Subscribe
Share
Share
Embed
Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Hello, and welcome to A Health Policy. I'm your host, Rob Lott. Imagine trying to summarize the health policy making process, boiling it down to its simplest, most fundamental goals. You could go in a lot of directions, but I might suggest something like do more of the things that keep people healthy, do fewer of those that don't. And then maybe along the way, remember to choose the more effective tools and the smoothest pathways when doing this work.
Rob Lott:But, of course, true health policy is a gazillion times more complex and less obvious. And even when the goals are clear, one can always be sure we have the right or best tools for the job. No wonder it's so hard. I've been thinking about this lately in terms of our approach to emergency department visits. Some portion of those visits just aren't emergencies and could be handled in other venues.
Rob Lott:It seems clear that shifting those visits elsewhere would be a good thing for people's health, for our system's overall spending, and really for population wide wellness writ large. Certainly, policymakers have tried to achieve that goal. Less clear is whether it's working, whether we might even be causing more harm than good by potentially discouraging essential urgent care, and whether other factors, like, say, a global pandemic, might also come into play. This uncertainty is the subject of today's health policy. I'm here with doctor Richard k Lukter, an assistant professor and internal medicine physician at UCLA's Geffen School of Medicine.
Rob Lott:Along with his coauthors, he's the author of an eye opening new article in the March issue of Health Affairs. Its title is also one of its main findings. Quote, socioeconomically disadvantaged groups may have underused the emergency department for nonavoidable visits from 2018 to 2022. There's a lot to learn from this paper, and I can't wait to dig in. Doctor Richard Kaluchter, thanks for joining us today.
Richard Leuchter:Hi, Rob. Thanks so much for having me. It's great to be here with you.
Rob Lott:So let's maybe set the stage here. What do we know about trends in emergency department use among socioeconomically disadvantaged patients before the COVID nineteen pandemic?
Richard Leuchter:Yeah. So ED use represents really a massive portion of health care utilization and expenditures. We're talking about, you know, twenty percent of US adults making ED visits each year amounting to over $70,000,000,000 annually. So naturally, there's been a lot of research to characterize these trends and also looking at ways to reign in these costs. So during the decade preceding the pandemic, we know that ED utilization increased somewhere on the order of, you know, 10 to 20% overall depending on the sources you look at.
Richard Leuchter:And it increased most rapidly among socioeconomically disadvantaged patients. And the HHS actually reported on this to congress in 2021, and they used insurance status, specifically Medicaid, as a surrogate for socio economic disadvantage since, you know, you have to be either low income or disabled to qualify. So what this HHS report showed was that Medicaid patients went from accounting for about twenty five percent of these kind of low acuity treat and release ED visits in 02/2009 to thirty five percent of them in 2018. So a pretty large increase in the proportion there over the decade. And as a result of this increased utilization, I think policymakers have said, hey.
Richard Leuchter:Let's pass laws designed to reduce avoidable ED utilization among Medicaid patients since they are the highest utilizers of this service. Now in this paper, we're talking about two types of ED visits here. Potentially avoidable ones for things like ear infections, UTIs, low back pain, and then potentially nonavoidable ones, which are for everything else. And, historically, policymakers have wanted to target the avoidable ED visits since those are the ones that are most amenable to treatment in an office based setting.
Rob Lott:Okay. That makes sense. Pretty straightforward. Can you say a little bit about what's driving that increase that you just described? Sort of what are factors that would influence changes in how a particular population uses or doesn't use the emergency department?
Richard Leuchter:As you might imagine, that's a a complex question with many factors driving it. I think if you had to kind of distill it down into a couple key ones, it would really be access and perception. So in terms of access, what I mean is that a lot of medical issues arise after hours. Right. And if you're, you know, let's say a wage worker, maybe you work multiple jobs, you rely on public transit, you don't get paid time off.
Richard Leuchter:Getting to a clinic during business hours just might not be realistic. And this is a real issue actually empirically, right? Studies have quantified avoidable ed visits. And they've shown that when you restrict those visits to those that only occurred during hours that urgent cares or immediate cares were open, estimates for the number of ED visits that are potentially avoidable actually dropped by upwards of forty percent. So a lot of these visits are are happening after hours, so people just don't have another option.
