The ER, 9-1-1and the Supermarket

An important fallacy undergirds the logic of the article below and the scholarly article on which it is based. The fallacy: Somehow people should conform their behavior to the systems created by the medical biz rather than vice versa.  It’s important because it shows how a convention can become an axiom in our thinking. The medial business invented the ER, now the ED (Emergency Department).  It’s a delivery system.  The biz wants people to use the ED the way they, the biz leaders, think it should be used. But if thousands of ill people are coming to the ED, re-think the ED, don’t re-think the people or the insurance program!

Docs and nurses are fair-minded and compassionate and work themselves to exhaustion, physically and emotionally.  They often work what seems to me to be holy magic. It’s not an effort question, but an effectiveness question.  There seems to be a “we do the best we can” resignation about use of the ED.  But it’s not the best, it’s just a convention.  Instead of fretting about “crowded” ED’s, transform and expand the ED into a triage center, where docs assess people and  transfer them to the right treatment, from emergency surgery to counseling.   What an opportunity for innovation. The market is talking, no, it’s roaring: the ED is a great triage system.

The ED is just a technique dreamed up by humans. Let’s re-dream it.  While we are at it, let’s ditch the term “patient.”  Let’s use “person” in its place.  It will help the thinking.

Police can use 9-1-1 the same way. 9-1-1 is many wonderful things for the people but it is one thing that no one is making use of. 9-1-1 is a triage system. It gives us information on what is happening in the community. So let’s think about it that way. Rather than stack up demand like the ED does, use demand like the ED should.

Marketing firms would love to have a 9-1-1 system. Look what they do with scans of our groceries. They predict the most efficient, in economic terms, way to stock stores.  The cash register is a huge planning tool.

We can do better than the supermarket.

————-

Study sees rise in ER use by newly insured
By Chelsea Conaboy | GLOBE STAFF JANUARY 03, 2014

People newly enrolled in a health insurance program for the poor were more likely to seek emergency room treatment than people who remained uninsured, Boston-area researchers have found, providing the best evidence to date that the national Medicaid expansion that began this week is unlikely to lead to a decline in emergency services.

The study was published online Thursday by the journal Science, just as millions of Americans have become newly eligible for Medicaid coverage under the Affordable Care Act. Some politicians have suggested that uninsured people who did not have a regular doctor or who delayed treatment as their condition worsened would, once they had coverage, get more of their care in a doctor’s office, rather than the emergency room, where providing it is often more costly.

Previous research on what happened to emergency room usage in Massachusetts, which expanded its Medicaid program and required that most residents have health insurance in 2006, have reached conflicting conclusions. But the new study, of about 25,000 low-income adults randomly selected in 2008 to enroll in Oregon’s Medicaid program, found that the newly insured increased their visits to emergency rooms.

Over an 18-month period, about 42 percent of the new Medicaid enrollees visited the emergency department. In the same period, about 35 percent of those who did not receive Medicaid visited the emergency department. Similar increases were reported by the new Medicaid recipients in an earlier study that looked at use of prescription drugs, hospital stays, and outpatient visits

“Basic economic theory is, if you lower the price, people use it more,” said Amy Finkelstein, a Massachusetts Institute of Technology economist and a senior author on the paper.

‘Policy makers should make decisions based on this evidence that the program has real costs.’

It was not a foregone conclusion in this case, however, that reducing the cost of an emergency room visit would increase use, she said, because the cost of a visit to a primary care doctor and of preventive services that may have helped them avoid the emergency room also decreased with insurance coverage.

Yet, emergency department use among those on Medicaid increased during businesses hours, nights, and weekends. While there was no increase in visits classified as nonpreventable emergencies, there was an increase for visits deemed preventable or treatable by a primary care doctor.

A 2011 study found that overall emergency department visits increased in Massachusetts in the two years after the state expanded insurance coverage under the 2006 state health care law, though visits for “low severity” problems declined slightly.

Dr. Peter Smulowitz, an emergency physician at Beth Israel Deaconess Medical Center and lead author of that study, said he and colleagues have more recently reviewed emergency department use across Massachusetts and found a small increase in pockets of the state that had seen the largest gains in insurance coverage. The study is pending publication.

Data published in the New England Journal of Medicine in 2011, however, found that emergency room usage was already increasing in Massachusetts and nearby states before the expansion of health insurance coverage here and that the law did not change the trend in Massachusetts when compared with the other states.

The Oregon study is unique in that it is a randomized controlled study, considered the gold standard in medical research but rarely feasible in health policy research. The state of Oregon created a valuable study scenario when, because the state had money only for a small expansion of the program, it held a lottery for Medicaid coverage, providing insurance to some people and leaving others uninsured.

Past work by principal investigators Finkelstein and Katherine Baicker, a professor of health economics at Harvard School of Public Health, and their colleagues at the National Bureau of Economic Research in Cambridge has found that the lottery winners were more likely to report feeling better about their mental and physical health and had less financial strain, including fewer bills sent to collection. But there was no improvement in key health factors, such as blood pressure or blood sugar levels, as compared with the uninsured.

With the latest study, Baicker said, the body of research out of Oregon has disproved both the worst and best predictions for Medicaid: that it is an expensive program that does little to improve access to care and overall health, or alternatively, that it is a money-saving program that clearly improves health. The results are far more nuanced.

“Policy makers should make decisions based on this evidence that the program has real costs,” she said. “It’s not free. And it has real benefits. Beneficiaries are clearly better off.”

The authors noted that their study did not draw any conclusions about whether an increase in emergency department use is good or bad, for patients or the health care system. They also say the study population was not representative of people being added to Medicaid rolls nationally; the participants were largely white and urban.

The new Oregon study is an important one showing “there is no free lunch when you expand insurance coverage,” said Jonathan Gruber, an economist at the Massachusetts Institute of Technology who had been involved in other work in Oregon with Finkelstein and Baicker but not in this research. Gruber was an architect of the Massachusetts health law and the Affordable Care Act.

Gruber said it is clear that covering millions more Americans will cost more. He pointed to estimates by the Centers for Medicare & Medicaid Services that the federal law will increase health care spending in the United States by a fraction of a percent per year.

Chelsea Conaboy can be reached at chelsea.conaboy@globe.com. Follow her on Twitter @cconaboy.

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About stephenomeara

My name is Jim Jordan. I have had the privilege of working with the Boston Police Department and hundreds more departments over my nearly 30-year career in police administration and city government. I am now teaching and consulting independently at www.sergeantsleadership.org. I have learned the best of what I know from the thousands of smart, dedicated and ethical police personnel and scholars who have guided me along the way. My address is named for the great Reform commissioner of the Boston Police at the turn of the 20th century. Commissioner O'Meara died just a short while before the Strike in 1919. He was replaced by a vicious puppet (of Gov. Coolidge) named Edwin U. Curtis. Had O'Meara lived events may have turned out quite differently.
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