To say that healthcare delivery in this country is in a state of flux would be a massive understatement. To say with any conviction where, exactly, things are headed would be an equally massive conceit. Since the passage of the ACA we have seen large numbers of patients enrolled in insurance plans who were previously uninsured. This has been a boon for those previously unable to afford private insurance but doing well enough to make them ineligible for government-backed plans.
For others it has not been such a pleasant transition. Some people who liked their insurance plans found them cancelled for a variety of reasons (ACA standards, employer whims, etc.) and now find themselves shopping for comparable care on the new exchanges. And in some cases what they find is more restrictive than what they previously enjoyed, with fewer choices of providers and fewer hospitals in network.
The recent midterm elections did little to add clarity to the situation. With Republicans soon to be in control of Congress and a President not afraid to act on his own authority if need be, we can safely assume there will be considerable conflict in the months ahead.
What remains clear through all this fog is the fact that people need healthcare they can both afford and trust. It is also my belief that access to quality care should be available to everyone who needs it. For many newly insured under the expansion of Medicaid, the most convenient and comprehensive care venue is the hospital-based emergency department. (This wasn’t how the ACA envisioned it, and is not the most economically efficient means of healthcare delivery, but it goes to show how seemingly “simple” solutions — just give everyone access to Medicare and Medicaid! — can have unintended consequences.) In this case, for those with newly printed insurance cards issued through one of the exchanges, and long waits to see their assigned primary care physician, the ER has become the place to go for timely, comprehensive, and truly affordable, care.
Truly affordable for the patient, who has no co-pay or deductible for an ER visit. Less so for the hospitals and health care providers who must accept whatever these plans offer as payment in full regardless of whether or not it covers the actual cost of providing that care.
None of this is really new. Hospital based emergency departments have always provided the safety net for those without primary care doctors, insurance plans, or the wherewithal to pay for an office visit out of pocket. It was a part of the practice and something we accepted as such. As long as the majority of patients presenting to the ER had some means of paying for the service we could afford to treat those who did not.
The new health law throws this arrangement into some disarray. Instead of the ER functioning as the safety net for the indigent it is becoming more the treatment venue of either choice or last resort for the under-insured. This is a significant change in the healthcare dynamic. At some point the financial pressure on those hospitals with thin profit margins will be such that closure of either the entire operation, or at a minimum the emergency department, will need to be considered.
If this should come to pass, the effect on patients will be real and negative. With fewer emergency departments available the patient volumes at those remaining will increase. It will be a challenge to keep waiting times within reasonable limits and delays in care, with the potential for adverse outcomes, will ensue.
As we discussed in a previous installment, Healthcare On Demand, this new healthcare economy is driving the formation of alternative care models, such as urgent care centers staffed by fully trained and board certified ER physicians. As more patients avail themselves of these types of centers for their immediate care the volume seen at hospital ER’s will stabilize. But the payer mix of those who continue to use the ER for less than true emergency care will become an even larger problem as hospital and physician revenues decline.
It is impossible at this time to predict how this will play out absent a number of assumptions I think it is too premature to make. What form the law will take, what new regulations might be imposed, and what alternatives to the current insurance model might arise are all things we will have to wait to see.
But, I have my own ideas of what I think would be worth considering. In my next series, “Beyond the ER”, I’ll indulge in a little ‘What If’ to get a sense of the possible. For instance, what if we returned to a more cash-based payment system? What if providers and hospitals had to establish cost-based pricing? What if there was a way to have nearly everyone covered without resorting to an expansion of the safety net? What if?
The Full Series
Enjoy the full ER 101 series from start to finish. Our next series, “Beyond the ER”, is coming soon.