Docs fear reform will exacerbate ER overuse

March 24, 2010

One of the most agreed-upon reasons for health care reform was the expensive overuse of the emergency room by uninsured patients. But two Hoosier ER docs—one conservative, one liberal—say the implementation of health reform will leave that fundamental problem unresolved.

The health reform bill signed into law Tuesday by President Obama would expand insurance coverage to 92 percent of Americans by 2019. But of the 32 million extra Americans expected to have insurance coverage, half would be covered by an expansion of Medicaid, a federal-state program that pays woefully low rates to doctors and hospitals.

Medicaid in Indiana pays doctors about 60 percent of what it costs them to provide services, according to a December study by Seattle-based Milliman Inc. The new law would raise eligibility for Medicaid from families of four making just $5,500 a year to families of four making up to $29,000 a year. The state has much higher income caps to allow disabled and older adults, pregnant women and children whose parents are poor to enroll in Medicaid.

Dr. John McGoff, an ER doctor at Community Health Network in Indianapolis, noted that Medicaid includes few disincentives for enrollees who use the emergency room.

“I think you’re going to see utilization rates go through the roof. Whatever they’ve used as their actuarial cost on this will be a gross under-representation,” he said.

McGoff, a Republican who is trying to unseat Rep. Dan Burton (R-Indiana) in a race for Congress, thinks Obama’s health reforms are so bad he wants them repealed.

But his assessment of the impact on ERs is largely shared by Dr. Rob Stone, an ER doctor at Bloomington Hospital who supported Obama’s reforms even though he thinks they don’t go far enough.

Health reform would raise payments to primary care doctors to equal the rates paid by the federal Medicare program, which are roughly on par with doctors’ costs. That should help alleviate some of the burden as more doctors accept Medicaid patients.

But with Indiana and the nation already suffering a shortage of primary-care doctors, neither McGoff nor Stone expects there to be enough new doctors to cover the influx of new customers. Besides, doctors may gravitate to accept the 16 million new people who will buy private insurance through the state-based exchanges that will open in 2014.

“If more people go on Medicaid, but they can’t find a primary-care doctor, and they feel more free to come into the ER, then that’s going to load us up,” Stone said. “So that’s not so good.”

The American College of Emergency Physicians agrees. The group’s president, Angela Gardner, said in a statement Monday, “As we have seen in Massachusetts, though, health insurance coverage does not equal access to medical care, and emergency visits are increasing in that state. This means critical problems facing emergency patients are not going away.”

McGoff does think he will personally make more money under Obama’s reforms. He said one in four patients he sees is uninsured and pays little to none of his or her bill. If more people have at least Medicaid coverage, as poorly as it pays, he would likely come out ahead.

But Stone isn’t sure the patients will. He worries that it will still be difficult to find doctors he can refer patients to for the follow-up care they need after he sees them in the emergency room.

“Expanding Medicaid is not a great floor. It’s a creaky floor with a lot of holes in it. It’s going to cover too few people and take too long to do it,” Stone said, adding, “That’s why the work’s not done.”

Stone thinks the only way to truly provide access to care for all Americans is to expand the Medicare program for seniors, or something very like it, to all Americans.

McGoff thinks the government should provide subsidies for catastrophic care for all Americans only up to a certain income threshold. Smaller medical bills should be handled with privately purchased health savings accounts. And the cost of care and coverage, he said, should be reined in with caps on medical malpractice damages and the ability to buy health insurance across state lines.

“Selfishly, I should be in favor of this. But in reality, I’m dead set against it,” he said of the new health law. “I think this will further bankrupt a system that’s already bankrupt.”


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