A new study at Johns Hopkins found that the expansion of Medicaid under the Affordable Care Act had little effect on the number of emergency room visits.
Researchers at Johns Hopkins School of Medicine analyzed the ACA Medicaid expansion in 2014 in Maryland to see if the program made a difference in the amount of patients visiting the emergency room.
“Through the Medicaid expansion, there were some people who believed more patients would choose to go to primary care providers instead of the emergency department, because now they have health coverage, and there were some people who believed that the expansion would swamp the emergency department,” Eili Klein, an assistant professor of Emergency Medicine in the Johns Hopkins University School of Medicine, said in a press release. “We wanted to look at what actually happened.”Researchers examined patient visits at emergency departments across the state of Maryland for an 18-month time period before and an 18-month time period after the ACA Medicaid expansion took effect in 2014. The first six months of 2014 were excluded from the study.
The study, published July 24 in the Annals of Emergency Medicine, found the number of people covered by Medicaid in the state increased more than 20 percent as 160,000 Maryland residents enrolling in Medicaid. The total number of emergency room visits fell by more than 36,000 during the same time period.
“Thirty-six thousand may seem like a lot of visits, but, in Maryland, that only equates to about a 1 percent change,” Klein said. “So, the effect of expanding Medicaid seems to have had no effect on emergency department utilization at an aggregate level.”
The study found that Medicaid covered 6 percent more visits during that time period, but the number of uninsured patient visits also decreased by 6 percent.
“When the patients came in to the emergency department, the payer mix changed,” Klein said. “So people were much more likely to be insured now than they were previously. And most of that was people who were uninsured who then became insured by Medicaid.”
Researchers stressed that even though the ACA did not reduce the burden on emergency departments, the program does have benefits in that it protects patients from expenses of health care services and provides increased financial security to hospitals.
Dr. Lawrence L. Weed, who introduced a system for organizing patient data in the 1950s that is now used in hospitals all over the world, and who led the way in developing a computerized method for aiding in the diagnosis and treatment of diseases, died on June 3 at his home in Underhill, Vt. He was 93.
His son Lincoln confirmed the death.
In the early 1950s, Dr. Weed was a professor of medicine and pharmacology at Yale, where he spent most of his time doing research on microbial genetics. On occasion, though, he would accompany students on their hospital rounds and watch as they struggled to interpret the often chaotic patient notes left by doctors.
It was a sobering experience. “I realized then — and it was very upsetting — that they weren’t getting any of the discipline of scientific training on those wards,” Dr. Weed told The Journal of the American Medical Informatics Association in 2014. “When I pick up a chart that is a bunch of scribbles, I say: ‘That’s not art. It certainly isn’t science. Now, God knows what it is.’”
He responded by creating the problem-oriented medical record, or POMR, a way of recording and monitoring patient information. Two of its features have become nearly universal in health care: the compiling of problem lists and the SOAP system for writing out notes in a patient chart. SOAP stands for subjective, objective, assessment and plan, reflecting the steps that doctors and other health care providers should follow as they move from an initial patient encounter to tests, diagnosis and treatment.
Dr. Weed presented his new method in a two-part article in The New England Journal of Medicine, “Medical Records That Guide and Teach.” Published in 1968, it is one of the most frequently cited articles in the field of medical informatics.
“Saying that POMR was revolutionary almost understates it,” Dr. Charles Safran, the chief of the division of clinical informatics at Beth Israel Deaconess Medical Center and Harvard Medical School, told The Economist in 2005. “There’s probably no one who has more fundamentally affected the way we organize our work than Larry Weed. He fundamentally changed American medicine.”
With a grant from the Department of Health Education and Welfare (now Health and Human Services), Dr. Weed developed a computerized version of POMR that came to be known as Promis — the Problem-Oriented Medical Information System.
This led him, in the 1980s, to another innovation: “knowledge coupling” software linked to a database of medical knowledge derived from thousands of journal articles. Doctors could input the information gathered in the POMR process and then receive a list of possible diagnoses and treatment options, with arguments for and against each option.