Richard Leuchter:Among Medicaid patients, wait times are also a huge issue. These patients face much longer wait times for clinic appointments compared to other insured patients, which kinda makes the ED the most accessible resource to receive health care for them. In terms of the perception piece, what I mean by that is that other research has shown, especially in Medicaid and, you know, their vulnerable populations, that they sometimes perceive that care is better in the ED, you know, whether or not that's actually true, that's the perception. And patients also perceive it as less expensive since, you know, for example, Medicaid patients often don't have co pays for ED visits. And it's also sometimes viewed as kind of a one stop shop where you can go and you can get imaging done, and you can see maybe even a specialist or two in a single trip rather than scheduling multiple appointments over multiple days, which can be highly problematic for some populations.
Rob Lott:I think I'm not alone in having the experience of it being, the middle of the night, and I've got a screaming baby with a high fever. And the question is, do we have to go to the emergency room, or can we wait till the next day? And there are a million factors that affect that decision, obviously, whether I have work the next day and whether I have wheels to get from one place to the other, and what it's gonna cost and how long I'm expecting to wait. And I can imagine that for, people where the answer, do I have transportation, or is this gonna break my budget, that question suddenly becomes a lot more complex. So, not not a surprise there.
Rob Lott:I'm curious. This paper looks specifically during the sort of COVID time period. What was your hypothesis about how that affects EDUs among this population?
Richard Leuchter:Yeah. Well, you know, we we knew overall at the time we were, you know, writing this, that overall ED utilization dropped during the early pandemic and to a large extent, rebounded as well, you know, within the first six to to twelve months of the pandemic onset. But before this study, we didn't know, you know, if this trend persisted. We didn't know how it varied based on insurance status, and we didn't know how it varied based on those avoidable versus, you know, potentially nonavoidable visits. So there was evidence in the literature out there that other types of avoidable utilization, such as avoidable hospitalizations, actually increased among less well resourced patients, presumably due to the increased strain of the pandemic making it harder to access office based care.
Richard Leuchter:Right. Both in terms of, like you mentioned, maybe transportation, maybe finances, maybe loss of insurance due to loss of employment, all kinds of factors. So by that same logic, we hypothesized that if, you know, these were vulnerable groups are using the hospital more for, you know, avoidable conditions, maybe they're also relying on the ED more for avoidable conditions. And if that were the case, you know, we hypothesized that ED visits for the for these avoidable conditions and really all conditions would increase more for our Medicaid and our dual eligible population.
Rob Lott:Okay. So, let's get into it. What did your research, show? And were the findings consistent with your expectations?
Richard Leuchter:So interestingly, our our findings were actually the exact opposites of what we hypothesized. So there were really two stories going on here in parallel. One is about potentially avoidable ED visits, and one is about the potentially non avoidable ones. The first story really is about potentially avoidable visits, and we found that those declined during the early COVID pandemic, and they stayed down. Generally never got back to above 80% of pre pandemic levels.
Richard Leuchter:And we looked at the first really two and a half years of the pandemic, through the middle of twenty twenty two. The second story, though, was about the potentially nonavoidable visits. Those similar to the avoidable ones also fell in the first part of the pandemic, but then they rebounded to pre pandemic levels. However, the kicker is that this high level trend was actually very misleading. When we stratified by insurance type, we found that this rebound to quote, unquote normal only occurred among patients with commercial insurance or traditional Medicare.
Richard Leuchter:Patients with Medicaid or who or who were dual eligible for Medicaid and Medicare never started returning to the ED at pre pandemic levels. And by the end of our study period, their ED visit rates were actually only seventy five to eighty percent of what we would have expected based on data from before the pandemic. So one of these narratives is good, and the other one is concerning. The positive story here, right, is that we have a persistent reduction in potentially avoidable visits. This suggests, you know, people are using the ED less for low acuity conditions like upper respiratory infections, UTIs, you know, your low back pain, which on a population level suggests more efficient health care utilization.
Richard Leuchter:And this finding happened across all insurance types. That's good news. The concerning story is the disparity in EDUs for potentially nonavoidable visits. So we know that our Medicaid and our dual eligible patients are typically more socioeconomically disadvantaged than other insured populations. So this would suggest that these less well resourced patients are using the ED less than they might need for these higher acuity visits.
