March 11, 2025 • 23 mins
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Health Affairs' Senior Deputy Editor Rob Lott interviews Richard Leuchter from the University of California Los Angeles on his recent paper that explores how socioeconomically disadvantaged groups may have underused emergency departments for non-avoidable visits.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Rob Lott (00:31):
Hello, and welcome to A Health Policy. I'm your host,
Rob Lott. Imagine trying tosummarize the health policy
making process, boiling it downto its simplest, most
fundamental goals. You could goin a lot of directions, but I
(00:53):
might suggest something like domore of the things that keep
people healthy, do fewer ofthose that don't. And then maybe
along the way, remember tochoose the more effective tools
and the smoothest pathways whendoing this work.
But, of course, true healthpolicy is a gazillion times more
complex and less obvious. Andeven when the goals are clear,
(01:16):
one can always be sure we havethe right or best tools for the
job. No wonder it's so hard.I've been thinking about this
lately in terms of our approachto emergency department visits.
Some portion of those visitsjust aren't emergencies and
could be handled in othervenues.
It seems clear that shiftingthose visits elsewhere would be
(01:39):
a good thing for people'shealth, for our system's overall
spending, and really forpopulation wide wellness writ
large. Certainly, policymakershave tried to achieve that goal.
Less clear is whether it'sworking, whether we might even
be causing more harm than goodby potentially discouraging
(01:59):
essential urgent care, andwhether other factors, like,
say, a global pandemic, mightalso come into play. This
uncertainty is the subject oftoday's health policy. I'm here
with doctor Richard k Lukter, anassistant professor and internal
medicine physician at UCLA'sGeffen School of Medicine.
(02:22):
Along with his coauthors, he'sthe author of an eye opening new
article in the March issue ofHealth Affairs. Its title is
also one of its main findings.Quote, socioeconomically
disadvantaged groups may haveunderused the emergency
department for nonavoidablevisits from 2018 to 2022.
(02:44):
There's a lot to learn from thispaper, and I can't wait to dig
in. Doctor Richard Kaluchter,thanks for joining us today.
Richard Leuchter (02:52):
Hi, Rob. Thanks so much for having me.
It's great to be here with you.
Rob Lott (02:55):
So let's maybe set the stage here. What do we know
about trends in emergencydepartment use among
socioeconomically disadvantagedpatients before the COVID
nineteen pandemic?
Richard Leuchter (03:10):
Yeah. So ED use represents really a massive
portion of health careutilization and expenditures.
We're talking about, you know,twenty percent of US adults
making ED visits each yearamounting to over
$70,000,000,000 annually. Sonaturally, there's been a lot of
research to characterize thesetrends and also looking at ways
(03:31):
to reign in these costs. Soduring the decade preceding the
pandemic, we know that EDutilization increased somewhere
on the order of, you know, 10 to20% overall depending on the
sources you look at.
And it increased most rapidlyamong socioeconomically
disadvantaged patients. And theHHS actually reported on this to
(03:53):
congress in 2021, and they usedinsurance status, specifically
Medicaid, as a surrogate forsocio economic disadvantage
since, you know, you have to beeither low income or disabled to
qualify. So what this HHS reportshowed was that Medicaid
patients went from accountingfor about twenty five percent of
these kind of low acuity treatand release ED visits in 02/2009
(04:17):
to thirty five percent of themin 2018. So a pretty large
increase in the proportion thereover the decade. And as a result
of this increased utilization, Ithink policymakers have said,
hey.
Let's pass laws designed toreduce avoidable ED utilization
among Medicaid patients sincethey are the highest utilizers
of this service. Now in thispaper, we're talking about two
(04:40):
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, policymakershave wanted to target the
avoidable ED visits since thoseare the ones that are most
amenable to treatment in anoffice based setting.
Rob Lott (05:01):
Okay. That makes sense. Pretty straightforward.
Can you say a little bit aboutwhat's driving that increase
that you just described? Sort ofwhat are factors that would
influence changes in how aparticular population uses or
doesn't use the emergencydepartment?
Richard Leuchter (05:19):
As you might imagine, that's a a complex
question with many factorsdriving it. I think if you had
to kind of distill it down intoa couple key ones, it would
really be access and perception.So in terms of access, what I
mean is that a lot of medicalissues arise after hours. Right.
And if you're, you know, let'ssay a wage worker, maybe you
(05:39):
work multiple jobs, you rely onpublic transit, you don't get
paid time off.
Getting to a clinic duringbusiness hours just might not be
realistic. And this is a realissue actually empirically,
right? Studies have quantifiedavoidable ed visits. And they've
shown that when you restrictthose visits to those that only
occurred during hours thaturgent cares or immediate cares
(06:01):
were open, estimates for thenumber of ED visits that are
potentially avoidable actuallydropped by upwards of forty
percent. So a lot of thesevisits are are happening after
hours, so people just don't haveanother option.