Many doctors took a dim view of Dr. Weed’s innovation, regarding it as a challenge to their professional expertise. Dr. Weed saw it as a solution to an intractable problem — the unrealistic expectation that one brain, no matter how well trained, can store and apply the medical knowledge required to make proper decisions.
“For every complaint, for chest pain or abdominal pain, there can be 50 or 60 causes, and the doctor cannot remember all of them,” he told The Boston Globe in 1987. In an interview with The Permanente Journal in 2009, he said, “An epidemic of errors and waste is occurring as we persist in trying to do the impossible.”
Lawrence Leonard Weed was born on Dec. 26, 1923, in Troy, N.Y. His father, Ralph, was a salesman. His mother, the former Bertha Krause, was a homemaker.
Lawrence, known as Larry, was a gifted pianist with a fine baritone voice, but an interest in science led him to earn a chemistry degree from Hamilton College in Clinton, N.Y., in 1945.
After receiving a medical degree from Columbia University in 1947, he took mixed internships in medicine, chest medicine, surgery and clinical pathology at University Hospital in Cleveland and Bellevue Hospital in Manhattan.
Before completing a residency at Johns Hopkins University, he did basic research in biochemistry and microbial genetics at Duke University, the University of Pennsylvania and Walter Reed Army Medical Center (now the Walter Reed National Military Medical Center) in Washington. He then accepted a double appointment at Yale in pharmacology and medicine.
In 1952 he married Laura Brooks, a fellow intern in Cleveland with a medical degree from Yale. She died in 1997. In addition to his son Lincoln, he is survived by two other sons, Christopher and Jonathan; two daughters, Dinny Adamson and Becky Weed; a sister, Nancy Weed; two granddaughters; and two stepgranddaughters.
Dr. Weed’s eagerness to bring scientific rigor to medical record keeping led him in 1956 from Yale to Bangor, Me., where he accepted an offer to direct the new medical internship and residency program at Eastern Maine General Hospital. There he worked out the concepts of POMR.
After four years he became an assistant professor of microbiology at Case Western Reserve University in Cleveland, where, beginning in 1964, he also directed the outpatient clinic of Cleveland Metropolitan General Hospital. In his spare time, he sang with the Cleveland Orchestra Chorus under Robert Shaw.
It was in Cleveland that he began working with computers to develop the Promis system, which he took to the University of Vermont in 1969, where he became professor of community medicine. In the early 1980s he left to start the Problem-Knowledge Coupler Corporation, which developed knowledge-coupling software as well as a PC-based version of the POMR. He left the company in 2006. It was acquired in 2012 by the Atlanta-based company Sharecare, whose AskMD app uses Dr. Weed’s coupling software.
Dr. Weed could be a prickly ambassador for his ideas. He was not shy about criticizing American medical education — he proposed that traditional medical schools be radically restructured — and went a few steps beyond tough love in telling doctors about their limitations.
At one medical conference, as he argued for the superiority of his computer programs over traditional medical expertise, an unhappy surgeon rose to protest. Surely, the surgeon said, experience and intuition counted for something. Dr. Weed met him halfway.
“Well, I’m not saying you don’t have intuitive feelings,” he recalled answering in The Journal of the American Medical Informatics Association. “What I’m suggesting is that they may be worthless.”
Dr. Weed was the author of “Medical Records, Medical Education, and Patient Care: The Problem-Oriented Record as a Basic Tool” (1969); “Your Health Care and How to Manage It: Your Health, Your Problems, Your Plans, Your Progress” (1975); “Knowledge Coupling: New Premises and New Tools for Medical Care and Education” (1991); and “Managing Medicine” (1993).
His last book, the polemical “Medicine in Denial” (2011), written with his son Lincoln, outlined his plan for an overhaul of medical practice, with education aimed at fostering skills rather than knowledge.
He was impatient to see changes. “People have been saying to me since the 1960s, ‘You’re ahead of your time,’” he told the journal Modern Healthcare in 2012. “I say, ‘My God, you want me to live until 160? How long are you going to take?’”