key: cord-0758219-u6njdkcr
authors: Pines, Jesse M.
title: COVID-19, Medicare-for-All, and the Uncertain Future of Emergency Medicine
date: 2020-06-24
journal: Ann Emerg Med
DOI: 10.1016/j.annemergmed.2020.06.034
sha: 862dab164f59823fd0a10d1fedd3ce98e490307d
doc_id: 758219
cord_uid: u6njdkcr

nan

In this issue of Annals, Smulowitz et al. report on the possible impact of a single-payer Medicare-for-All program on payments to emergency physicians and out-of-pocket costs for treat and release emergency department (ED) visits. 1 A goal of Medicare-for-All is to address the under-and uninsured problem by moving everyone who is uninsured, publicly insured outside of Medicare, or on private insurance to Medicare insurance. Addressing insurance gaps is highly relevant to EDs who have high fixed costs and are required to deliver care for all regardless of the ability to pay. Using national datasets from 2013-2016, Smulowitz This analysis presents one possible outcome that would be good for both patients and emergency physicians. However, any enthusiasm should be tempered by three issues: First, Medicare-for-All is unlikely without broader change in how the U.S. political system works.

Second, the coronavirus pandemic (COVID-19) has caused major shifts in acute care and economics in general which have broad implications for EDs. Third, if surprise billing legislation passes, it would substantially reduce payments to EDs for the privately insured.

The late Princeton economist Uwe Reinhardt described many barriers to implementing Medicare-for-All. 2 Because American political campaigns receive support from special interests, lobbyists have great power over lawmakers and healthcare policy. Powerful insurance industry lobbyists do not favor Medicare-for-All and will vehemently promote continuing private health insurance. Altering lobbyist influence requires campaign finance reform, which is also strongly opposed by lobbyists benefitting from this status quo. While public health or care delivery crises foment desire to change payment policy, a Medicare-for-All system is unfeasible given the power the insurance industry wields over lawmakers. Other less drastic expansions of government-based insurance programs; for example, a public option to compete with private insurance companies or expanded eligibility for existing Medicare and Medicaid programs may be more realistic. The impact of such programs on ED economics would benefit from further analyses similar to the Smulowitz et al. study.

The COVID-19 pandemic markedly changed ED care its first few months. At the April trough, there was a 40-50% fall in year-over-year ED visits. Since then, recovery has been slow and incomplete. Visits fell because the public heard messages predicting overload and saw warzone-like images of EDs. Some wanted to "help" by avoiding care; others feared risking EDbased contagion. Social distancing also lowered ED visits by lowering other daily life risks such as the risk of injuries and other communicable diseases. Limitations on elective procedures also diminished acute post-procedural complications, further lowering ED demand.

Telehealth has also expanded dramatically since COVID-19 as it provides a socially distanced way to get care. Furthermore, restrictions on the ability to bill insurance have relaxed.

This has made telehealth broadly reimbursable, a policy which will likely outlast the pandemic.

While telehealth cannot provide definitive care for many acute conditions, it improves accessibility, aptly resolves some needs and can offer advice whether in-person care is necessary.

During COVID-19, telehealth increases correlated with falling ED and outpatient clinic visits suggesting telehealth substituted for in-person visits. 3 Retail clinics and urgent cares have historically not substantially impacted ED volume. 4, 5 A concern with the telehealth shift is the selective siphoning of low-acuity, privately insured, high margin ED patients. These patients give EDs a financial cushion to serve the critically ill, uninsured, and government insured which pay lower rates and in general have thin or negative margins. 6 Pre-COVID-19, the telehealth industry targeted these profitable patients with varied success. Yet since the arrival of COVID-19, this strategy has flourished. In the end, ED visits may not return to pre-COVID-19 levels, and the ones remaining may be lower margin, publicly insured higher-acuity visits. Another unusual facet of COVID-19: patients with severe illness delayed or avoided care with sites noting fewer ED patients for stroke and other lifethreatening conditions. This is both a public health concern as well as economic concern for EDs and hospitals.

An added threat of COVID-19 is the havoc it's caused on the economy, with unemployment summiting 15% in May 2020. 7 Greater unemployment will increase the uninsured and Medicaid enrollment, two groups whose only option is commonly the ED. States may also limit Medicaid coverage (including ED visits) to control costs with increasing enrollment and falling tax revenue to fund the program. Superimposed on this is another challenge: efforts to limit "surprise billing" (ie. out-of-network providers who seek compensation directly from patients when there is a gap in coverage) which gained momentum before COVID-19 and added support as the pandemic grew. All versions of surprise billing legislation create downward pressure on ED payments for the privately insured further threatening ED economics.

Taken together, these trends paint a gloomy picture of the potential future economics of EDs: Lower volumes and lower average payment per visit. 8 This may mean fewer ED jobs, lower compensation, and even ED closures that care for vulnerable populations such as innercity and rural facilities. The ability to garner institutional support to maintain emergency services will be harder as hospitals face similar economic challenges. The confluence of COVID-19, a shift to telehealth, a broader economic downturn, and surprise billing legislation may together be the tipping point that finally disrupts the fragile economics of hospital-based ED care.

Several unknowns could alter this trajectory. The first is whether telehealth reimbursement continues beyond COVID-19. Second is when the public will feel truly safe coming back again, which will require visible protective equipment, protocols for "clean" and "dirty" areas, and rapid COVID-19 testing. Third is the virus's trajectory: the height and width of additional spikes and the speed of return to normal with a vaccine or "new normal" with people ideally using facemasks. A durable pandemic with periodic openings and closings could suppress ED visits longer-term. Another unknown is the potential reliance on EDs to deliver COVID-19 care. If an effective treatment emerges, demand will markedly increase, particularly among the mild and moderately ill. The financial viability of alternatives to ED care (e.g. primary care) is also uncertain. With other, in-person options fading away, EDs may be the only option in some communities. The final unknown is that all the futurists may be wrong. Perhaps the world will just go back to normal, particularly if the virus loses potency or if Americans stop fearing it.

More than any time in recent history, the future of emergency medicine is uncertain. The COVID-19 pandemic has created short-term, seismic change and may change our long-term practice, payments, and employment options. But there are reasons to be hopeful. Emergency physicians have the skills and ability to adapt to a complex digital world. With great change will come great opportunity. Ultimately, emergency physicians are in an optimal position to innovate in an evolving COVID-19 and post-COVID-19 world.

The Impact of Medicare-for-All on Reimbursement for Emergency Care Treat and Release Visits

Priced Out: The Economic and Ethical Costs of American Health Care

Virtually Perfect? Telemedicine for Covid-19

Why Retail Clinics Do Not Substitute for Emergency Department Visits and What This Means for Value-Based Care

Association Between the Opening of Retail Clinics and Low-Acuity Emergency Department Visits

Is outpatient emergency department care profitable? Hourly contribution margins by insurance for patients discharged from an emergency department

National & state historic unemployment claims

The fragile economics of America's emergency departments