By Katie Kerwin McCrimmon

More Coloradans are using ERs, but people with Medicaid and Medicare use them the most, not the uninsured, according to a new analysis of the Colorado Health Access Survey (CHAS).

That finding surprised policymakers from The Colorado Trust and the Colorado Health Institute, who today released a new study on ER use in Colorado. High ER use among Medicaid patients will also become a focus of debate about whether Colorado should expand Medicaid under the Affordable Care Act.

Analysts think the uninsured may seek less ER care in part because many of them are young and relatively healthy.

“There’s a myth that’s been perpetuated that the uninsured rely on emergency departments for unnecessary services and that that’s the main place where they get care,” said Jeff Bontrager, director of research on coverage and access for the Colorado Health Institute.

“One of the key surprises was that the uninsured tended to have ED (emergency department) use rates that were much more comparable to people who have private insurance. That flies in the face of conventional wisdom,” Bontrager said.

In 2011, nearly 1.2 million Coloradans, or 22 percent of the population, visited a hospital emergency department at least once in the previous year, up from 1 million, or 20 percent of the population, three years earlier.

Nearly half of those who sought emergency care — 44 percent —  said their visit was for a condition that could have been treated in a doctor’s office or clinic had one been available when they needed help.

People with Medicaid — the poor, disabled, children and pregnant women — had the highest ED use rates (40 percent), followed by elderly patients on Medicare (30 percent). Uninsured people used the ED at a rate of 21 percent, a similar rate to those with private health insurance (19 percent).

Dr. Ned Calonge, president and CEO of The Colorado Trust, which funds the health survey, said there are no simple answers for why ED use has climbed. But he noted that patients say they have a difficult time finding doctors who will accept Medicaid. Waiting lists are long at safety net clinics and low-income patients say they often can’t get appointments quickly when they need care.

Why people seek emergency care. (Click on image to enlarge.) Source: Colorado Health Access Survey.

Other people who used ERs reported that they needed care after their doctor’s office was closed and that the ER was more convenient. Hospitals have been aggressively marketing short ER wait times with real-time web updates, mobile apps, texts and billboards.

“People make choices and they may be picking convenience over continuity of care,” Calonge said. “If I’m insulated from cost, I may just not worry about that.”

Calonge said one of the toughest health care dilemmas is figuring out a co-payment that makes people think carefully about using emergency services, but not one so high that people will avoid care when they need it.

“We’ve wrestled with this for a long time in health care. You can increase out-of-pocket costs. At the same time, we don’t want to raise them so high that…people make the wrong decisions. It’s a complex issue,” he said.

The increase in ED use rose as Colorado’s economy soured. Colorado’s Medicaid caseload is projected to climb to about 740,000 in fiscal year 2013-14, up 32 percent since 2010-11.

States across the country are pondering whether to expand Medicaid to even more people as the Affordable Care Act (ACA) goes into effect. The U.S. Supreme Court ruling that upheld the ACA also gave states the power to decide whether to expand Medicaid.  Many Republican governors have said they will not do so. Colorado Gov. John Hickenlooper has not made a decision yet. High costs for Medicaid patients seeking care in EDs and elsewhere will be a key factor as Colorado policymakers decide how to proceed after the Nov. 6 election.

Calonge noted that ED use rose in Massachusetts after the state required everyone to buy health insurance.

“But, it started adjusting over time. A population that hasn’t been using the system might have pent up needs,” Calonge said.

Ideally, more patients will have regular medical homes in clinics and at doctors’ offices where they can seek less expensive, non-emergency care.

“Regardless of what happens with the election, regardless of what happens with the Affordable Care Act, all of these issues are the same. Ultimately, we’re going to have to figure out how we address them. (ED) use isn’t going to go away by itself,” Calonge said.

Among other key findings:

• The highest users of EDs are young children, adults ages 65 and older, people with disabilities or in poor health, African Americans and people with the lowest incomes.
• High users are also many of the same people who are covered by Medicaid.
• Underinsured Coloradans, those with health insurance, but who still spend more than 10 percent of their income on medical expenses, used EDs at a rate of 30 percent — more often than people who were uninsured.
• ED visits were lowest (12 percent) in the mountain resort counties of Eagle, Garfield, Grand, Pitkin and Summit.
• Mesa County in western Colorado had the highest rates of ED usage (32 percent). The Grand Junction area is often cited as a national leader for low-cost health coverage. Analysts were uncertain why the survey found such high ED usage rates there.
• Nearly 200,000 Coloradans are frequent ED visitors, meaning they sought emergency care three or more times in one year. People with Medicare and Medicaid used EDs most frequently. Those with disabilities and in poor health use EDs more frequently.

When people explained why they sought emergency care, 79 percent said they needed help after hours, 63 percent said they couldn’t get an appointment when they needed it, 45 percent said the ED was more convenient and 28 percent said doctors would not accept their health insurance.

Rates at which people seek emergency care throughout Colorado. (Click on image to enlarge.) Source: Colorado Health Access Survey.

“We tend to see higher use of the ED among vulnerable populations in Colorado. That can mean lots of different things: low-income, poor health status or some minority groups who may be disenfranchised from the health care system,” Bontrager said.

Seniors and children also frequently need ED care.

“The question really becomes are the resources available to handle additional Coloradans covered by Medicaid? How are their health care needs going to be met and are there providers that are available (to serve them)?” Bontrager said.

He said EDs and people who seek care in them have both been demonized for ratcheting up health care costs. Some ED use is absolutely appropriate, for instance for accidents and heart attacks.

For those who don’t need emergency care, policymakers need to find ways to cut wait times, improve care coordination, offer lower-cost after-hours options and support patients as they try to navigate confusing health systems.

“If you have access to primary care and a relationship with a medical home or a doctor, you are less likely to report to an ED to try to get treatment for something that may not be an emergency,” Bontrager said.

The CHAS is based on in-depth surveys of more than 10,000 Colorado households. Pollsters collected the most recent data in 2011. The Trust has committed $4.5 million to conducting the survey every other year until at least 2017.