Richard Leuchter:Many of these visits aren't amenable for treatment in the office based setting. Think about heart failure, for example. So it's a pretty scary prospect if these patients are simply altogether foregoing this important high acuity care. Meanwhile, patients who historically have greater resources, so in this case, we're talking about our commercially insured patients, you know, maybe our, you know, fee for service Medicare patients. They have resumed using the ED just as they were pre pandemic.
Richard Leuchter:It's business as usual for them. So, overall, relative ED under use by our Medicaid and our dual eligible patients is yet another vulnerability of The US health care system that was exposed by the COVID nineteen pandemic.
Rob Lott:Okay. Really fascinating finding there. Take me back if you can remember. What was your first reaction when the sort of numbers came came back and the results were different than than what you were expecting?
Richard Leuchter:First thing was, let's run it again because we we didn't expect that. And, you know, we check the code. We we do all those those checks there. So I think we were all a little bit surprised. And when we actually put our heads together and sat down more to think about it, we did come up with, you know, some some different hypotheses, and it it did start to make a little bit more sense.
Richard Leuchter:But nevertheless, still definitely a surprising finding.
Rob Lott:Nice. Well, that's some really important context and a a nice picture of the research process, a glimpse behind the curtain. In a moment, I'd like to ask you how you think our system can respond going forward. But first, let's take a quick break. And we're back.
Rob Lott:I'm here with doctor Richard k Lukter talking about his paper from the March issue of Health Affairs and learning about, variable trends in emergency department use for different people and, different kinds of care. Doctor Luchter, do you think we are now on a completely new post pandemic pathway, if you will, a kind of new universe or new timeline when it comes to trends in EDUs after the pandemic? Or is it only a matter of time before things eventually regress to the mean?
Richard Leuchter:This is an excellent point about the possible regression to the mean here. Our study ended in August 2022, which as I mentioned is almost two and a half years, into the pandemic. The landscape then was certainly more promising than it was in March of twenty twenty in terms of infection severity, immunity, kind of our overall understanding and fears surrounding COVID. But I would say I wouldn't say things have reached a new normal as they have now. So I think what that means is one key takeaway is that further research is definitely needed to determine if these effects persisted, these trends persisted after the end of the COVID public health emergency in early twenty twenty four.
Richard Leuchter:And the other key piece, I think, that needs to be studied is the downstream health outcomes associated with reduced ED utilization. Right? Our findings suggest that Medicaid and dual eligible patients may be foregoing important ED care, but it will be critical to evaluate if this has led to downstream morbidity and mortality. Did not go into the ED actually cause, you know, worse outcomes for heart failure or even scarier, did that cause, you know, somebody to, to pass away unnecessarily. It will also be important to evaluate to what extent, if any, this care has been shifted from the ED to alternative settings like primary care.
Richard Leuchter:But to answer your question, you know, I think, you know, we do need to look to see if these are durable effects, but also it's important to remember that there were populations that we looked at where there already was a regression to the mean, right? Our commercially insured and our traditional Medicare patients did bounce back to pre pandemic levels. So that would kind of. Are you against the idea that there will be a full regression to the mean among Medicaid or dual eligible patients because you would say, well, if it's happened in two other populations, why hasn't it happened already in these ones?
Rob Lott:Okay. Fair enough. So, I think one of the other big trends that, jumped out at most people in terms of pandemic and post pandemic health care is the use of telehealth. And I'm curious, if you contemplated that in developing, this research and, what, if anything, you found?
Richard Leuchter:Yeah. We definitely did think a lot about telehealth here. Actually, one of the senior authors and, one of my mentors, John Moffi, who's a coauthor on the paper, has studied, telehealth quite a bit in conjunction with the other coauthors on the paper. And what they have shown actually among other researchers is that there is an association with increased telehealth adoption and kind of modest declines in EDUs. So that does suggest, you know, probably to some extent, right, there is a substitution effect of shifting ED care to telehealth, which you know, makes sense with the massive expansion of telehealth we saw during the pandemic.
Richard Leuchter:So I think certainly some of the decline that we're seeing in this paper and ed utilization might be that substitution, but there's a couple of reasons. I think it's unlikely to account for all of it. First is that, prior work we and others have done have shown that telehealth is really not an adequate substitution for a lot of acute care. You know, we've previously shown actually that patients who have their immediate ED follow-up visit by telehealth are more likely to come back to the ED than those who have an in person visit. And then the other, I think, key piece of information is that we know that Medicaid patients are less likely to adopt video visits compared to other insured populations.
