A Philosopher's Blog

Emergency Rooms & Obamacare

Posted in Business, Ethics, Law, Medicine/Health, Philosophy, Politics by Michael LaBossiere on January 24, 2014
Typical scene at a local emergency room

(Photo credit: Wikipedia)

On the face of it, the idea seems reasonable enough: if a person has health insurance, then she is less likely to use the emergency room. To expand on this a bit, what seems sensible is that a person with health insurance will be more likely to use primary care and thus less likely to need to use the emergency room. It also seems to make sense that a person with insurance would get more preventative care and thus be less likely to need a trip to the emergency room.

Intuitively, reducing emergency room visits would be a good thing. One reason is that emergency room care is rather expensive and reducing it would save money—which is good for patients and also good for those who have to pay the bills for the uninsured. Another reason is that the emergency room should be for emergencies—reducing the number of visits can help free up resources and lower waiting times.

As such, extending insurance coverage to everyone should be a good thing: it would reduce emergency room visits and this is good. However, it turns out that extending insurance might actually increase emergency room visits. In what seems to be an excellent study, insurance coverage actually results in more emergency room visits.

One obvious explanation is that people who are insured would be more likely to use medical services for the same reason that insured motorists are likely to use the service of mechanics: they are more likely to be able to pay the bills for repairs.

On the face of it, this would not be so bad. After all, if people can afford to go to the emergency room and be treated because they have insurance, that is certainly better than having people suffer simply because they lack insurance or the money to pay for care. However, what is most interesting about the study is that the expansion of Medicaid coverage resulted in an increase in emergency room visits for treatments that would have been more suitable in a primary care environment. That is, people decided to go to the emergency room for non-emergencies. The increase in emergency use was significant—about 40%. The study was large enough that this is statistically significant.

Given that Obamacare aims to both expand Medicaid and ensure that everyone is insured, it is certainly worth being concerned about the impact of these changes on the emergency room situation. Especially since one key claim has been that these changes would reduce costs by reducing emergency room visits.

One possibility is that the results from the Medicaid study will hold true across the country and will also apply to the insurance expansion. If so, there would be a significant increase in emergency room visits and this would certainly not results in a reduction of health care costs—especially if people go to the expensive emergency room rather than the less costly primary care options. Given the size and nature of the study, this concern is certainly legitimate in regards to the Medicaid expansion.

The general insurance expansion might not result in significantly more non-necessary emergency room visits. The reason is that private insurance companies often try to deter emergency room visits by imposing higher payments for patients. In contrast, Medicaid does not impose this higher cost. Thus, those with private insurance will tend to have a financial incentive to avoid the emergency room while those on Medicaid will not. While it would be wrong to impose a draconian penalty for going to the emergency room, one obvious solution is to impose a financial penalty for emergency room visits—preferably tied to using the emergency room for services that can be provided by primary care facilities. This can be quite reasonable, given that emergency room treatment is more expensive than comparable primary care treatment.  In my own case, I know that the emergency room costs me more than visiting my primary care doctor—which gives me yet another good reason to avoid the emergency room.

There is also some reason to think that people use emergency rooms rather than primary care because they do not know their options. That is, if more people were better educated about their medical options, they would chose primary care options over the emergency room when they did not need the emergency room services. Given that going to the emergency room is generally stressful and typically involves a long wait (especially for non-emergencies) people are likely to elect for primary care when they know they have that option.  This is not to say education will be a cure-all, but it is likely to help reduce unnecessary emergency room visits. Which is certainly a worthwhile objective.

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Mystery Patients

Posted in Ethics, Medicine/Health, Politics by Michael LaBossiere on July 3, 2011

Image via Wikipedia

While many people still dream of becoming (or marrying) doctors, there is a shortage of primary care doctors. Folks in government are concerned about this and one of the most recent proposals is to have people pose as patients in order to determine the difficulty of getting care. One critical part of this is to determine if doctors are rejecting patients who belong to government health programs in favor of the more lucrative private insurance patients. This is, obviously enough, based on the mystery shopper model.

One obvious concern about this method is that it can be seen as a form of spying and also as a deception. While such deceit is acceptable in law enforcement and intelligence operations, this is justified by the fact that the targets are potential (or actual) criminals and enemies. However, the doctors are not suspected of acting illegally and hence the use of this method seems to be questionable.

A second obvious concern is that the money used in this program could be better spent in making positive contributions to health care-such as providing support for doctors willing to provide primary care services for people who are in government programs or in other ways. It is already well established that we need more primary care doctors and it seems almost equally obvious that doctors prefer patients who have private insurance.  This is, of course, due to the main factor of money. In a free market system in which the main goal is to maximize profits, doctors have little incentive to pursue the lower paying career paths or to accept patients on government assistance. As such, there seems little reason to conduct a secret survey in order to learn what already seems to be known.

However, there is certainly merit in investigating the problems that motivated the mystery patient plan. However, this is something that should be done openly rather than with mystery patients.

While it would be nice of people to go through medical school and run their business solely to help people, that sort of devotion to others certainly cannot be expected of people. As such, the most plausible solutions involve providing financial incentives. This can be done by increasing support for medical school students in return for a service commitment and also making the government payouts more appealing to doctors who have money on their minds.


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