15 September 2008

Man Bites Dog

Suburban Doc linked to Slate's interesting article on ER crowding and over-use.

Kudos to the authors for having the ability to see through the conventional wisdom that it's the uninsured and the non-urgent care that drive the overcrowding crisis:

The oft-repeated claim is that if we can just find a way to get the abusers out of the E.R. waiting rooms, we'd eliminate many of the high costs associated with health care in the United States. The problem is that this story of the healthy, cavalier, uninsured E.R. abuser is largely a myth. . . . the uninsured don't even use the E.R. any more often than those with insurance do. And now, a new study shows that the increased use of the E.R. over the past decade (119 million U.S. visits in 2006, to be precise, compared with 67 million in 1996) is actually driven by more visits from insured, middle-class patients who usually get their care from a doctor's office.
This fact (emphasis mine) is the most striking thing I have learned in the time I have been following the crisis in Emergency Medicine. Though one minor quibble: the situation is both better and worse than presented above. According to the CDC, the number of ED visits in 1996 was 90 million, not 67 million, so the increase is a mere 32% instead of the 67% reported above. What they did not report is that the number of hospitals with EDs has declined from about 6,000 in 1990 to 3800 in 2006. So, while the number of visits increased, the number of ED beds to accommodate those visits declined precipitously.

As a working ED doctor, I and my colleagues do tend to focus on the perceived over-use of the ED by uninsured and medicaid patients, and the CDC data does back that perception up. The uninsured are twice as likely to visit the ER, and medicaid patients are four times as likely to visit the ER as commercially insured patients (82 vs 48 vs 21 visits per year per 100 patients). But according to the recent data cited by the Slate authors, this was not the driver of the rate of increase of ED visits -- it's the insured patient who do have doctors.

So why is this demographic increasing their usage of the ER? On the physician side:
  • Inadequate pay for, and numbers of, PCPs forces them to schedule their clinics fully, leaving little time for acutely ill patients in the office.
  • PCPs have no financial incentive to reduce ED utilization
  • Malpractice concerns are a positive incentive to direct ill patients to the ER
On the patient side:
  • Consumers' unwillingness to accept scheduling delays in obtaining tests or consultations.
  • Patients' perceptions that they did have an emergency.
  • Perception of quality care at the ED.
  • Convenience and 24/7 availability of the ED.
For our part, EDs have been a willing victim in this crisis. Most EDs make no effort to screen or redirect patients who do not, in fact, have an emergency. (This can be done under EMTALA, though care is needed.) Many hospitals market their EDs as fast, efficient, and high-tech, hoping to attract more paying, insured customers. We create fast tracks to move minor patients through more rapidly, freeing up resources for the truly ill. But all this does is increase the capacity of the ED, and health care follows the "Field of dreams" paradigm: build it, and they will come. Increased capacity drives increased utilization.

Some of these trends are irreversible, I think. The ED is an efficient, albeit expensive, place for rapid and focused evaluations. This fact alone ensures that the ED will remain the resource of first resort for patients who need or want an urgent work-up. As hospitals wake up to the fact that their financial health is increasingly reliant on the performance of the ED (more than half of hospital admissions now originate there), it is predictable that more resources will be dedicated towards expending and updating EDs. In fact, in my neck of the woods, I can think of half a dozen hospitals, my own included, which recently have or soon will be undertaking major renovations to the ERs. This will, however, not solve the overcrowding problem, since these expansions are generally behind the curve and at best barely adequate to meet the future growth. The need for excess capacity to meet surges -- pandemic flu, natural disaster, etc -- is rarely if ever built into the new development.

Even if the nation's ERs all suddenly expanded to a size that they could meet current demand, that would only remove one bottle-neck. The inadequate number of hospital beds and obligate boarding of admitted patients in the ER will continue, putting strain on the capability of ED staff to care for new patients. And the continuing collapse of primary care in the US will shunt more patients in as well.

Good for my business, I guess. More volume, more docs: growth is good, right?

Well, good for me; maybe not for the nation's health. Sorry about that, guys.


  1. Did you see TBTAM's recent post? A patient's insurance company refused to pay for home health to do dressing changes for a wound and suggested the patient go to the ER for daily dressing changes.

  2. Funny...you talk about hospital beds and how it relates to the ER. The NYS DOH wanted to close hospitals, and reduce beds all around NYS. They actually wanted to close 7 hospitals in my area. It is mess.

    The DOH actually came to town and told people to merge or close. It was done by location, but not really by practice focus. The doh wanted religious affliated hospitals to merge with private, county hospitals to merge with non-profits....

    The DOH merges had little to do with a hospital's preformance.


  3. No clinics in our city take our insurance. It's BlueCross/BlueShield but apparently we're "over the line" for coverage. The nearest clinic that /does/ take our insurance is a 45 minute drive.

    Of course, if we were to show up at the ED with (X MINOR COMPLAINT), our insurance would eat the significantly higher fees.

    Go figure.

    (Hubby's ear is clogged with earwax. We've tried every OTC out there - it's been a week and it's only getting worse. So why not hop over to Walgreen's clinic & have a PA look at it? But, no...)

  4. I use the ED a couple times a year for my chronic cluster headaches. I only go in after I've tried oxygen in non-breather mask, imitrex stat dose, ativan, double dose of inderal...etc. they have standing orders my from doc there, every time I get treated like I'm one of the over crowders or a drug seeker. I understand why they could see it that way, but in your opinion is there anything I can do as a patient to make the experience for both doctor and I easier? When I'm in the middle of a ED level attack I'm barely functional, but I could do something to make the docs understand.

  5. Ahh, Miranda, been there done that too many times to count. (Yeah, I'm sorry that I self-harm and I need 200 stitches! Ever been /there/?!)

    As a patient, you can minimize your shit and still get shit. The problem isn't you. But it gets extrapolated to you. Because shit happens and will still happen. Ignore it because it's not you.

    I worked the front end. One more migraineur and I'd kill myself. Sucks for the guys with migraines that would come in. It just gets old. You have to understand. Never mind the folks that should be there. MIs, strokes, broken bones. For every person that could come or go - that flu chick that's barfing her brains out, the person with the Real Migraine - you'll get a bunch of shit. Colds. The flu. (I might have barfed.) Drug seekers.


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