Promising Primary Care Program Cuts Unnecessary ER Visits

Research Corner
November 14, 2023

Soleil Shah, MD, MSc, Research Reporter

Soleil Shah writes Tradeoffs’ Research Corner, a weekly newsletter bringing you original analysis, interviews with leading researchers and more to help you stay on top of the latest health policy research.

One of the biggest reasons I became a primary care doctor was to help keep people healthy, as opposed to only helping them after they get sick. Today’s featured study is a testament to the power of primary care, particularly when it comes to keeping patients out of the hospital. I hope you’ll find the results as thought-provoking as I did. 

P.S. Next week we’re off for Thanksgiving, returning Nov. 28! We hope you, too, will find time to rest, recharge and maybe enjoy a little pumpkin pie.

Promising Primary Care Program Cuts Unnecessary ER Visits

Earlier this year, the share of people in the U.S. without health insurance hit an all-time low. But the uninsured rate remains glaringly high among the country’s roughly 10 million undocumented immigrants.

Half of these folks still report lacking insurance, compared to just 6% of U.S.-born citizens. Most remain ineligible for full Medicaid benefits and unable to buy Obamacare coverage.

Research shows patients without health insurance are more likely to skip or delay medical care and to lack a regular source of care. Can the U.S. find a way to improve access to care for these immigrants — even as lawmakers leave them in an uninsured limbo? 

Absolutely, suggests a study recently published in the American Economic Review by Adrienne Sabety, Jonathan Gruber, Jin Yung Bae and Rishi Sood.

A smoother path to primary care led to fewer ER visits

This team of researchers and New York City officials partnered to run a rigorous randomized evaluation of a pilot program that connected undocumented residents who have low incomes to primary care. Their study shows this approach can work — it not only improved access to primary care, but also slashed emergency room visits by nearly one-fourth.

The intervention sounds simple: Book an initial primary care visit at one of nine city-owned clinics for any eligible undocumented person who wants one. People in the study’s control group were offered information about these clinics, but not given any direct help scheduling an initial appointment.

However, speaking with Rishi Sood (one of the New York City officials who led this study) gave me an extra appreciation for how big of a lift this intervention really was. In just the first couple months, he told me, his team interacted with prospective patients who hailed from 77 different countries and spoke 32 different languages.

Sood and his team took specific steps to ease some concerns that have historically dissuaded this population from seeking health care. The nine participating clinics, for example, were selected because they specialize in serving immigrants and have a legal obligation to serve patients regardless of insurance status or ability to pay.

By the end of the study period, people offered help booking an appointment were nearly 30% more likely to report having a primary care provider than those in the control group.

What I found even more impressive was the impact that this increased access to primary care had on people’s use of the emergency room. For patients who lack insurance, the ER is often the only available source of regular care — even for chronic conditions like diabetes or asthma that can be easily and more cheaply managed in a primary care clinic.

This paper provides strong evidence that many people will pick the more cost-effective option when it’s also easy. Compared to people who received no help booking a primary care appointment, those who did get that help made 23% fewer trips to the emergency room. The impact was even greater — a 32% dip — among patients with at least one chronic condition.

“To find that we drove down emergency department usage — particularly for primary care treatable conditions like hypertension and diabetes — that was really exciting,” Sood said.

Cost and workforce questions could hinder efforts to replicate a promising pilot

As impressive as this intervention’s impact was on health care access and ER use, the study does leave a trio of important questions unanswered.

First, we don’t know whether the easy access to primary care actually improved people’s health. The researchers did report some positive signs — more patients got checked for hypertension and diabetes, for example — but they acknowledged the study’s 14-month time period is likely too short to detect “meaningful changes” in health outcomes. 

Secondly, it is unclear what this intervention’s overall effect on health care costs would be in the long run. While the savings from the decrease in ER visits were significant, they only offset about one-quarter of the program’s total costs. If these primary care visits do in fact improve people’s health for years on end, the savings might accumulate.

The last big question: How generalizable are these findings to other cities and other underserved populations?

“You do wonder if we would find effects this large in a population that is low-income but doesn’t face the same baseline barriers to accessing care as undocumented immigrants,” said Sarah Miller, a University of Michigan associate professor who was not involved in the study.

Miller also noted that attempts to scale-up this approach could run into logistical hurdles, perhaps the biggest being America’s dwindling primary-care workforce. “At some point,” she said, “the low capacity of primary-care physicians and offices is going to kick in.”

From 2005 to 2015, the supply of primary-care physicians in the United States fell by 11% and a recent JAMA study found fewer than one in 10 internal medicine residents are interested in primary-care careers.

This study offers lawmakers who recently clashed over a bill intended to bolster the primary-care workforce one more reason to put aside their differences and do what they can to lure more providers to primary care.

Three Other Studies You Might Have Missed…

  • Less than a third of people who have called the 988 Suicide and Crisis lifeline with serious psychological distress — including frequently feeling significantly depressed or worthless — say they are very likely to call the hotline again. (JAMA Network Open)

  • Uninsured patients with Type 2 diabetes experienced a 21% reduction in hemoglobin A1c — a measure of average blood sugar levels — over the course of six months after receiving free diabetes medications. (American Journal of Managed Care)

  • From 2006 to 2022, the percentage of people each year who switched from traditional fee-for-service Medicare to Medicare Advantage more than tripled, whereas the percentage switching from Medicare Advantage to traditional Medicare declined. (Health Affairs)