Fwd: qotd: The Oregon Medicaid ED “experiment” and the overuse myth

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-------- Original Message --------
Subject: qotd: The Oregon Medicaid ED "experiment" and the overuse myth
Date: Thu, 9 Jan 2014 13:53:55 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



The New York Times
January 2, 2014
Emergency visits seen increasing with health law
By Sabrina Tavernise

Supporters of President Obama's health care law had predicted that
expanding insurance coverage for the poor would reduce costly emergency
room visits because people would go to primary care doctors instead. But
a rigorous new experiment in Oregon has raised questions about that
assumption, finding that newly insured people actually went to the
emergency room a good deal more often.

The study, published in the journal Science, compared thousands of
low-income people in the Portland area who were randomly selected in a
2008 lottery to get Medicaid coverage with people who entered the
lottery but remained uninsured. Those who gained coverage made 40
percent more visits to the emergency room than their uninsured
counterparts during their first 18 months with insurance. …

In remarks in New Mexico in 2009, Mr. Obama said: "I think that it's
very important that we provide coverage for all people because if
everybody's got coverage, then they're not going to the emergency room
for treatment." …

"I suspect that the finding will be surprising to many in the policy
debate," said Katherine Baicker, an economist at Harvard … and one of
the authors of the study….
http://www.nytimes.com/2014/01/03/health/access-to-health-care-may-increase-er-visits-study-suggests.html


Comment by Kip Sullivan, JD

Last Friday the New York Times, the Wall Street Journal and other media
outlets trumpeted the news that a recent study shows that low-income
people newly insured through Medicaid use 40 percent more emergency room
services than a control group of low-income people who remained
uninsured. In a sane world, this finding would not have deserved any
coverage, much less headlines on front pages. The conditions that would
cause Medicaid enrollees to visit the ER more than the uninsured have
been known for a long time, and it's well known that some of these
conditions have been getting worse. The conditions include:

• the uninsured use roughly half as many health care services as the
insured,

• the uninsured are in worse health than the insured and have more
unmet medical needs, and

• Medicaid enrollees have much more trouble finding primary care
doctors and specialists who will take Medicaid than the privately insured.

Anyone familiar with these facts could have predicted that if the State
of Oregon were to offer Medicaid coverage to 10,000 of its poor people
those people would make more visits to emergency rooms than an uninsured
control group. But the media's fascination with this paper suggests the
study's results were indeed surprising to "many in the [health] policy
debate," as Ms. Baicker asserted.
How do we explain the surprise? I nominate the overuse myth – the
conventional wisdom that the main reason America's per capita health
care costs are double those of the rest of the industrialized world is
that doctors order, and patients demand, great volumes of unnecessary
medical services. The overuse myth has led far too many policymakers on
the left and the right to think that emergency rooms are vastly
overused. Liberals like Obama use the myth to claim better coverage will
reduce all that unnecessary ER use and free up money to insure the
uninsured. Conservatives use the myth to decry more coverage. According
to conservatives, better coverage will just encourage poor people to
consume even more unnecessary care. As conservative blogger Avik Roy
wrote on the Forbes blog about the new study, "Because Medicaid was
nearly free to the program's enrollees, those enrollees ended up seeking
– and receiving – lots of inappropriate care."
http://www.forbes.com/sites/theapothecary/2014/01/02/new-oregon-data-expanding-medicaid-increases-usage-of-emergency-rooms-undermining-central-rationale-for-obamacare/

In fact, researchers have determined (with the luxury of hindsight, it
should be noted) that only 10 percent of Medicaid enrollees go to
emergency rooms for non-urgent matters, which is close to the 7 percent
rate seen in the privately insured http://www.hschange.com/CONTENT/1302/.

Like all sturdy myths, the overuse myth has a kernel of truth to it –
some overuse of medical services does occur. But underuse is far more
common than overuse, even among the insured, possibly four times worse
according to a 2003 study by Elizabeth McGlynn et al. in the New England
Journal of Medicine. Even for some expensive procedures like heart
surgery underuse is far worse than overuse.
The media's surprise at the new study's finding and reporters' and
right-wing bloggers' eagerness to report the political winners and
losers of this story concealed the real problems, notably:

• Because America sequesters its poor people in a separate program
called Medicaid, it has never found the political will to pay the
providers who care for poor people anywhere near as much as we pay
providers for taking care of everyone else;

• this policy has made it difficult for Medicaid recipients to find
doctors;

• this difficulty is further aggravated by the widespread use of
managed care in Medicaid programs which forces recipients to pick
doctors from "preferred" lists; and

• Despite these facts, Oregon sought to increase coverage under
Medicaid while doing little to increase the supply of primary care
providers or the resources available to those who treat Medicaid enrollees.

In a sane world, we wouldn't be debating whether a rich nation should be
attempting to insure a minor portion of its uninsured through a separate
and underfunded program for the poor. But if we must debate whether to
do that, the least we can do is focus on the real issues, not promises
of cost containment based on a false assumption, in this case, that
overuse is our main problem and underuse, high prices and excessive
administrative costs are nonexistent or trivial.

The truth is we are going to need to put more money into primary care in
this country, and it will have to come from somewhere. Single-payer
supporters propose that it come from reduced prices and reduced
administrative waste. By clinging to their pet version of overuse,
managed-care and high-deductible advocates dodge the issue. Managed care
advocates claim that even within the underfunded world of Medicaid
greater access to primary care can be paid for without harm to patients
by reducing overuse via capitation, report cards, pay-for-performance,
ACOs and other vaguely defined "changes to the delivery system."
High-deductible advocates claim consumption of medical services by poor
people can be reduced without harm (because the foregone services
weren't necessary), and the savings can be directed to lower taxes or a
lower deficit. Neither claim is credible.