Contrary to goals, ER visits rise under Obamacare

Three-quarters of emergency physicians say they've seen ER patient visits surge since Obamacare took effect — just the opposite of what many Americans expected would happen.

A poll released today by the American College of Emergency Physicians shows that 28% of 2,099 doctors surveyed nationally saw large increases in volume, while 47% saw slight increases. By contrast, fewer than half of doctors reported any increases last year in the early days of the Affordable Care Act.

Such hikes run counter to one of the goals of the health care overhaul, which is to reduce pressure on emergency rooms by getting more people insured through Medicaid or subsidized private coverage and providing better access to primary care.

A major reason that hasn't happened is there simply aren't enough primary care physicians to handle all the newly insured patients, says ACEP President Mike Gerardi, an emergency physician in New Jersey.

"They don't have anywhere to go but the emergency room," he says. "This is what we predicted. We know people come because they have to."

Experts cite many root causes. In addition to the nation's long-standing shortage of primary care doctors — projected by the federal government to exceed 20,000 doctors by 2020 — some physicians won't accept Medicaid because of its low reimbursement rates. That leaves many patients who can't find a primary care doctor to turn to the ER — 56% of doctors in the ACEP poll reported increases in Medicaid patients.

Emergency room usage is bound to increase if there's a shortage of primary care doctors who accept Medicaid patients and "no financial penalty or economic incentive" to move people away from ERs, says Avik Roy, a health care policy expert with the free market Manhattan Institute.

"It goes to the false promise of the ACA," Roy says, that Medicaid recipients are "given a card that says they have health insurance, but they can't have access to physicians."

Complicating matters, low-income patients face many obstacles to care. They often can't take time off from work when most primary care offices are open, while ERs operate around the clock and by law must at least stabilize patients. Waits for appointments at primary care offices can stretch for weeks, while ERs must see patients almost immediately.

"Nobody wants to turn anyone away," says Maggie Gill, CEO of Memorial University Medical Center in Savannah, Ga. "But there's no business in this country that provides resource-intensive anything and can't even ask if you're going to be able to pay."

Some people who have been uninsured for years don't have regular doctors and are accustomed to using ERs, even though they are much more expensive. A 2013 report from the Robert Wood Johnson Foundation says going to an ER when a primary care visit would suffice costs $580 more for each visit.

Damian Alagia, chief physician executive for KentuckyOne Health, says he's seen the trend play out in his large hospital system. There are more than a half-million people in the state newly insured through Obamacare. Many who put off care in the past now seek it in the place they know — the ER. "We're seeing an uptick pretty much across the system in our ERs," he says, calling the rise "significant" in both urban and rural hospitals.

Gerardi acknowledges that some people come to the ER for problems that would be better handled in a primary or urgent care office. But he says the ER is the right place for patients with vague but potentially life-threatening symptoms, such as chest pain, which could be anything from a heart attack to indigestion.

ER volumes are likely to keep climbing, and hospitals are working to adapt. Alagia says his ERs have care management professionals who connect patients with primary care physicians if they don't already have them. Gill says her Georgia hospital has a "whole staff in the emergency room dedicated to recidivism," who follow up with patients to see whether they've found a primary care doctor, are taking their medications or need help with transportation to get to doctors.

Still, seven in 10 doctors say their emergency departments aren't ready for continuing, and potentially significant, increases in volume. Although the numbers should level off as people get care to keep their illnesses under control, Alagia says, "the patient demand will outstrip the supply of physicians for a while."