Two things that we know: One, that sick people turning up in emergency rooms is the least cost-effective way to treat them, and two, that most of the costs in healthcare are tied up in treating the chronically ill. But knowing what the problem is and solving it are two different things, as new reports this week demonstrate.
A report by the Centers for Disease Control and Prevention found that Americans made 119 million emergency room visits in 2006, and increase of 32% in a decade. Perhaps even more disturbing was the study's conclusion that patients with Medicaid use emergency services at a rate of 82 per 100 persons, compared to 21 per 100 for those with private insurance. Of all hospital impatient admissions, nearly half come through the ED, up from 36% a decade ago.
The report certainly suggests that despite many well-meaning initiatives to encourage people to make better use of physician offices, clinics, and other primary providers, patients still are choosing—since the numbers arriving by ambulance remained relatively stable—to take the most intensive route possible.
Maybe "choosing" is not the correct word. A convergence of more uninsured, shrinking availability of primary care physicians, and the declining willingness of those physicians to take government reimbursement at reduced rates is forcing people to the wrong healthcare door. So what to try next? Raise copays into the thousands? Boost primary care strength at a financial loss? The solutions don't get any more appealing. Another study, this one from the Annals of Internal Medicine, found that as many as one in three uninsured—an estimated 16 million—have a chronic condition for which they either receive no treatment or show up in emergency rooms for their care. True numbers of how many uninsured have a condition like high blood pressure or diabetes are difficult to estimate since many have not touched the healthcare system.
These two studies are not so much new information as they are an invoice—a little reminder that the bill is due and that the interest rate will hurt. Managing inflow to the ED may well require some more aggressive policies no one really wants, and the costs for truly treating all those chronically ill uninsured are really going to hit hard with any discussion of universal coverage.