Richard Leuchter:They use, you know, telephonic visits instead. And those just simply aren't sufficient to replace a lot of ED care. So I think overall, right, expansion of telehealth may partially explain the findings we're talking here, but they do not completely redress this emerging disparity.
Rob Lott:Over many years, there's been a theory that the overreliance on ED use for nonemergency care is a major contributor to high costs and poor outcomes, and this theory has driven a lot of public policy movement, if you will. It's used as an argument for expanding insurance coverage, expanding Medicaid, building the marketplaces, for example. And I wonder if when you look at that theory through the lens of this paper, what do you see?
Richard Leuchter:So I think overall, the paper is supportive of the idea of Medicaid expansion, and I'll tell you why here. You know, when you look at states or policy makers that have been supportive of expansion, one argument they make is that expanding Medicaid gives people coverage for ED services and actually lowers the barriers for them to use the ED. In fact, you know, the HHS report that I mentioned earlier notes that relative ED utilization by uninsured population actually decreased during the twenty tens, while Medicaid utilization increased during that period. So they say, well, if we expand Medicaid, we're gonna have more ED utilization. It's gonna drive up costs further.
Richard Leuchter:But because this paper shows a reversal in that trend, it pokes holes in that argument. So we showed that avoidable ED utilization decreases massively for Medicaid patients. If you look at absolute rates, it decreased more so than any other insured population. And this has been a durable effect at least two and a half years into the pandemic. So this paper really argues against the idea that expanding Medicaid will suddenly result in inefficient EDUs.
Richard Leuchter:I think that in addition to Medicaid expansion, the other key policy piece, here is really, regarding policy that impacts legislation to curb ED utilization, of which there has really been a lot over the past decade. So for example, Anthem tried to deny payments for avoidable ED visits for patients in 2018. Actually, UnitedHealth tried to do the same thing in the wake of the pandemic in 2021. They tried to deny those payments. And there's also a precedence of state Medicaid programs targeting avoidable EDUs.
Richard Leuchter:Washington state tried to deny payments for these in 2012. Arizona tried to deter EDUs among their Medicaid patients by implementing ED co payments for them. I think that was 2015. And we know that right now, CMS is looking at ways to improve the efficiency of our ed utilization. So with this in mind, I think there are two additional key takeaways for policymakers who focus on ED utilization.
Richard Leuchter:The first is particularly important in this current era of Doge and economic austerity policies. So to put this in economic terms, you know, I think what we show is that policies targeting avoidable EDUs among Medicaid patients will likely carry diminishing returns, and they will not be as impactful as cost saving measures as they would have been before the pandemic. So let's double click on that. Right? If you remember that post pandemic avoidable ED visits for Medicaid patients have fallen fifty five to seventy percent of expected rates now in the post pandemic era.
Richard Leuchter:So what this means is that our highest yield opportunities to reduce avoidable ED visits have already been exhausted. So as a corollary to this is really the second key takeaway, which is that any policies that explicitly seek to deter avoidable ED visits among Medicaid patients risk greater unintended spillover to nonavoidable visits. As I mentioned, you know, the lowest hanging fruits to reduce avoidable ED utilization have already been picked. So if you keep trying to get more juice out of that lemon, you're going to start getting a bunch of seeds and pulp and other things that you may not want. So So in this case, you know, we're talking about spillover from avoidable to nonavoidable visits.
Richard Leuchter:Your interventions are more likely to have off target effects because that target is getting smaller. So I think both of these key takeaways are really just a cautionary tale that, you know, policymakers need to be careful when designing post pandemic policies that try to reduce EDU utilization and curb those costs.
Rob Lott:Got it. Wow. I I love that metaphor of the lemonade. I might have to ask our producer if we have the rights to maybe play some Beyonce on the, on our way out of the episode. But, even if we don't, I want to say thank you for, joining us here today on Health Odyssey.
Richard Leuchter:Well, thanks so much for having me, Rob. This was a lot of fun, and I enjoyed talking to you.
Rob Lott:And to our listeners, thanks for tuning in. In. If you enjoyed it, please tell a friend. Don't forget to smash that subscribe button and tune in next week. Thanks for listening.
Rob Lott:If you enjoyed today's episode, I hope you'll tell a friend about a healthy policy.