha-what?
What is it with these doctors? I’m at a loss. We’ll go point by point here:
- Medicaid is broke. Check.
- Poor people use the ER more often. I’ll assume for the sake of argument this is true. Check.
- Only 16% of ER visits are truly emergencies. Now things get murky. The study Dr. Rangel is quoting seems to be looking at end-diagnoses, not symptoms. In my 4 ER shifts, maybe out 20% of the people I’ve seen have been truly emergencies or urgencies. However, the people’s symptoms have been a much higher percentage of possible emergencies! Sure, you see 10 chest pains for every 1 heart attack, but how the hell are our patients supposed to know that? A patient got poked in the eye pretty bad. Should he wait until morning? Or go into the ER? A patient feels nauseous and light-headed, and has one episode of shaking. We find nothing wrong with him, but I’d get myself to an ER immediately, too!
- Next up: If we follow the “poor people” line, we’ll go ahead and assume they’re probably also the least educated, too. So now we’re asking the least educated of our population to properly differentiate between emergent and non-emergent. (Some things are “duh,” but honestly, most of them aren’t.) The rich get richer, and the poor get sicker. (As a commenter noted on Dr. Rangel’s site, perhaps Medicaid patients go to the ER more often because so few doctors see Medicaid patients anymore.)
- If we want incentives and disincentives (carrots and sticks), let’s make an actual, viable system. If you go to the ER now with your Medicaid or whathaveyou, you may get a bill for several thousand dollars. Ha! That’s what you make in 3 months! What a joke! In a perverse system like this, people will respond just as perversely. No doctors at clinics? Ridiculous bills? Might as well just use the ER when I need it, since the whole system’s a joke.
- And finally for Dr. Thompson’s doozy: of course you don’t have a problem with Health Savings Accounts and people making their own health care decisions. You know exactly what decisions to make–you’re a doctor! That’s what you’re supposed to do–make health care decisions. But as I’ve said before, people that need health care urgently pick the closest hospital; no one bargain shops (as if you could get prices anyway). And which patient has the time and energy (and background) to research the costs and benefits of a certain study, and to interpret what the research actually means clinically?
Can we please, please, PLEASE stop with the patchwork nonsense where we try to eliminate limit health care for the poorest and sickest and drive all the burden onto our already-burdened-with-their-illness patients? Can we see the forest amongst those trees? Can we see that hitting one group with this policy or that one will only create more burden in the long run, and that the only real solution is one that affects us all? Single-payer, multi-payer, I don’t even care at this point–I just wish people would see the big picture. (And no, not the big picture of your specialty. Zoom out one more time. The big picture of everyone.)
I’ll have more time for a response later, Graham. For now, I will note only that you, like many single-payor advocates, conflate the concept of “health care” with “health insurance”. The difference, though, is crucial to this argument. No one wants to limit health care to the poorest and sickest.
best,
Flea
Graham, I saw this article and immediately thought of you; and it rather relates to this current post, even. Check it out.
http://www.cnn.com/2006/HEALTH/05/30/healthier.canadians.ap/index.html
- LM
I don’t think I’m confusing the two, Flea–just noting that health insurance is pretty well linked to health care and health care access; it also helps define what health care people get in the first place.
Maybe the absurd insurance rates large corporations have to pay for employee health insurance will lead to them giving congress the push it needs to inact a sensible universal medicare program. As I understand it, presently Medicare administrative costs are less than half those of comparable private insurance administrative costs.
I just want to thank you for creating this site as it serves as a genuine source of hope for all medical students and those who have wondered where the heart of medicine has gone… or if it still exists. I worked for years with “at-risk” populations, mostly children, but often with their families as well and have seen firsthand the fallout of the current Medicaid system for those who are both lacking in basic education and basic needs. There is absolutely no doubt in my mind that emergency visits are directly related to a lack of ongoing/primary care for much of the population.
I’d also have to agree that the patient-mediated health-funds make about as much sense as the move to make 401k plans a matter of serious investment for the individual worker: neither has any meaningful training, and at least one of these projects has failed outrightly already.
I’m a pre-med student at the U of MN. Just took my MCATs. This past semester, I had about 7 episodes of idiopathic anaphylaxis. I had never had one before, and yes, they still really don’t know why I was having the reactions in the first place. But I now have thousands and thousands of dollars in debt that I don’t know what to do with. “I personally see nothing wrong with health savings accounts and allowing patients to be in charge of their health care decisions.” What happens to me then? The next time I have a reaction, I’m supposed to decide if I can intubate myself rather than going to the ER? Because I cost too much? No, I think that’s a decision for a doctor to make.
Graham:
When I made the comment about health savings accounts, I was not referring to emergencies. Maybe the health care scene has changed greatly since I retired from practice, but my patients usually would call me or one of the doctors with whom I shared call, when they had a problem. If it seemed like an emergency, I would advise them that I would meet them in the ER.
There have been many studies done about ER utilization and they have all shown that maybe 20% of ER patients have true emergencies. URI’s, sore throats, flu, nausea and vomiting, are common diagnoses made on ER patients.
I feel sorry for KJ, but didn’t the U of MN have student health insurance? If not something is really wrong with the U of MN.
The reason “poor” people use the ER more often, is that they don’t have primary care physicians. So instead of being able to call their PCP, they go to the ER.
In spite of what you say about the ER, I would agree with Dr. Rangel and Flea, in that many of the patients who instinctively head for the ER could avoid that trip and the expense by calling their doctor of going to an Urgency Clinic, which cost far less than an ER.
