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NEJM Authors Seek Solutions to Keep Medicaid Clients out of the Emergency Department


Concepts from the patient-centered medical home model can offer answers to giving the newly insured a place to find care outside of the emergency department setting.

One promise of Medicaid expansion is the opportunity to keep those who previously lacked insurance from seeking routine care in the emergency room. In time that may happen, but in the short term it’s not always the case, as authors discuss in commentary published today in the New England Journal of Medicine.

For a variety of reasons, many newly insured continue to seek care where they always have: in the emergency department (ED). Some cannot find a primary care doctor who will take Medicaid; others have always gone to the ED and don’t know another way.

What is clear, according to authors Ari B. Friedman, MS, Brendan Saloner, PhD, and Renee Y. Hsia, MD, is that a sizable share of these new Medicaid beneficiaries have pent-up healthcare needs that are being addressed at great cost. As a study in Oregon found, many newly insured are increasing their ED use, at least temporarily.

The authors note that while policy solutions have called for charging these clients a penalty for inappropriate ED use, real-world factors can make this practice unfair and impractical. A patient with chest pains may think that he is having a heart attack and go to the ED, and it will only be determined later that the condition was not life-threatening. Also, the authors note, financial penalties assume clients have alternatives to the ED when that may not be the case.

The better solution, they write, is to create viable alternatives to the ED using “key components of the patient-centered medical home model, including care coordination, case management, extended hours, and walk-in visits.” They write that the ACA gives state the ability—and money—to experiment with ways to help Medicaid clients manage chronic conditions or severe mental illness, the culprits that account for the lion’s share of ED spending. At present, 16 states have adopted the program.

A common hurdle to good primary care, they write, is transportation. “Yet ironically,” they write, “states such as Indiana that are seeking to penalize patients for ED use have used the same waiver process to curtail nonemergency transportation.” Tools such as taxi vouchers or paratransit are essential, since options such as urgent care clinics may steer clear of the poorest areas.

Finally, the authors write, more must be done to triage patients over the phone, either by training 911 dispatchers or having a physician on-call system. It may make more sense to send a physician to the patient’s home, they write.

“ED waiting rooms impose a substantial time cost on people seeking care, yet more patients visit the ED every year,” they write. “Burdening patients with a bill if the cause of their visit is retroactively deemed not to have been an emergency will probably prove neither equitable nor effective in directing patients to alternative settings,” the authors write. Such practices could, in fact, have unintended consequences. Patients who fear being charged may avoid care when conditions are still manageable, only to need more expensive care later.

It will take leadership from CMS and Medicaid officials in the states to encourage creativity and alternatives, expansion of current demonstration projects, or restoration of lost transportation supports, they write.


Friedman AB, Saloner B, Hsia RY. No place to call home—policies to reduce ED use in Medicaid. N Engl J Med. 2015;372(25):2382-2385.

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