Reform Update: Only 10% of Medicaid ER use is unnecessary, MACPAC says

Last year, healthcare reform supporters reeled after the media gave widespread attention to a study of a 2008 Medicaid expansion in Oregon showing it had increased emergency room use by low-income adults. “A stop sign in front of Obamacare's Medicaid expansion,” one paper headlined its report. The uproar continued last January when the full study appeared in the journal Science.

This week, the Medicaid and CHIP Payment and Access Commission released its official pushback document (PDF). It seeks to separate fact from fiction by explaining how and why low-income Medicaid beneficiaries seek care in emergency departments.

“Because of the kind of conversations going on, we decided to look at what the experts have to say on this,” said Anne Schwartz, executive director of MACPAC.

The analysis covers topics such as whether Medicaid beneficiaries are going to the ER more than ever before, intentionally going to ERs for non-urgent care needs, and whether it's truly the case enrollees can't find primary-care doctors. The research is based on literature reviews of dozens of studies and research papers.

Its key findings:

• Most ED use among Medicaid enrollees is necessary.
• Most Medicaid beneficiaries have a primary-care doctor or a usual place for care, so aren't using the ED as an alternative provider.
• There's no evidence to suggest expanding Medicaid will result in increased ED use. Some states that have expanded the program saw no increase in ED utilization, while in others the uptick was short-lived.

“If people believe these myths, it may lead to a policy that limits access to emergency care,” said Dr. Robert O'Connor, vice president of the American College of Emergency Physicians. “Already, you hear about states attempting to cap the amount of ER visits that they'll reimburse for at some arbitrary number.”

Providers from around the country say the MACPAC analysis has provided them with ammunition needed to counter faulty claims made about Medicaid beneficiaries. “This is an issue that sort of requires myth-busting, because I feel like what we hear in popular press, and even in policy circles, that ER use among this group is always a negative thing,” said Dr. Maria Raven, an assistant professor of emergency medicine at the UCSF School of Medicine, San Francisco.

The key myth addressed by the report—and one clinicians are most happy to see debunked—involves the charge that most ED use by Medicaid enrollees is unnecessary. In fact, the majority of ED visits by Medicaid patients are for urgent symptoms and serious medical problems that require prompt medical attention, with non-urgent visits account for just 10% of all Medicaid-covered ED visits for non-elderly patients, according to the briefing paper.

The reason many believe that most emergency room use is inappropriate is that there are studies that cite large percentages of ED visits paid for by Medicaid and managed-care insurance companies as being deemed either avoidable or preventable. However, MACPAC notes that these studies don't capture the experience of care in real time.

“Hopefully policymakers will come to see the complexities of the issue and not only try to save costs by clamping down on ED use but actually try to provide other alternatives for an increasing number of patients who qualify for Medicaid as Medicaid expands,” said Dr. Renee Hsia, an attending physician at San Francisco General Hospital and Trauma Center.

Many Medicaid recipients do struggle to find doctors, the brief noted, but those issues are common to many regularly insured people with similar social circumstances. They often have trouble getting through to their doctor's practice by phone or reaching a physician after hours; have difficulty getting an appointment; have language barriers; and lack transportation, the report found.

The report also claimed that there is insufficient evidence that Medicaid expansion would lead to increased ER use across the country this year. It pointed to a series of studies following states that have had limited Medicaid expansions prior to the Affordable Care Act. MACPAC found that some experienced no increase in ED use and others experiencing short-lived increases. There is not enough evidence to suggest Medicaid expansion states would experience an across-the-board increase in ER use, the report concluded.

It's unlikely the brief will quiet opponents of Medicaid expansion, of course, especially in states that haven't expanded the program. “It is common sense to believe if the government adds 14 to 20 million more people to the Medicaid program, through the Affordable Care Act, usage of all types of healthcare will increase for this population, including the ED,” said Dr. Roger Stark, healthcare analyst at the Washington Policy Center.

Gov. Mike Pence has met with HHS Secretary Sylvia Mathews Burwell to push for his recently submitted waiver to expand Medicaid with a private-insurance purchase option. But he admits the agency has some concerns about the plan.

"We're not there yet," Pence said following the get-together July 30. "They have raised a number of issues, but I took the opportunity to make our case." He did not disclose the nature of the differences to media, but did promise he would walk away from the proceedings if the government attempted to change his proposal too drastically.

Indiana, like several other Republican-controlled states, wants a waiver that will allow it to use federal Medicaid expansion funds to purchase coverage for adults 19 to 64 earning up to 138% of the federal poverty level. Pence also wants the ability to charge those above 100% of the federal poverty level a monthly contribution of around $25 a month to help pay for their care and if they don't, lock them out of the healthcare program for six months.

A superior court in California declined to grant an injunction to stop the state's dual-eligible demonstration.

The Patient Protection and Affordable Care Act created the Financial Alignment Initiative, which gave states the option to launch three-year demonstration projects in which the care for those that are eligible for both Medicare and Medicaid would be aligned and overseen by a single health plan. That plan would receive a capitated payment rate.

The Los Angeles County Medical Association and several independent living centers attempted to halt California's program, alleging that the state has not honored its commitment to make the enrollment forms at or below a sixth-grade reading level. Since many duals have cognitive disabilities, they may not realize that they are potentially agreeing to severe ties with their current providers to join the program, they argued.

Follow Virgil Dickson on Twitter: @MHvdickson