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Limited access to primary care increases ED use among Medicaid patients, report finds


A MACPAC report challenges commonly held beliefs about Medicaid patients and their use of emergency departments.

Only 10% of emergency department (ED) visits by Medicaid patients are for non-urgent care, according to a new report from the Medicaid and Children’s Health Insurance Program Payment and Access Commission (MACPAC), which sought to fact-check several commonly-held beliefs about Medicaid. 

MACPAC, a non-partisan federal advisory committee, analyzed several recent studies of ED use and found that the vast majority of ED visits by Medicaid enrollees are medically necessary.

READ: Medicaid pay increases set to continue next year in 6 states

However, the report also confirms that Medicaid patients do visit the ED more frequently than those with private insurance or who are uninsured, but it attributes part of the problem to Medicaid patients’ struggle to access primary care. One-third of adult enrollees and 13% of child enrollees have experienced difficulties with finding a primary care provider.

“Given Medicaid’s historically low reimbursement rates, the shortage of primary care physicians accepting these patients isn’t surprising,” said Alex Rosenau, DO, FACEP, president of the American College of Emergency Physicians, in a written statement. “This lack of access to primary care is even more acute for Medicaid patients with disabilities, who are disproportionately represented on Medicaid rolls. The lack of access to primary care certainly contributes to Medicaid patients’ use of the ER, but for Medicaid patients with serious mental illness, multiple illnesses and homelessness, even having a primary care physician is no bar against appropriate emergency department use.” 

The MACPAC report says that decreasing use of the ED among Medicaid patients isn’t as simple as expanding access to primary care. The report says frequent users of the ED may suffer from mental illness, chronic illness or other complex cases that may not be solved directly by increasing access to primary care.

“Expanding the availability of primary care could lead to more efficient use of the ED,” the report concludes. “However, ED use is likely to remain relatively high in Medicaid until new delivery models are in place to address the needs of frequent users.”

The Affordable Care Act allowed for the expansion of Medicaid eligibility to adults with incomes up to 138% of the federal poverty level. Twenty-four states have opted not to expand Medicaid, and an Urban Institute report found that could leave 6.7 million uninsured in 2016.

But a study published in Science this past January fueled the controversy surrounding Medicaid expansion, when it found that ED use in Oregon was 40% higher among the newly insured.

READ: Emergency room visits increase for newly insured in Oregon, study finds

The MACPAC report acknowledged the findings of the Oregon study, but it says there is insufficient evidence to determine whether Medicaid expansion will lead to a surge in ED use nationwide. It said the effects would likely differ from state to state. 

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Jennifer N. Lee, MD, FAAFP