Among Medicaid patients, waittimes are also a huge issue.
These patients face much longerwait times for clinic
(06:21):
appointments compared to otherinsured patients, which kinda
makes the ED the most accessibleresource to receive health care
for them. In terms of theperception piece, what I mean by
that is that other research hasshown, especially in Medicaid
and, you know, their vulnerablepopulations, that they sometimes
(06:41):
perceive that care is better inthe ED, you know, whether or not
that's actually true, that's theperception. And patients also
perceive it as less expensivesince, you know, for example,
Medicaid patients often don'thave co pays for ED visits. And
it's also sometimes viewed askind of a one stop shop where
you can go and you can getimaging done, and you can see
(07:02):
maybe even a specialist or twoin a single trip rather than
scheduling multiple appointmentsover multiple days, which can be
highly problematic for somepopulations.
Rob Lott (07:13):
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 thequestion is, do we have to go to
the emergency room, or can wewait till the next day? And
there are a million factors thataffect that decision, obviously,
whether I have work the next dayand whether I have wheels to get
(07:38):
from one place to the other, andwhat it's gonna cost and how
long I'm expecting to wait. AndI can imagine that for, people
where the answer, do I havetransportation, or is this gonna
break my budget, that questionsuddenly becomes a lot more
complex. So, not not a surprisethere.
(08:01):
I'm curious. This paper looksspecifically during the sort of
COVID time period. What was yourhypothesis about how that
affects EDUs among thispopulation?
Richard Leuchter (08:13):
Yeah. Well, you know, we we knew overall at
the time we were, you know,writing this, that overall ED
utilization dropped during theearly pandemic and to a large
extent, rebounded as well, youknow, within the first six to to
twelve months of the pandemiconset. But before this study, we
didn't know, you know, if thistrend persisted. We didn't know
(08:34):
how it varied based on insurancestatus, and we didn't know how
it varied based on thoseavoidable versus, you know,
potentially nonavoidable visits.So there was evidence in the
literature out there that othertypes of avoidable utilization,
such as avoidablehospitalizations, actually
increased among less wellresourced patients, presumably
(08:57):
due to the increased strain ofthe pandemic making it harder to
access office based care.
Right. Both in terms of, likeyou mentioned, maybe
transportation, maybe finances,maybe loss of insurance due to
loss of employment, all kinds offactors. So by that same logic,
we hypothesized that if, youknow, these were vulnerable
(09:17):
groups are using the hospitalmore for, you know, avoidable
conditions, maybe they're alsorelying on the ED more for
avoidable conditions. And ifthat were the case, you know, we
hypothesized that ED visits forthe for these avoidable
conditions and really allconditions would increase more
for our Medicaid and our dualeligible population.
Rob Lott (09:39):
Okay. So, let's get into it. What did your research,
show? And were the findingsconsistent with your
expectations?
Richard Leuchter (09:48):
So interestingly, our our findings
were actually the exactopposites of what we
hypothesized. So there werereally two stories going on here
in parallel. One is aboutpotentially avoidable ED visits,
and one is about the potentiallynon avoidable ones. The first
story really is aboutpotentially avoidable visits,
and we found that those declinedduring the early COVID pandemic,
(10:11):
and they stayed down. Generallynever got back to above 80% of
pre pandemic levels.
And we looked at the firstreally two and a half years of
the pandemic, through the middleof twenty twenty two. The second
story, though, was about thepotentially nonavoidable visits.
Those similar to the avoidableones also fell in the first part
(10:31):
of the pandemic, but then theyrebounded to pre pandemic
levels. However, the kicker isthat this high level trend was
actually very misleading. Whenwe stratified by insurance type,
we found that this rebound toquote, unquote normal only
occurred among patients withcommercial insurance or
traditional Medicare.
(10:51):
Patients with Medicaid or who orwho were dual eligible for
Medicaid and Medicare neverstarted returning to the ED at
pre pandemic levels. And by theend of our study period, their
ED visit rates were actuallyonly seventy five to eighty
percent of what we would haveexpected based on data from
before the pandemic. So one ofthese narratives is good, and
(11:15):
the other one is concerning. Thepositive story here, right, is
that we have a persistentreduction in potentially
avoidable visits. This suggests,you know, people are using the
ED less for low acuityconditions like upper
respiratory infections, UTIs,you know, your low back pain,
which on a population levelsuggests more efficient health
care utilization.
(11:35):
And this finding happened acrossall insurance types. That's good
news. The concerning story isthe disparity in EDUs for
potentially nonavoidable visits.So we know that our Medicaid and
our dual eligible patients aretypically more socioeconomically
disadvantaged than other insuredpopulations. So this would
(11:55):
suggest that these less wellresourced patients are using the
ED less than they might need forthese higher acuity visits.