When a patient, who has insurance, is required to pay little if any co-pay, their utilization of the health care system is going to be far greater than if they were in a situation where they would question the necessity of the recommended treatment because they would have to pay 20% or so of the bill.
When one is a medical student many things look so “black and /or white,” but when a physician has been in private practice for even a few years, he/she learns that there are many shades of gray.
John W. Thompson, MD:
The health care scene has changed greatly. Here’s another shade of grey for you to consider. Many “poor” and yes “middle class” people cannot afford to have a primary care physician to screen their need for an ER visit because their primary care physician requires a yearly physical with tests as a requirement for continuum of care. In a family of four, on a tight budget this is a barrier to access.
Dr. Thompson is right about the amount of copay and the total abuse the ED sees. I am in the military where everything is 100% free to the patient (the taxpayers pick up the bill). Talk about abuse. In between the real stuff instead of something interesting like a crackhead or some suck thing, I get a healthy 19 year old who has vomited twice in 3 hours and doesn’t want to train today. Makes you crazy. A 10 dollar copay in our system would cut so much abuse. Steve
Maybe we should be looking at other reasons that low income people are using the ER more than others. Could it be that with their working hours they have limited access to primary care and thus feel that the ER is the only option during hours in which they’re not working. Maybe instead of punishing, the government should be educating people on alternatives to the ER!
Kate:
The government should educate people on alternatives to the ER? Think about what you are saying: how exactly do you propose that the government educate people in this way? Send teachers to doctors’ offices?
It’s MY responsibility to educate patients re: use of ED services. And I do this, but as long as there are no disincentives to prevent ED abuse, and no incentives to avoid it, it will continue.
best,
Flea
In our family of six, only my youngest has insurance–Medicaid, actually. Youngest was born with a birth defect, but in spite of now being an amputee, she is otherwise healthy. For her ortho stuff, she is seen at Shriners Hospital for Children, where it’s free, no matter your financial status. My husband has two incomes, and neither employer offers insurance. When I left my job to stay at home with my kids, I lost my insurance, so I’ve only been to a doctor via our local health department for a regular exam once in those three years (except for pre-natal care when I was pregnant w/ youngest, c/o medicaid).
I consider us to be low-middle income, and I’m one of the ones who would NOT use the ED for a fever–I would suck it up, take the kid to the Health Dept. (if a doc was there that day) or to a pediatrician if the HD wasn’t available, and I’d just have to make payments on the fee. My sister-in-law, (who has depended on welfare for most of her life), however, will go to the ED in a heartbeat–they know they won’t be refused care there–even if her child has only been running a fever for a few hours (and it pisses me off!) I think that’s why most low income people go–they won’t be asked for any money when they get there. If a fee was charged for non-emergencies, I think it would cut down on those types of visits. I know my SIL wouldn’t go if they asked her for money up-front.
Flea,
In my country doctors ARE the government in so much as they are part of a government funded system. So, by saying it is the doctor’s responsiblity to educate patients about alternatives to the ED they are actually an extension of the government. But, I think there are other ways to educate the public about alternatives to the ED, such as after hours clinics. A good example – my local grocery store also has an after hours clinic, which of course is publicly funded because I live in a public-care country, and this clinic is advertised at the storefront as an alternative to the ED. So, a good number of the people shopping at this grocery store (which is huge) should now be educated about one ED alternative. Initiatives like walk-ins and after hours clinics can really make a difference to ED useage if implemented properly.
Kate,
That’s education? We’re doing this in the US right now. See:
http://drfleablog.blogspot.com/2006/02/boys-and-girls-shorts-half-off.html
It’s not education, it’s bad care.
best,
Flea
I kind of straddle the fence between both positions. I’ve worked in the ER for several years and I can definitely agree with some of the compliants of more seasoned ER doctors. We do receive a fair number of non-emergencies. Now, I work at LA County’s ER so my perspective might be different since the hospital works with a very large poor, Spanish-speaking population. I have also seen a fair number of people (sometimes up to 3 people in a given shift, our ER has about 24 beds) coming into our hospital because they want cheap (free) access to prescription medications. That being said, I can easily imagine why ERs across Los Angeles have been shutting down. The ERs hemorrhage money and many that we serve cannot pay. There are many times when the lines to the ER have looped out the door and around the block.
All this being said, we have a large set of problems but I believe few definitive solutions. The doctors who posted previously have done so but I believe they’ve posited very short-term solutions to what will exacerbate a very long term problem. What might be a greater use is more preventative education in low-income communities and directing them to alternative clinics. But what do I know? I’m not in med school yet.
Flea,
Don’t go tarring every walk-in clinic with the same brush. The clinics in my community are staffed during off-hours by family physicians from the community who take turns on a rota covering clinic duty. In on-hours they are the primary offices of two physicians who see their regular patients. I agree, it is dangerous to implement clinics where patients don’t see doctors but see other professionals who have different scopes of care. However, walk-ins staffed by family physicians during evenings/weekends are a great thing and take a huge burden off emergency rooms in my city.
Kate
Gentlemen, I have worked ER off and on (in a variety of city sizes–small, med, and large) for the better part of 29 years as an RN. Some communities have no medicaid accepting mds, but in most, there are. It never fails that 5 minutes after their doctor’s clinic closes, someone who has been ill for 3 weeks and has a magic medicaid card will call or show up in the er. Not every day, but certainly often enough to create great skeptism. In small rural areas, the patient’s have been educated and if not the hours are in the newspaper. They frequently have a choice….
I just stumbled on your blog, and I’m loving it. That aside, I can only say that I am thrilled to be living in Canada where this debate is still only theoretical…