ER Visits Jump Under ACA

Advocates of the Affordable Care Act have long argued that extending medical coverage to millions of people would reduce their reliance on expensive emergency room care. That would save billions of dollars in unnecessary health costs that are passed on to consumers and employers in the form of higher insurance premiums.

Initial signs, however, point in the opposite direction.

Hospitals across Orange County, and nationwide, are reporting sharp to moderate increases in ER visits. And many of them attribute it to the millions of people who are newly insured on account of the health reform law, also known as Obamacare.

In other words, many people are seeking care at emergency rooms not because they are uninsured but precisely because they now have insurance.

In a recent survey by the American College of Emergency Physicians, nearly half of ER doctors queried said they had seen a rise in emergency visits since the beginning of the year, and 86 percent expected ER visits to increase over the next three years.

“When I speak with other emergency physicians, it seems as if volume has increased faster since the Affordable Care Act than in the past,” said Mark Reiter, president of the American Academy of Emergency Medicine, who works at St. Thomas Rutherford Hospital in Murfreesboro, Tenn.

Not all hospitals are seeing an increase, which may reflect the demographics of their patients and the hospitals’ contracts with insurers. And where ER visits are rising there may be other factors at play, including lack of primary access, an improving economy and patients’ attitudes about where to seek care.

Some industry executives and observers caution against drawing early conclusions. The whole health care system is evolving rapidly under Obamacare, they note, and with a public education campaign and greater access to primary and urgent care, people may eventually kick the habit of going to the ER for symptoms that could be easily treated elsewhere.

But so far, the general trend in ER visits is upward. And financially speaking that is not good news, since visiting the ER costs about $580 more on average than the same treatment administered in a doctor’s office, according to a national study last fall by the Robert Wood Johnson Foundation.

Many people who visit the emergency room don’t need to be there, but studies diverge widely on exactly how many. One survey shows that nearly half of patients visiting the ER can wait longer than an hour to be seen. Another says 76 percent could have been treated at a doctor’s office or urgent care clinic. A third puts that figure at only about 10 percent.

Countywide, the ER patient load has risen by an average of 4.4 percent since January, according to data provided by the county’s Emergency Medical Services agency. By contrast, the volume of ER visits in Orange County was flat from 2009 to 2013.

“So we are above anything we would have expected from the previous years’ trend,” said Samuel Stratton, the agency’s medical director.

Stratton believes the economic recovery could help explain the rise in ER use. “During recessions, emergency department traffic drops, and when the economy is improving, it goes up,” he notes. “So it could be that or it could be the Affordable Care Act. We don’t really know.”

Some Orange County hospitals are reporting increases much higher than the county average:

–Visits to the emergency room at UC Irvine Medical Center rose by 10.9 percent in July from a year earlier, a sharp acceleration from the annual increase of 5.1 percent in July 2013. In May, ER visits were up 10.7 percent from a year earlier, compared with a rise of 1.8 percent in May 2013.

Wait times are also up, and the hospital’s emergency department is seeing more insured people who show up for the sake of convenience rather than for true emergencies, said spokesman John Murray.

–At Kaiser Permanente’s two Orange County ERs, patient volume is up 11 percent this year, compared with a rise of 6.5 percent in 2013. “While we cannot attribute the increase in volumes solely to the Affordable Care Act, we do know that we are seeing many individuals that are seeking care for the first time,” Kaiser said in an emailed statement.

–At Fountain Valley Regional Hospital, ER visits were up 7.6 percent in the first six months of this year, compared with an increase of 1.9 percent last year, said Peter Anderson, medical director of the hospital’s emergency department. He said the increase was due in large part to formerly uninsured people now covered through Orange County’s MediCal agency, CalOptima.

Statewide, 1.4 million bought health plans through the state’s exchange, Covered California, which was created under the health reform law. And more than 2 million Californians are newly insured — or expect to be — due to more generous eligibility criteria for Medicaid, the federal-state insurance program for low-income people, which is called MediCal in California.

Across the U.S., more than 15 million people have obtained insurance through one of the Obamacare insurance exchanges, through Medicaid, or through the Children’s Health Insurance Program, another federal-state partnership. Recent surveys showing a sharp drop in the number of people without insurance suggest that a large proportion of them were previously uninsured.

Studies show that MediCal patients are more likely to visit the ER than the uninsured or people with commercial insurance. That’s because they tend to have higher rates of chronic disease and often have less access to primary care. Many doctors have stopped accepting MediCal patients, and the ones that do may have such large caseloads that getting a quick appointment with them is extremely difficult.

Many hospitals say their emergency departments are seeing a significant number of newly insured MediCal patients.

At Long Beach Memorial Medical Center, where emergency room visits are up by more than 8 percent, two-thirds of the increase is related to the expansion of MediCal and one-third to patients who bought health plans through Covered California, says Diana Hendel, the hospital’s CEO.

Emergency room use is also higher, though more moderately, at its sister hospitals in Orange County — Saddleback Memorial and Orange Coast Memorial, Hendel said.

While many hospitals are seeing rising ER volumes, some are not. At St. Jude Medical Center in Fullerton, emergency room visits are unchanged this year, said hospital spokeswoman Dru Ann Copping.

For some, rising ER visits have been the norm for some time.

At California Hospital Medical Center in downtown Los Angeles, “our volume has jumped about 10 percent this year, but the truth is that we jumped 10 percent last year and 8 percent the year before, so attributing it to the Affordable Care Act is not really fair,” said Marc Futernick, medical director at the hospital’s ER and president-elect of the California chapter of the American College of Emergency Physicians.

Indeed, a large part of the reliance on emergency rooms is built into the health care system, says Sara Rosenbaum, a professor of health policy at George Washington University in Washington, D.C. She notes that health plans and doctors often send their patients to the ER even when it might not be the optimal place for treatment.

“Some of this may be a temporary phenomenon and could change as people begin to use their coverage better,” Rosenbaum says. “But to the extent that the health plans and networks are sending people to the ER, it’s not going to change.”

Martha Gonzalez, a 47-year old uninsured Santa Ana resident who visited the ER at Western Medical Center Santa Ana earlier this week for dizziness and nausea, said that when she was insured previously under MediCal, she would have called her doctor for the same symptoms.

“But if it was after hours, he probably would have told me to come to the ER,” Gonzalez says.

Rosenbaum said the health system has to change in some fundamental ways before Obamacare can deliver on the cost savings it has promised.

“Are we turning out enough primary care doctors? Are doctors working in practices that can offer at least some evening and weekend hours?” she asks.

Some hospital executives believe that with a public education campaign and greater availability of alternatives, such as urgent care clinics and appointments with primary care physicians, the use of ERs can ultimately be limited to the most serious cases.

“I think over time you will see it work out so that people will figure out which access point they need to go to,” says Suzanne Richards, CEO of Western Medical Center Santa Ana. “I don’t think the ER will remain people’s first access point.”

Hendel notes that at Long Beach Memorial and its sister hospitals, patients who come into the ER are given a followup appointment with a primary care doctor. Second visits to the ER are down 50 percent among patients who have a primary care appointment after their first trip to the ER, she says.

“That is really telling and bodes well for the future,” Hendel says. “It could eventually reduce ER use and lower costs.”

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