Many of these visits aren'tamenable for treatment in the
office based setting. Thinkabout heart failure, for
example. So it's a pretty scaryprospect if these patients are
simply altogether foregoing thisimportant high acuity care.
(12:16):
Meanwhile, patients whohistorically have greater
resources, so in this case,we're talking about our
commercially insured patients,you know, maybe our, you know,
fee for service Medicarepatients. They have resumed
using the ED just as they werepre pandemic.
It's business as usual for them.So, overall, relative ED under
use by our Medicaid and our dualeligible patients is yet another
(12:38):
vulnerability of The US healthcare system that was exposed by
the COVID nineteen pandemic.
Rob Lott (12:43):
Okay. Really fascinating finding there. Take
me back if you can remember.What was your first reaction
when the sort of numbers camecame back and the results were
different than than what youwere expecting?
Richard Leuchter (12:56):
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 checksthere. So I think we were all a
little bit surprised. And whenwe actually put our heads
together and sat down more tothink about it, we did come up
with, you know, some somedifferent hypotheses, and it it
did start to make a little bitmore sense.
(13:18):
But nevertheless, stilldefinitely a surprising finding.
Rob Lott (13:21):
Nice. Well, that's some really important context
and a a nice picture of theresearch process, a glimpse
behind the curtain. In a moment,I'd like to ask you how you
think our system can respondgoing forward. But first, let's
take a quick break. And we'reback.
(13:55):
I'm here with doctor Richard kLukter talking about his paper
from the March issue of HealthAffairs and learning about,
variable trends in emergencydepartment use for different
people and, different kinds ofcare. Doctor Luchter, do you
think we are now on a completelynew post pandemic pathway, if
(14:16):
you will, a kind of new universeor new timeline when it comes to
trends in EDUs after thepandemic? Or is it only a matter
of time before things eventuallyregress to the mean?
Richard Leuchter (14:30):
This is an excellent point about the
possible regression to the meanhere. Our study ended in August
2022, which as I mentioned isalmost two and a half years,
into the pandemic. The landscapethen was certainly more
promising than it was in Marchof twenty twenty in terms of
infection severity, immunity,kind of our overall
(14:52):
understanding and fearssurrounding COVID. But I would
say I wouldn't say things havereached a new normal as they
have now. So I think what thatmeans is one key takeaway is
that further research isdefinitely needed to determine
if these effects persisted,these trends persisted after the
end of the COVID public healthemergency in early twenty twenty
(15:14):
four.
And the other key piece, Ithink, that needs to be studied
is the downstream healthoutcomes associated with reduced
ED utilization. Right? Ourfindings suggest that Medicaid
and dual eligible patients maybe foregoing important ED care,
but it will be critical toevaluate if this has led to
downstream morbidity andmortality. Did not go into the
(15:38):
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 alsobe important to evaluate to what
extent, if any, this care hasbeen shifted from the ED to
alternative settings likeprimary care.
(15:59):
But to answer your question, youknow, I think, you know, we do
need to look to see if these aredurable effects, but also it's
important to remember that therewere populations that we looked
at where there already was aregression to the mean, right?
Our commercially insured and ourtraditional Medicare patients
did bounce back to pre pandemiclevels. So that would kind of.
(16:22):
Are you against the idea thatthere will be a full regression
to the mean among Medicaid ordual eligible patients because
you would say, well, if it'shappened in two other
populations, why hasn't ithappened already in these ones?
Rob Lott (16:34):
Okay. Fair enough. So, I think one of the other big
trends that, jumped out at mostpeople in terms of pandemic and
post pandemic health care is theuse of telehealth. And I'm
curious, if you contemplatedthat in developing, this
research and, what, if anything,you found?
Richard Leuchter (16:55):
Yeah. We definitely did think a lot about
telehealth here. Actually, oneof the senior authors and, one
of my mentors, John Moffi, who'sa coauthor on the paper, has
studied, telehealth quite a bitin conjunction with the other
coauthors on the paper. And whatthey have shown actually among
other researchers is that thereis an association with increased
(17:18):
telehealth adoption and kind ofmodest declines in EDUs. So that
does suggest, you know, probablyto some extent, right, there is
a substitution effect ofshifting ED care to telehealth,
which you know, makes sense withthe massive expansion of
telehealth we saw during thepandemic.
So I think certainly some of thedecline that we're seeing in
(17:41):
this paper and ed utilizationmight be that substitution, but
there's a couple of reasons. Ithink it's unlikely to account
for all of it. First is that,prior work we and others have
done have shown that telehealthis really not an adequate
substitution for a lot of acutecare. You know, we've previously
shown actually that patients whohave their immediate ED
(18:02):
follow-up visit by telehealthare more likely to come back to
the ED than those who have an inperson visit. And then the
other, I think, key piece ofinformation is that we know that
Medicaid patients are lesslikely to adopt video visits
compared to other insuredpopulations.
