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
- 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.
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.