Why the Affordable Care Act may not rein in ED imaging

One of the side effects of the Patient Protection and Affordable Care Act championed by its supporters was supposed to be a drop in emergency department (ED) volumes, however, an editorial published online Sept. 26 in the Journal of the American College of Radiology argues this drop may not be realized.

The rationale behind the predicted decrease in ED volumes was related to access to primary care, according to Rakesh A. Shah, MD, of Winthrop-University Hospital in Mineola, N.Y. Twenty million Americans have gained coverage or enrolled in new plans in the past year, and the thought was these patients would use standard primary care rather than the safety net of the ED.

Shah pointed out that previous state-level expansions of coverage have instead led to an increase in the use of EDs. A 2006 reform bill in Massachusetts, for example, expanded coverage and was associated with a small but consistent increase in ED use from 2004 to 2009. Oregon expanded its Medicaid program in 2008 and the result was an increase in ED use by as much as 40 percent, according to Shah.

The issue may be a lack of primary care physicians to see newly insured patients, wrote Shah. There is a projected shortfall of 45,000 primary care physicians by 2020. “Increased coverage will not translate into increased access to primary care services unless those physicians are available. The combination of increased insurance coverage and decreasing accessibility to primary care physicians may serve as a driver of the utilization of emergency departments, which are required to see patients at any time.”

For radiology, this could impact the utilization of CT imaging, which has been closely monitored since it saw explosive growth in the early 2000s. Even if steps are taken to ensure appropriateness of CT imaging in the ED, a rising absolute number of patients could lead to larger ED imaging volumes.

“[T]his expansion of coverage may not decompress patient volume in emergency departments, as many of its advocates had hoped, but in fact potentially increase emergency department utilization,” wrote Shah. “Radiology departments should be prepared in the years to come for an increased volume of imaging from emergency departments and the manpower and equipment necessary to meet this potential surge.”