They use, you know, telephonicvisits instead. And those just
simply aren't sufficient toreplace a lot of ED care. So I
(18:26):
think overall, right, expansionof telehealth may partially
explain the findings we'retalking here, but they do not
completely redress this emergingdisparity.
Rob Lott (18:35):
Over many years, there's been a theory that the
overreliance on ED use fornonemergency care is a major
contributor to high costs andpoor outcomes, and this theory
has driven a lot of publicpolicy movement, if you will.
It's used as an argument forexpanding insurance coverage,
(18:56):
expanding Medicaid, building themarketplaces, for example. And I
wonder if when you look at thattheory through the lens of this
paper, what do you see?
Richard Leuchter (19:09):
So I think overall, the paper is supportive
of the idea of Medicaidexpansion, and I'll tell you why
here. You know, when you look atstates or policy makers that
have been supportive ofexpansion, one argument they
make is that expanding Medicaidgives people coverage for ED
(19:29):
services and actually lowers thebarriers for them to use the ED.
In fact, you know, the HHSreport that I mentioned earlier
notes that relative EDutilization by uninsured
population actually decreasedduring the twenty tens, while
Medicaid utilization increasedduring that period. So they say,
well, if we expand Medicaid,we're gonna have more ED
utilization. It's gonna drive upcosts further.
(19:51):
But because this paper shows areversal in that trend, it pokes
holes in that argument. So weshowed that avoidable ED
utilization decreases massivelyfor Medicaid patients. If you
look at absolute rates, itdecreased more so than any other
insured population. And this hasbeen a durable effect at least
(20:12):
two and a half years into thepandemic. So this paper really
argues against the idea thatexpanding Medicaid will suddenly
result in inefficient EDUs.
I think that in addition toMedicaid expansion, the other
key policy piece, here isreally, regarding policy that
impacts legislation to curb EDutilization, of which there has
(20:36):
really been a lot over the pastdecade. So for example, Anthem
tried to deny payments foravoidable ED visits for patients
in 2018. Actually, UnitedHealthtried to do the same thing in
the wake of the pandemic in2021. They tried to deny those
payments. And there's also aprecedence of state Medicaid
programs targeting avoidableEDUs.
(20:56):
Washington state tried to denypayments for these in 2012.
Arizona tried to deter EDUsamong their Medicaid patients by
implementing ED co payments forthem. I think that was 2015. And
we know that right now, CMS islooking at ways to improve the
efficiency of our edutilization. So with this in
mind, I think there are twoadditional key takeaways for
(21:20):
policymakers who focus on EDutilization.
The first is particularlyimportant in this current era of
Doge and economic austeritypolicies. So to put this in
economic terms, you know, Ithink what we show is that
policies targeting avoidableEDUs among Medicaid patients
will likely carry diminishingreturns, and they will not be as
(21:42):
impactful as cost savingmeasures as they would have been
before the pandemic. So let'sdouble click on that. Right? If
you remember that post pandemicavoidable ED visits for Medicaid
patients have fallen fifty fiveto seventy percent of expected
rates now in the post pandemicera.
So what this means is that ourhighest yield opportunities to
(22:04):
reduce avoidable ED visits havealready been exhausted. So as a
corollary to this is really thesecond key takeaway, which is
that any policies thatexplicitly seek to deter
avoidable ED visits amongMedicaid patients risk greater
unintended spillover tononavoidable visits. As I
mentioned, you know, the lowesthanging fruits to reduce
(22:27):
avoidable ED utilization havealready been picked. So if you
keep trying to get more juiceout of that lemon, you're going
to start getting a bunch ofseeds and pulp and other things
that you may not want. So So inthis case, you know, we're
talking about spillover fromavoidable to nonavoidable
visits.
Your interventions are morelikely to have off target
(22:48):
effects because that target isgetting smaller. So I think both
of these key takeaways arereally just a cautionary tale
that, you know, policymakersneed to be careful when
designing post pandemic policiesthat try to reduce EDU
utilization and curb thosecosts.
Rob Lott (23:06):
Got it. Wow. I I love that metaphor of the lemonade. I
might have to ask our producerif we have the rights to maybe
play some Beyonce on the, on ourway out of the episode. But,
even if we don't, I want to saythank you for, joining us here
today on Health Odyssey.
Richard Leuchter (23:26):
Well, thanks so much for having me, Rob. This
was a lot of fun, and I enjoyedtalking to you.
Rob Lott (23:30):
And to our listeners, thanks for tuning in. In. If you
enjoyed it, please tell afriend. Don't forget to smash
that subscribe button and tunein next week. Thanks for
listening.
