Since Obamacare, L.A. County ER visits show hospitals in 'state of flux'

With the expansion of healthcare, many are watching how the Affordable Care Act affects emergency room use

A key measure of hospital emergency room use in Los Angeles County shows continued growth during the first six months of Obamacare, but also points to shifting patterns of where patients are choosing to receive urgent medical treatment.

With the healthcare expansion last year, many are watching how the Affordable Care Act affects emergency room use.

President Obama has promised his signature health law will gradually reduce expensive ER visits as access to other kinds of care is expanded. Critics contend newly insured patients — especially those enrolled in Medi-Cal, the state's low-income health program that picks up most patient costs — aren't likely to seek care elsewhere, and will overwhelm emergency rooms.

Neither of those outcomes were clearly evident in the first months of the new healthcare system's operation in Los Angeles County, according to a Los Angeles Times analysis.

Data hospitals report to the state show that as insurance coverage was extended to hundreds of thousands of residents, ER visits for ailments not serious enough to require an admission grew 3.9% in the county in the first half of 2014, compared with the same period the previous year. The growth is in line with annual increases of 3% to 5% in the three years prior to the federal healthcare overhaul.

Despite little rise in overall emergency room use, the analysis found some significant changes in the distribution of those outpatient ER visits.

The county's three large public hospitals, which historically have cared for many uninsured patients, recorded a 9% drop in such cases. At the same time, several private hospitals reported double-digit percentage increases in outpatient visits, the analysis found.

What the uneven and changing usage patterns mean — and whether they signal the beginning of a long-term rearrangement of how patients will seek treatment — is not yet clear.

Shannon McConville, a health policy researcher at the Public Policy Institute of California, said the slight growth in visits not leading to an admission — generally considered less serious cases that include those that Obamacare aims to divert away from emergency rooms — was "good news."

In addition, several private hospitals said they have, at least for now, been able to handle increases in ER patient visits.

Torrance Memorial Medical Center's emergency department had an average of 199 patients per day in September, compared with 172 per day in the same month in 2013, said Dr. Brian Miura, co-medical director of urgent care at the center.

The hospital added doctors and nurses to cope with the new patients, and has plans to add more staff in the coming months, he said. The increased visits aren't likely to go "down any time in the near future," Miura said.

Public hospitals, which have had longstanding problems with overcrowding and long emergency room wait times, are looking forward to long-term relief in patient loads, experts say.

"We certainly want the burden to be lifted off of our county hospitals," said UCLA health policy professor Dylan Roby. But that shouldn't be the risk of overcrowding private hospitals that patients may choose to visit instead, he added.

Dr. Christina Ghaly, a top planner with the county Department of Health Services, said the decrease in outpatient visits at her agency's medical centers — Los Angeles County-USC Medical Center in L.A., Olive View in Sylmar and Harbor-UCLA near Torrance — are partly a byproduct of programs put in place to transition to Obamacare.

Three years ago, people who would be eligible for expanded Medi-Cal coverage under the Affordable Care Act were enrolled in a county-run program that allowed them to visit county clinics and doctors. Now, those patients are assigned to primary care doctors and are less inclined to head to emergency rooms for minor problems, she said.

Across the county, the number of emergency room patients covered under expanded Medi-Cal insurance rose from 31% in the first half of 2013 to 38% in 2014. The proportion of ER patients without insurance dropped from 18% in the first half of 2013 to 15% in the first half of 2014.

County officials say that with all the changes, overall ER patient traffic at the public hospitals has remained about the same. That's because, without changing admission criteria, there's been an increase in ER visits by patients whose ailments require a hospital stay. The increased admissions, they say, came mostly from new patients choosing Harbor-UCLA Medical Center, which recently underwent a major upgrade and remodeling.

The initial data on ER visits shows "it really does vary across different communities, across different types of hospitals," said health researcher McConville. "Hospitals are kind of in a state of flux."

Indeed, of Los Angeles County's 74 emergency rooms, 11 treated an additional 2,000 patients or more in the first six months of 2014 compared with the same time in 2013, state records show.

The pace of growth in outpatient ER visits in Los Angeles County accelerated during the first six months of 2014. They were 1.8% higher during the comparable first quarter of 2013, but up 6.1% from the previous year during the second quarter.

Some analysts suspect the increase reflects a lag in signups for Obamacare by some patients until late spring, as well as a bureaucratic bottleneck in the state Capitol that delayed approval of thousands of new Medi-Cal applications.

Experts are divided on whether and when ER visits will level off.

Researcher McConville said there's no guarantee that expanding health coverage will bring down ER visits. The rates of ER use have been rising for several years, she said, in part because more doctors refer patients to emergency departments to ensure they get quick care or are admitted to the hospital.

And for many patients, the emergency room seems like the easiest way to get treatment without an appointment or referral. "It's sort of a one-stop shop," she said.

Lynette Breaux, 35, waited to see a doctor recently in the emergency room at Inglewood's Centinela Hospital Medical Center, which had one of the county's largest increases in outpatient visits — 3,610 more in the first half of 2014.

Breaux, who lives in the Westmont area, said she uses the ER, rather than an urgent care clinic or a primary care doctor, because it's quicker. She said she's visited the ER six times in recent years.

"They know my history here," she said.

Long-term studies examining an expansion of health insurance in Massachusetts eight years ago found ER visits declined or were unchanged. However, another study released last year and cited by Obamacare critics found that newly insured patients in Oregon receiving Medicaid, the government program for the poor and elderly, initially went to the emergency room 40% more than people without coverage.

Yet another study released by UCLA in October found that previously uninsured patients initially visited the ER at very high rates, but the rate dropped off dramatically within a year.

Cathy Fickes, chief executive of St. Vincent Medical Center west of downtown, said it will take time for the full effect of expanded healthcare coverage to become clear. Giving people insurance doesn't mean you "flip a switch" and people know where to go and how best to access care, she said.

Many patients using the hospital's emergency room, which has experienced a 14% jump in outpatient visits in the first six months of 2014, have insurance, she said. But they don't know how to find a regular doctor to provide routine care, she said.

More patient education is needed so the newly covered can make the most of their medical care options, Fickes said.

"There still is a public perception that if you're sick, you can go to the emergency room and they'll take care of everything."

soumya.karlamangla@latimes.com

Twitter: @skarlamangla

ryan.menezes@latimes.com

Twitter: @ryanvmenezes

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