Sunday, July 1, 2012

Affordable Health Care

As an Emergency Physician, I am concerned about the effects of the Affordable Care Act (ACA) on Utah.  I agree that we need affordable health care available to all citizens.  We also need better access for patients.  However, a couple of observations: 

First, Utah currently has about 13% uninsured patients.  Most of these patients have no regular physician.  Currently, due to the EMTALA laws, any person seeking emergency medical care must be seen and treated in the ED at any time without regard to their ability to pay.  This effectively provides a safety net for them.   However, the safety net can entrap patients:  the care is episodic and the patient is often discharged without a primary care doctor relationship.  It is not ideal. Further, ED care is the most expensive outpatient treatment available.  Pres. Obama noted that each ED bill exceeds a thousand dollars or more.  This is NOT affordable or sustainable health care. However, thousands of uninsured Utah patients utilize EDs each month, because they have nowhere else to go. 

Next, under the SCOTUS ruling Utah will choose if we embrace expansion of Medicaid  eligibility.  According to the Dept of Health, the Utah Medicaid expansion under the ACA will provide health insurance to 100,000 or more currently uninsured Utah patients.  This will provide much needed insurance and it will cost millions of tax dollars.  Further, currently Utah is already underserved in Primary care and many specialties.  We do not have enough physicians for our existing patient population.  Adding thousands more to the Medicaid insured pool of patients will further crowd existing clinics and systems.  As a result, Medicaid patients who according to State Medicaid officials already over utilize EDs, will increasingly seek care in EDs due to limited Primary care access. 

The SCOTUS ruling will also affect those currently with private insurance.  The popular provisions such as additional coverage of patients to age 26, elimination of pre-existing conditions, and other modifications has and will raise insurance premiums.  Many patients will opt to use higher deductibles, health savings accounts and other methods to keep their costs down.  In order to save money, these patients may not visit their physicians as much, and get sicker and then, end up in the ED with even more serious conditions. 

From the emergency medicine view, implementation of this far-reaching law will be complex and challenging.  Here are some solutions I propose for increasing affordable and timely medical care: 

Restore the existing University of Utah Medical school class size to at least one hundred students a year.  Cutting class size was short sighted and this needs to be remedied this coming year. While a longer term solution, it will keep more talented Utah college students here and provide for physicians in the future. 

Increase Utah Medicaid community clinic staffing with more same date and weekend appointments.  This will provide lower cost, timelier access for patients and decrease ED over utilization by Medicaid and other patients. Primary care physicians would lead teams of mid level providers, nurse practitioners, etc. to expand affordable access while ensuring quality of care. 

Use coordinated care counseling in the EDs to educate patients on preventative medical care and appropriate utilization, communication and continuity of care with their primary care physicians. 

Encourage insurers and hospitals to establish lower cost urgent care hospital clinics as an alternative to full emergency care. 

Expand community clinics for substance abuse and psychiatric counseling and care.  Currently, thousands of such patients are treated in EDs, each year, due to lack of outpatient facilities. These clinics would be more effective, lower cost resource for and an alternative to the EDs.  Further, the jails and corrections facilities could also use such clinics and decrease the recidivism rates of their inmates.   

In summary, we are in a crisis regarding health care and reform.  The SCOTUS interpretation of the ACA is both a threat and an opportunity.  How we deal with this will make all the difference.