If you enjoyed today's episode,I hope you'll tell a friend
about a healthy policy.
Hello, and welcome to A Health Policy. I'm your host,
Rob Lott. Imagine trying tosummarize the health policy
making process, boiling it downto its simplest, most
fundamental goals. You could goin a lot of directions, but I
(00:53):
might suggest something like domore of the things that keep
people healthy, do fewer ofthose that don't. And then maybe
along the way, remember tochoose the more effective tools
and the smoothest pathways whendoing this work.
But, of course, true healthpolicy is a gazillion times more
complex and less obvious. Andeven when the goals are clear,
(01:16):
one can always be sure we havethe right or best tools for the
job. No wonder it's so hard.I've been thinking about this
lately in terms of our approachto emergency department visits.
Some portion of those visitsjust aren't emergencies and
could be handled in othervenues.
It seems clear that shiftingthose visits elsewhere would be
(01:39):
a good thing for people'shealth, for our system's overall
spending, and really forpopulation wide wellness writ
large. Certainly, policymakershave tried to achieve that goal.
Less clear is whether it'sworking, whether we might even
be causing more harm than goodby potentially discouraging
(01:59):
essential urgent care, andwhether other factors, like,
say, a global pandemic, mightalso come into play. This
uncertainty is the subject oftoday's health policy. I'm here
with doctor Richard k Lukter, anassistant professor and internal
medicine physician at UCLA'sGeffen School of Medicine.
(02:22):
Along with his coauthors, he'sthe author of an eye opening new
article in the March issue ofHealth Affairs. Its title is
also one of its main findings.Quote, socioeconomically
disadvantaged groups may haveunderused the emergency
department for nonavoidablevisits from 2018 to 2022.
(02:44):
There's a lot to learn from thispaper, and I can't wait to dig
in. Doctor Richard Kaluchter,thanks for joining us today.
Richard Leuchter (02:52):
Hi, Rob. Thanks so much for having me.
It's great to be here with you.
Rob Lott (02:55):
So let's maybe set the stage here. What do we know
about trends in emergencydepartment use among
socioeconomically disadvantagedpatients before the COVID
nineteen pandemic?
Richard Leuchter (03:10):
Yeah. So ED use represents really a massive
portion of health careutilization and expenditures.
We're talking about, you know,twenty percent of US adults
making ED visits each yearamounting to over
$70,000,000,000 annually. Sonaturally, there's been a lot of
research to characterize thesetrends and also looking at ways
(03:31):
to reign in these costs. Soduring the decade preceding the
pandemic, we know that EDutilization increased somewhere
on the order of, you know, 10 to20% overall depending on the
sources you look at.
And it increased most rapidlyamong socioeconomically
disadvantaged patients. And theHHS actually reported on this to
(03:53):
congress in 2021, and they usedinsurance status, specifically
Medicaid, as a surrogate forsocio economic disadvantage
since, you know, you have to beeither low income or disabled to
qualify. So what this HHS reportshowed was that Medicaid
patients went from accountingfor about twenty five percent of
these kind of low acuity treatand release ED visits in 02/2009
(04:17):
to thirty five percent of themin 2018. So a pretty large
increase in the proportion thereover the decade. And as a result
of this increased utilization, Ithink policymakers have said,
hey.
Let's pass laws designed toreduce avoidable ED utilization
among Medicaid patients sincethey are the highest utilizers
of this service. Now in thispaper, we're talking about two
(04:40):
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, policymakershave wanted to target the
avoidable ED visits since thoseare the ones that are most
amenable to treatment in anoffice based setting.
Rob Lott (05:01):
Okay. That makes sense. Pretty straightforward.
Can you say a little bit aboutwhat's driving that increase
that you just described? Sort ofwhat are factors that would
influence changes in how aparticular population uses or
doesn't use the emergencydepartment?
Richard Leuchter (05:19):
As you might imagine, that's a a complex
question with many factorsdriving it. I think if you had
to kind of distill it down intoa couple key ones, it would
really be access and perception.So in terms of access, what I
mean is that a lot of medicalissues arise after hours. Right.
And if you're, you know, let'ssay a wage worker, maybe you
(05:39):
work multiple jobs, you rely onpublic transit, you don't get
paid time off.
Getting to a clinic duringbusiness hours just might not be
realistic. And this is a realissue actually empirically,
right? Studies have quantifiedavoidable ed visits. And they've
shown that when you restrictthose visits to those that only
occurred during hours thaturgent cares or immediate cares
(06:01):
were open, estimates for thenumber of ED visits that are
potentially avoidable actuallydropped by upwards of forty
percent. So a lot of thesevisits are are happening after
hours, so people just don't haveanother option.
Among Medicaid patients, waittimes are also a huge issue.
