Neil Canavan

February 20, 2014

NEW YORK CITY — In some emergency departments, the Affordable Care Act is contributing to overcrowding because of the influx of newly insured patients seeking care and the reduction in the number of healthcare providers willing to accept Medicaid patients. In other emergency departments, it appears to be having the opposite effect.

"People are concerned about the impact of the Affordable Care Act on their practice," said William Durkin, MD, president of the American Academy of Emergency Medicine (AAEM) here at the AAEM 20th Annual Scientific Assembly. "Some members are telling me that they're not as busy as anticipated, and others are telling me that volumes have gone up appreciably. The impact tends to be different, depending on the region of the country you're in."

A study in Oregon looking at the limited expansion of Medicaid in 2008 showed that the increased insurance coverage resulted in a 40% increase in emergency department use overall, with 0.41 more visits per person (Science. 2014;343:263-268).

"I'm not worried yet because our volumes haven't increased," said Dr. Durkin. However, "as time goes on and more people are able to wave an insurance card, and the family practice or internist won't see them or can't see them because they are booked 2 months out, we will probably be seeing increased volumes."

So who is going to see all these patients? "Certainly, the good part of the Affordable Care Act is that, theoretically, a majority of our patients now have some sort of funding," Dr. Durkin told Medscape Medical News. "However, you have to keep in mind that physician's pay at Medicaid rates, depending on the state, might not be the greatest, and it may be difficult to find physicians who will take those patients."

Although this is a widely held opinion, a recent report from the US Department of Health and Human Services (HHS) states that the percentage of office-based physicians who report accepting new Medicare patients did not change significantly from 2005 to 2012, with 87.9% of physicians accepting new Medicare patients in 2005 and 90.7% accepting them in 2012.

The HHS report provides some evidence of what physicians are willing to financially accept, but does not address the issue of where they are willing to accept it. Intentional or not, one of the effects of the Affordable Care Act is a consolidation of practices, and this is leaving many areas, especially rural locations, without enough doctors.

"I think you're going to see greater use of physician extenders, especially outside of metropolitan areas," said Dr. Durkin. He pointed out that although there might not be money in the rural budget for a full-time physician, there is often enough for a physician extender.

Doctor Shortage

Another possibility is telemedicine. "I recently went to lecture at the University of Mississippi and they had a whole bank of monitors connecting them to rural emergency settings that just had a PA, and it worked quite well," Dr. Durkin explained. Obviously, having the patient in the same room is preferable, "but if you have a reliable person on the other side of that screen who can do the exam with you, that may be the best way to go."

This approach might also be the best way to relieve overcrowding in urban emergency departments. An ongoing pilot program launched by the University of San Diego Health System uses cameras to link patients to on-call physicians outside the hospital. High-fidelity sound and video allows for the off-site examination of a patient's eyes, ears, nose, throat, skin, and heartbeat.

Dr. Durkin said he is disappointed that the new law didn't address tort reform. "I think they missed a great opportunity to reform healthcare in this country. Tort reform would have been a big one. I know so many physicians who order scans or blood work that they know are not needed; they feel that they have to do it to cover all the malpractice bases."

Tort Reform

A recent study showed the average cost of defending against a malpractice claim is $25,000, and to actually go to court is $140,000. This is despite the fact that only 1% of emergency-department-based claims result in a verdict for the plaintiff (Acad Emerg Med. 2010;17:553-660).

To address this and other emergency-department-related issues, Dr. Durkin said he encourages members to get involved. "We've not been at the legislative table as much as we should," he noted. "I'm trying to remedy that. We hired a lobbyist a little over a year ago and we've been very active politically since that time." Dr. Durkin said he also encourages members to speak out. "I've discovered that the politicians actually want to hear from us. They seek our advice and are interested in what we have to say."

It is extremely important, he noted. "You have to be there at the table. If you're not, you're most likely not going to be happy with the end result. And once those regulations get written, it's really tough to change them."

Dr. Durkin has disclosed no relevant financial relationships.

American Academy of Emergency Medicine (AAEM) 20th Annual Scientific Assembly. February 13, 2014.

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