New sicker Medicaid patients boosting ER usage

By Katie Kerwin McCrimmon

New Medicaid patients are sicker and have flocked to hospital ERs at higher rates in states like Colorado that expanded Medicaid than in non-expansion states, according to a new study from the Colorado Hospital Association.

The analysis found that increases in ER usage jumped three times faster in states that expanded Medicaid compared to those that did not during the second quarter of 2014. Use of emergency departments increased 5.6 percent in the second quarter of 2014 over the same period in 2013 in states that expanded Medicaid. States that did not expand Medicaid saw more ER usage too, but at a lower increase of 1.8 percent during the second quarter of this year compared to last year.

ER photo from file art

The Colorado analysis parallels a study of Oregon’s Medicaid population published in Science in January that found ER use climbed once people got Medicaid.

Advocates for reform argue that if people get insurance, they’ll seek care in more affordable doctors’ offices rather than in costly hospitals.

Across the country, fewer uninsured patients are racking up hospital charges, which was one of the key goals of the Affordable Care Act. And in Colorado, commercial insurance companies are paying less to hospitals. Payments to hospitals for privately insured patients declined 5.9 percentage points from the second quarter of 2013 compared to the same period this year, according to the analysis.

Hospital charges for Medicaid patients have gone way up, while charity care is going down. (Source: Colorado Hospital Association.)

Hospital charges for Medicaid patients have gone way up, while charity care is going down. (Source: Colorado Hospital Association.)

While the Colorado Hospital Association pushed hard for Medicaid expansion here, the new data from their analysis could fuel bitter election year battles over the Affordable Care Act.

Political analyst Eric Sondermann said health reform remains a pivotal and divisive issue in campaigns and while news that new Medicaid patients are flocking to ERs shouldn’t surprise anyone, politicians in Colorado’s hard-fought Senate race could seize on the issue.

“For Cory Gardner, this is red meat because it just verifies what they were all worried about vis-à-vis Obamacare,” Sondermann said.

At the same time, supporters of Rep. Gardner’s Democratic foe, Sen. Mark Udall, will be thrilled to hear that Obamacare is working.

Use of the Emergency Department at Colorado hospitals. (Source: Colorado Hospital Association.)

Use of the Emergency Department at Colorado hospitals. (Source: Colorado Hospital Association.)

“They’ll say, ‘My God. We’re getting all these uninsured people covered.’ I just think this further locks people into their respective corners,” Sondermann said.

Indeed analysts at the Colorado Hospital Association and Medicaid managers both said they expected newly insured Medicaid patients — who may have put off care for years —to flock to ERs now that they have health insurance.

As of late July, 1,068,332 people — or about one of every five Coloradans — had health coverage through Medicaid.

“A newly-insured person typically uses more health care. ER use goes up until the person understands how the system works,” said Chris Tholen, vice president of financial policy for the Colorado Hospital Association.

Over time, he expects ER usage to go down.

While hospital costs for uninsured people are dropping, Tholen said this analysis did not focus on relative costs for patients. In general, hospitals receive lower reimbursement rates for Medicaid patients than they do for privately insured customers.

Tom Massey, director of policy, communications and operations for Colorado’s Medicaid programs and a former Republican lawmaker, said it’s much better for people to get care early rather than waiting until their health problems worsen.

“Quite honestly, we anticipated the fact that there would be significant pent-up demand with our new expansion population. The fact that they’ve come in early and often is probably a very good sign,” Massey said.

Colorado chose to do the Medicaid expansion at a time when the federal government is picking up 100 percent of the costs for newly eligible patients. In future years, Colorado and other states will have to pick up part of the tab for the additional patients.

Among Colorado’s total Medicaid population, about 255,000 people have been added to the rolls since expansion started at the beginning of the year.

Massey said now that people are getting signed up for care, the next challenge will be “changing the culture with these folks.”

“We’re trying to transition them into a wellness mode where they take responsibility for their health over time. That will do a great deal to decrease costs,” Massey said.

Colorado has been working to enroll as many Medicaid recipients as possible in what are called Accountable Care Collaboratives. Under these models, patients are supposed to get more lower-cost help from their primary care providers and care coordinators instead of showing up at hospitals.

So far, nearly 70 percent of all Medicaid patients or about 687,831 people are enrolled in accountable care programs.

Massey said Medicaid managers are working to put “more boots on the ground” in counties to help educate people about their options for finding primary care.

He said health navigators need to teach people who have gone to ERs all their lives “that it’s a much better health model for you to go to a primary care doctor.”

Massey predicts some on the right will seize the analysis as evidence that health reform is too expensive.

“I used to be one of those on the right, but we’d all agree that actually having people (with health coverage) is much more beneficial than waiting until cancer reaches stage 3 or diabetes or heart problems get worse. It’s much more cost-effective to treat these (illnesses) on the front end,” Massey said.

He said people who never had insurance were avoiding care and therefore were sicker.

“We had anticipated that a number of these folks, who had not had access to primary care before, were going to have treatment avoidance and would come in. The earlier we get them in, and get their conditions treated or mitigated, the further we’ll be ahead in the long run,” Massey said.

Tholen of the Colorado Hospital Association said he too expected patients to be sicker.

“It takes time to get uncontrolled, chronic conditions to a stable place,” he said.

“This is not an indictment of the ACA in any way. This is a measurement of how hospital volumes have changed in the early implementation of the ACA,” Tholen said. “These are the numbers you would expect to see.”







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