These patients face much longerwait times for clinic
(06:21):
appointments compared to otherinsured patients, which kinda
makes the ED the most accessibleresource to receive health care
for them. In terms of theperception piece, what I mean by
that is that other research hasshown, especially in Medicaid
and, you know, their vulnerablepopulations, that they sometimes
(06:41):
perceive that care is better inthe ED, you know, whether or not
that's actually true, that's theperception. And patients also
perceive it as less expensivesince, you know, for example,
Medicaid patients often don'thave co pays for ED visits. And
it's also sometimes viewed askind of a one stop shop where
you can go and you can getimaging done, and you can see
(07:02):
maybe even a specialist or twoin a single trip rather than
scheduling multiple appointmentsover multiple days, which can be
highly problematic for somepopulations.
Rob Lott (07:13):
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 thequestion is, do we have to go to
the emergency room, or can wewait till the next day? And
there are a million factors thataffect that decision, obviously,
whether I have work the next dayand whether I have wheels to get
(07:38):
from one place to the other, andwhat it's gonna cost and how
long I'm expecting to wait. AndI can imagine that for, people
where the answer, do I havetransportation, or is this gonna
break my budget, that questionsuddenly becomes a lot more
complex. So, not not a surprisethere.
(08:01):
I'm curious. This paper looksspecifically during the sort of
COVID time period. What was yourhypothesis about how that
affects EDUs among thispopulation?
Richard Leuchter (08:13):
Yeah. Well, you know, we we knew overall at
the time we were, you know,writing this, that overall ED
utilization dropped during theearly pandemic and to a large
extent, rebounded as well, youknow, within the first six to to
twelve months of the pandemiconset. But before this study, we
didn't know, you know, if thistrend persisted. We didn't know
(08:34):
how it varied based on insurancestatus, and we didn't know how
it varied based on thoseavoidable versus, you know,
potentially nonavoidable visits.So there was evidence in the
literature out there that othertypes of avoidable utilization,
such as avoidablehospitalizations, actually
increased among less wellresourced patients, presumably
(08:57):
due to the increased strain ofthe pandemic making it harder to
access office based care.
Right. Both in terms of, likeyou mentioned, maybe
transportation, maybe finances,maybe loss of insurance due to
loss of employment, all kinds offactors. So by that same logic,
we hypothesized that if, youknow, these were vulnerable
(09:17):
groups are using the hospitalmore for, you know, avoidable
conditions, maybe they're alsorelying on the ED more for
avoidable conditions. And ifthat were the case, you know, we
hypothesized that ED visits forthe for these avoidable
conditions and really allconditions would increase more
for our Medicaid and our dualeligible population.
Rob Lott (09:39):
Okay. So, let's get into it. What did your research,
show? And were the findingsconsistent with your
expectations?
Richard Leuchter (09:48):
So interestingly, our our findings
were actually the exactopposites of what we
hypothesized. So there werereally two stories going on here
in parallel. One is aboutpotentially avoidable ED visits,
and one is about the potentiallynon avoidable ones. The first
story really is aboutpotentially avoidable visits,
and we found that those declinedduring the early COVID pandemic,
(10:11):
and they stayed down. Generallynever got back to above 80% of
pre pandemic levels.
And we looked at the firstreally two and a half years of
the pandemic, through the middleof twenty twenty two. The second
story, though, was about thepotentially nonavoidable visits.
Those similar to the avoidableones also fell in the first part
(10:31):
of the pandemic, but then theyrebounded to pre pandemic
levels. However, the kicker isthat this high level trend was
actually very misleading. Whenwe stratified by insurance type,
we found that this rebound toquote, unquote normal only
occurred among patients withcommercial insurance or
traditional Medicare.
(10:51):
Patients with Medicaid or who orwho were dual eligible for
Medicaid and Medicare neverstarted returning to the ED at
pre pandemic levels. And by theend of our study period, their
ED visit rates were actuallyonly seventy five to eighty
percent of what we would haveexpected based on data from
before the pandemic. So one ofthese narratives is good, and
(11:15):
the other one is concerning. Thepositive story here, right, is
that we have a persistentreduction in potentially
avoidable visits. This suggests,you know, people are using the
ED less for low acuityconditions like upper
respiratory infections, UTIs,you know, your low back pain,
which on a population levelsuggests more efficient health
care utilization.
(11:35):
And this finding happened acrossall insurance types. That's good
news. The concerning story isthe disparity in EDUs for
potentially nonavoidable visits.So we know that our Medicaid and
our dual eligible patients aretypically more socioeconomically
disadvantaged than other insuredpopulations. So this would
(11:55):
suggest that these less wellresourced patients are using the
ED less than they might need forthese higher acuity visits.
