There are many arguments to make in regards to the benefits accrued by insuring more Americans. One of the anticipated benefits is to decrease the use of emergency room services by the uninsured, who often do not have a primary care physician. A recent study published in ” Science” magazine by Taubman (no relation) and others studied the effect of expanded government – sponsored health insurance in Oregon on emergency room usage. What they found was just the opposite. Newly insured patients used the emergency room 40% more than their uninsured counterparts. The increase in visits was across a broad range of conditions, and the vast majority of the increased visits could have been treated in lower cost primary care physician offices. An accompanying editorial states, “It is possible to argue that this represents greater access to necessary care, or that it shows that insurance serves as further encouragement to seek unnecessarily expensive treatment……Based on this paper’s findings, we have a good reason to anticipate a large increase – and almost surely not a decrease – in traffic to already overburdened emergency departments across the country.”
The reasons for the observed increases in ER use are likely many. One reason may be that patients are just doing what they were told; many busy primary care practices who already have schedules filled with non-emergent cases may tell patients to go to the emergency room so as not to disrupt their schedules. In addition more and more primary care practices employ physician extenders such as nurse practitioners and physician assistants who do not have the training or experience that allows them to comfortably see and treat sicker patients in an office setting. By contrast, in our unique practice model we always keep slots open for sick visits and whenever possible attend to people the same day. Finally, many hospitals (for profit and non- profit) incessantly advertise that patients should come and utilize their emergency rooms by instilling fear that a routine flu might be something more serious. While this may be good for the hospital’s bottom line, that calculus may be changing in Maryland (see previous post on Maryland Medicare Waiver).
Regardless of the causes, the health care system has to deal with the consequences. Warns the editorial, “Whether or not you think universal coverage is a good idea, we had better start planning for it.”
The Affordable Care Act (Obama Care) will allow millions of previously uninsured Americans to purchase health insurance at “affordable” rates. However, if the consumer decides that the health insurance premiums are too high, they may not enroll, and they will continue to rely on hospital emergency rooms for their primary, as well as emergency care. In either event, the current shortage of primary care physicians will be exacerbated.
In Maryland, if reimbursements to experienced primary care practices are cut to 20% or less than Medicare, current medical students may choose a different specialty than primary care.
Many experienced primary care physicians may choose to retire early rather than accept inadequate reimbursement for their services. This will leave primary care to less-experienced primary care physicians and their physician assistant and nurse practitioner helpmates. This could lead to more expensive diagnostic testing of the patient, in order to arrive at a timely and correct diagnosis than an experienced primary care physician would require.
Primary care physicians are the front line troops in our health care system. Their
numbers must increase, or our health care system will be degraded. Adequate compensation must be provided for their years of expensive medical training, their long working hours, and their accumulated expertise.