Some Surprises On Emergency Room Use
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A few months ago, the New England Healthcare Institute (NEHI) issued a report on non-urgent use of Emergency Departments. It didn’t get that much public attention, which is too bad. It offered some interesting insights.
First of all, inappropriate — or non-urgent — use of the Emergency Room was not limited to uninsured populations. It showed up across the board. People covered by private insurance, Medicaid and Medicare were just as likely to use the ER for non-urgent care as people without health insurance. About 20% of all ER visits by privately insured and Medicare patients were for non-urgent purposes. About 24% of all ER visits by Medicaid beneficiaries and people without any insurance were for non-urgent purposes.
Second, another 25% of all ER visits for each group were for primary care treatable/preventable maladies. In other words, almost half of all ER visits were either for conditions that could have waited at least 24 hours to be addressed, or could have been solved in a doctor’s office.
Hmmm…We all read stories all the time about how crowded the ER is at many local hospitals, and the burden this puts on the care delivery system. We usually assume this is due to inappropriate use that’s driven by uninsured people seeking the only source of open access care that’s available to them. We also assume, correctly, that this is a pretty expensive and inefficient use of health care delivery resources. ER’s typically cost about 2-5 times more than a physician’s office to treat non-emergency conditions.
National statistics put the cost of treating non-urgent conditions in ERs at about $21 BILLION. In 2005, non-urgent care in the ER in Massachusetts cost about $1 Billion — or around 40% of all ER charges.
These stats, all by themselves, make Minute Clinics and their various clinical incarnations a no-brainer. How can anyone who believes that health care costs are too high look at this data and presume that a Minute Clinic is a bad idea?
But these data also illustrate the limits of a care delivery system that’s built increasingly on a specialty care model. If 70% of all physicians are specialists and only 30% are in primary care — and some 40% of what goes on in an ER belongs in the office a primary care provider, something’s wrong. NEHI is discussing a demonstration/research project they will do in conjunction with the Institute for Healthcare Improvement and some of the IHI’s member hospitals and physicians to figure out if there’s a better way to handle the delivery of non-urgent care.
DHCFP had 2 similar reports released on “preventable” ER visits highlighting the fact that the insured were big users of the ER for preventable illnesses. And the hours of these visits were also not restricted to evening and weekends as one might suspect. Instead people try to get appts from primary care doctors and are sent to the ER because they have no appt slots. We also heard that people avoid their doctors for injuries if they want to ensure that they get a MRI or other scan as the ER doesn’t have the same prior approval restrictions that are the norm in primary care offices. Why don’t insurers look at which physician groups do better at keeping their patients out of ER for primary treatble conditions or require the ones they contract with to have partnerships with other physicians to ensure they have the capacity to see patients sooner. Are there any P4P programs around this issue?
ERs are notoriously busy as you mention and many of what is seen in the ER today is non-urgent and clearly not life threatening. Many patients are not willing to wait even an hour or so to be seen when an ER is busy. Makes me wonder why they even showed up.
Most patients are unable to be seen by their PCP and the ER is their only other option much of the time. As you mentioned we need loads more primary care providers in all areas of the country but unless the financial portion of medicine gets fixed this is unlikely to change soon. Even with an increase in PCPs the benefits of such would take a while to be realized.
Perhaps instead of paying primary care providers more, we need to pay specialist less. Even out the playing field a bit for the good of all of us.
The bottom line here is access to primary care. Even in place such as Massachusetts, where health care is supposedly top notch and abundant, it is extremely difficult to find a primary care physician that accepts new patients. If you are lucky enough to have a primary care physician, you will still find it difficult to get an appointment within a reasonable time, when you really need care.
The obvious solution to this problem is to attract future physicians to primary care, and to have more urgent care centers available for patients.