Many of these visits aren'tamenable for treatment in the
office based setting. Thinkabout heart failure, for
example. So it's a pretty scaryprospect if these patients are
simply altogether foregoing thisimportant high acuity care.
(12:16):
Meanwhile, patients whohistorically have greater
resources, so in this case,we're talking about our
commercially insured patients,you know, maybe our, you know,
fee for service Medicarepatients. They have resumed
using the ED just as they werepre pandemic.
It's business as usual for them.So, overall, relative ED under
use by our Medicaid and our dualeligible patients is yet another
(12:38):
vulnerability of The US healthcare system that was exposed by
the COVID nineteen pandemic.
Rob Lott (12:43):
Okay. Really fascinating finding there. Take
me back if you can remember.What was your first reaction
when the sort of numbers camecame back and the results were
different than than what youwere expecting?
Richard Leuchter (12:56):
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 checksthere. So I think we were all a
little bit surprised. And whenwe actually put our heads
together and sat down more tothink about it, we did come up
with, you know, some somedifferent hypotheses, and it it
did start to make a little bitmore sense.
(13:18):
But nevertheless, stilldefinitely a surprising finding.
Rob Lott (13:21):
Nice. Well, that's some really important context
and a a nice picture of theresearch process, a glimpse
behind the curtain. In a moment,I'd like to ask you how you
think our system can respondgoing forward. But first, let's
take a quick break. And we'reback.
(13:55):
I'm here with doctor Richard kLukter talking about his paper
from the March issue of HealthAffairs and learning about,
variable trends in emergencydepartment use for different
people and, different kinds ofcare. Doctor Luchter, do you
think we are now on a completelynew post pandemic pathway, if
(14:16):
you will, a kind of new universeor new timeline when it comes to
trends in EDUs after thepandemic? Or is it only a matter
of time before things eventuallyregress to the mean?
Richard Leuchter (14:30):
This is an excellent point about the
possible regression to the meanhere. Our study ended in August
2022, which as I mentioned isalmost two and a half years,
into the pandemic. The landscapethen was certainly more
promising than it was in Marchof twenty twenty in terms of
infection severity, immunity,kind of our overall
(14:52):
understanding and fearssurrounding COVID. But I would
say I wouldn't say things havereached a new normal as they
have now. So I think what thatmeans is one key takeaway is
that further research isdefinitely needed to determine
if these effects persisted,these trends persisted after the
end of the COVID public healthemergency in early twenty twenty
(15:14):
four.
And the other key piece, Ithink, that needs to be studied
is the downstream healthoutcomes associated with reduced
ED utilization. Right? Ourfindings suggest that Medicaid
and dual eligible patients maybe foregoing important ED care,
but it will be critical toevaluate if this has led to
downstream morbidity andmortality. Did not go into the
(15:38):
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 alsobe important to evaluate to what
extent, if any, this care hasbeen shifted from the ED to
alternative settings likeprimary care.
(15:59):
But to answer your question, youknow, I think, you know, we do
need to look to see if these aredurable effects, but also it's
important to remember that therewere populations that we looked
at where there already was aregression to the mean, right?
Our commercially insured and ourtraditional Medicare patients
did bounce back to pre pandemiclevels. So that would kind of.
(16:22):
Are you against the idea thatthere will be a full regression
to the mean among Medicaid ordual eligible patients because
you would say, well, if it'shappened in two other
populations, why hasn't ithappened already in these ones?
Rob Lott (16:34):
Okay. Fair enough. So, I think one of the other big
trends that, jumped out at mostpeople in terms of pandemic and
post pandemic health care is theuse of telehealth. And I'm
curious, if you contemplatedthat in developing, this
research and, what, if anything,you found?
Richard Leuchter (16:55):
Yeah. We definitely did think a lot about
telehealth here. Actually, oneof the senior authors and, one
of my mentors, John Moffi, who'sa coauthor on the paper, has
studied, telehealth quite a bitin conjunction with the other
coauthors on the paper. And whatthey have shown actually among
other researchers is that thereis an association with increased
(17:18):
telehealth adoption and kind ofmodest declines in EDUs. So that
does suggest, you know, probablyto some extent, right, there is
a substitution effect ofshifting ED care to telehealth,
which you know, makes sense withthe massive expansion of
telehealth we saw during thepandemic.
So I think certainly some of thedecline that we're seeing in
(17:41):
this paper and ed utilizationmight be that substitution, but
there's a couple of reasons. Ithink it's unlikely to account
for all of it. First is that,prior work we and others have
done have shown that telehealthis really not an adequate
substitution for a lot of acutecare. You know, we've previously
shown actually that patients whohave their immediate ED
(18:02):
follow-up visit by telehealthare more likely to come back to
the ED than those who have an inperson visit. And then the
other, I think, key piece ofinformation is that we know that
Medicaid patients are lesslikely to adopt video visits
compared to other insuredpopulations.
