25 July 2008

The Uninsured and the ER Overcrowding Crisis

The Annals of Emergency Medicine says that the uninsured do not seem to be to blame.

While this is maybe a little counterintuitive, it is consistent with my experience. Our ED has a poor payer mix, but our uninsured percentage is only about 18-20%, give or take. This number has been fairly steady over the eight years I have been at my current job, and the linked article in Annals implies that the national number has been steady to modestly declining. Given that the numbers of the uninsured have been increasing as a fraction of total population, a decline in the fraction of ED patients without insurance is indeed significant.

What does it mean? I think that it first supports the notion that those without funding for their health care are likely to defer care. Given the number of ED patients presenting with non-emergency conditions, this could be viewed as a feature, not a bug -- but I will reject that as overly cynical. Surely some fraction of the uninsured are in fact deferring needed emergency care due to their inability to pay. Not good.

More significantly, I think this ultimately is related to Kevin's passionate concern about the impending death of primary care in this country. The conclusion the authors drew, quite reasonably in my opinion, is that the increase in utilization of the ER stems from "disproportionate increases in use by nonpoor persons and by persons whose usual source of care is a physician's office." Why are they coming in to the ER? Because there are not enough primary care doctors, and because primary care is so fiscally tenuous that they need to schedule themselves to the hilt to maximize their revenue. If you have a doctor, and you get sick, there is an even likelihood that your doctor will not be able to care for you -- they do not have the time or the capacity to squeeze in their patients when they get acutely ill, especially if their care will involve a procedure, diagnostic studies, or IV therapy. So you get sent to the ER.

I've said it before, and I'll say it again: "Just go to the ER" is not a national health care policy. (despite what Our Dear Leader may think.)

But when you underfund primary care, create a system which reward procedures and skimps on cognitive services, freeze medicare reimbursements on top of it all, it is predictable and unsurprising that the more time- and resource-intensive acute illnesses get shunted to the ER. While it's good for my business, it is decidedly not good for patients, who deserve to be cared for when possible by their personal doctors in a setting where they can devote sufficient time to their care, and it is not good for the country, because ER care is incomplete, fragmented, and expensive.

Memo to Congress: fix primary care, and much of the ER crisis will be alleviated, too.

3 comments:

  1. There also seems to be a pathetic lack of ability to direct admit patients anymore. Primary care docs will see patients in their office and then send them to the ER for the ER docs to arrange specialist consults and admits. I would have thought hospitalists would have solved this problem but I think the primary care docs are so overwhelmed they don't even have the time to wait for a call back from the hospitalists. Its easier just to call the ER and say "I'm sending someone over who needs an admit." I call it the "well baby check" syndrome. Its really all primary care is about anymore, anything out of the ordinary and it throws a wrench in the system.

    I also think the ER's ability to take care of certain problems more efficiently is responsible for some of the overcrowding. Abdominal pain, chest pain, etc requires a workup that can only efficiently be done in the ER. If you're a primary care doc, trying to get lab and a stat CT of the abd done and the results back in a timely manner would be a logistical nightmare.

    I love it when the referring doc then calls and insists that the patient go straight back and not have to wait at triage. OR the patient says "my doctor told me to tell you I needed to go straight back." Oh, sure, he really gets to decide the triage order.

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  2. I wonder if NPs are going to take over the gap left by fleeing PCPs?

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  3. As an ER employee of >20 years, I must concur with pdx nurse in one regard. Nobody could be more aware than myself of the attitude towards utlizing the ER for non emergent care; but I have and will probably continue to do so. Caveat: I am a middle class, middle aged Blue Cross subscriber whose husband is a nurse at a large urban midwestern teaching hospital and I am a a MENSA member-not a neurotic, welfare, drug seeking type. What has first hand ER observation taught me? Hmmm....I develop new onset, fairly severe abdominal pain. I call my PCP of just over a year (whom I have seen only once in our "get acquainted" visit as I have no chronic medical maladies). Am told I can be squeezed in the next day (did I mention I have 5-6/10 RLQ pain)? See doctor next day. The entire time his gaze is concentrated somewhere above my left ear. Palpates my belly, asks a few questions (and sorry baby docs who are positive that only many years of technical, esoteric education enables them to know what questions to ask-and what the answers should be), I had already asked myself those questions, which I know from being "pimped" for many years by documenting H & Ps, physically ordering resultant tests, viewing the results and recording which further tests & meds are appropriate based on that information. A person of average intelligience can pick up a thing or two that way-over 20 yesrs! He seemed put out rather than otherwise when I gave him an excellent history without his having to ask -before you ID me as one of those smartasses, I'm really, really not-just not stupid & tired of being treated as though I am merely a bother whose every c/o must be somatic (this is a new phenomenom, didn't used to be this way). After watching him gaze into the air for awhile, I am sent out with instructions not to eat anything spicy (no, really?), a handful of out patient scripts (and an NSAID for my pain-pain seems to be an inconsequential consideration), and my co-pay receipt. It seems, hurting pretty badly and now a little worried, that I am to drive out to the county for my OP labs, and a plain KUB/upright. What he expected to find out from the KUB I have yet to discover. Tests showed nothing conclusive-pain dissipated over a few days-forgot about it. Six months later, pain returns-worse. Saw dr again-ordered same tests!! Left the office, drove straight to a county ER(waits are less and staff seem less harried). Had lab tests, US, and medicated effectively for pain. Paid $50copay vs. $15 @ dr office-OK by me. US revealed ovarian cyst, which must have ruptured spontaneously since I have had no return of symptoms. Tell me what incentive I have to see my PCP again? My own observation is that most ER regulars have figured this out as well. When I am ill or hurting, I need care and answers now-not a shrug of the shoulders and driving all over town, still hurting! I'm not a high maintenance patient by any means-but I want my doctor to treat me as he/she would treat themselves. Increasingly, neither I nor anyone of my acquaintance receives that except in an ER.

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