They use, you know, telephonicvisits instead. And those just
simply aren't sufficient toreplace a lot of ED care. So I
(18:26):
think overall, right, expansionof telehealth may partially
explain the findings we'retalking here, but they do not
completely redress this emergingdisparity.
Rob Lott (18:35):
Over many years, there's been a theory that the
overreliance on ED use fornonemergency care is a major
contributor to high costs andpoor outcomes, and this theory
has driven a lot of publicpolicy movement, if you will.
It's used as an argument forexpanding insurance coverage,
(18:56):
expanding Medicaid, building themarketplaces, for example. And I
wonder if when you look at thattheory through the lens of this
paper, what do you see?
Richard Leuchter (19:09):
So I think overall, the paper is supportive
of the idea of Medicaidexpansion, and I'll tell you why
here. You know, when you look atstates or policy makers that
have been supportive ofexpansion, one argument they
make is that expanding Medicaidgives people coverage for ED
(19:29):
services and actually lowers thebarriers for them to use the ED.
In fact, you know, the HHSreport that I mentioned earlier
notes that relative EDutilization by uninsured
population actually decreasedduring the twenty tens, while
Medicaid utilization increasedduring that period. So they say,
well, if we expand Medicaid,we're gonna have more ED
utilization. It's gonna drive upcosts further.
(19:51):
But because this paper shows areversal in that trend, it pokes
holes in that argument. So weshowed that avoidable ED
utilization decreases massivelyfor Medicaid patients. If you
look at absolute rates, itdecreased more so than any other
insured population. And this hasbeen a durable effect at least
(20:12):
two and a half years into thepandemic. So this paper really
argues against the idea thatexpanding Medicaid will suddenly
result in inefficient EDUs.
I think that in addition toMedicaid expansion, the other
key policy piece, here isreally, regarding policy that
impacts legislation to curb EDutilization, of which there has
(20:36):
really been a lot over the pastdecade. So for example, Anthem
tried to deny payments foravoidable ED visits for patients
in 2018. Actually, UnitedHealthtried to do the same thing in
the wake of the pandemic in2021. They tried to deny those
payments. And there's also aprecedence of state Medicaid
programs targeting avoidableEDUs.
(20:56):
Washington state tried to denypayments for these in 2012.
Arizona tried to deter EDUsamong their Medicaid patients by
implementing ED co payments forthem. I think that was 2015. And
we know that right now, CMS islooking at ways to improve the
efficiency of our edutilization. So with this in
mind, I think there are twoadditional key takeaways for
(21:20):
policymakers who focus on EDutilization.
The first is particularlyimportant in this current era of
Doge and economic austeritypolicies. So to put this in
economic terms, you know, Ithink what we show is that
policies targeting avoidableEDUs among Medicaid patients
will likely carry diminishingreturns, and they will not be as
(21:42):
impactful as cost savingmeasures as they would have been
before the pandemic. So let'sdouble click on that. Right? If
you remember that post pandemicavoidable ED visits for Medicaid
patients have fallen fifty fiveto seventy percent of expected
rates now in the post pandemicera.
So what this means is that ourhighest yield opportunities to
(22:04):
reduce avoidable ED visits havealready been exhausted. So as a
corollary to this is really thesecond key takeaway, which is
that any policies thatexplicitly seek to deter
avoidable ED visits amongMedicaid patients risk greater
unintended spillover tononavoidable visits. As I
mentioned, you know, the lowesthanging fruits to reduce
(22:27):
avoidable ED utilization havealready been picked. So if you
keep trying to get more juiceout of that lemon, you're going
to start getting a bunch ofseeds and pulp and other things
that you may not want. So So inthis case, you know, we're
talking about spillover fromavoidable to nonavoidable
visits.
Your interventions are morelikely to have off target
(22:48):
effects because that target isgetting smaller. So I think both
of these key takeaways arereally just a cautionary tale
that, you know, policymakersneed to be careful when
designing post pandemic policiesthat try to reduce EDU
utilization and curb thosecosts.
Rob Lott (23:06):
Got it. Wow. I I love that metaphor of the lemonade. I
might have to ask our producerif we have the rights to maybe
play some Beyonce on the, on ourway out of the episode. But,
even if we don't, I want to saythank you for, joining us here
today on Health Odyssey.
Richard Leuchter (23:26):
Well, thanks so much for having me, Rob. This
was a lot of fun, and I enjoyedtalking to you.
Rob Lott (23:30):
And to our listeners, thanks for tuning in. In. If you
enjoyed it, please tell afriend. Don't forget to smash
that subscribe button and tunein next week. Thanks for
listening.
If you enjoyed today's episode,I hope you'll tell a friend
about a healthy policy.
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