Why people overuse the E.R.

Health and medicine explained.
Sept. 12 2008 7:06 AM

The Allure of the One-Stop Shop

The real reasons why people go to the E.R. when they shouldn't.

Drs. Zachary F. Meisel and Jesse M. Pine chatted online with readers about this story. Read the transcript.

(Continued from Page 1)

What about those long E.R. waits when patients get there—aren't they a disincentive for going unless you're sure you're having a real emergency? Yes, E.R. crowding has been shown to lower patient care and satisfaction. And yet, patients may still rationally decide that the E.R. is more efficient than waiting for a doctor's appointment, waiting more for outpatient lab and radiology tests, and then waiting again for another appointment to review and discuss the results. In 2005, the EMPATH study, a national survey of emergency-department patients, sought to answer why patients choose the E.R. rather than other sources of care. The authors found that nearly all such patients believed they had a real emergency. They also cited an appreciation for quality and convenience. Over the past 30 years, E.R.s have insisted on the availability of rapid test results and highly trained personnel. The EMPATH study suggests that patients with nonemergency cases may also now seek the high-tech, high-quality E.R. care just because it's there. This affects how doctors use the system, too: sending patients to the E.R. when they have a new symptom, need a CT scan, or should see a specialist. E.R.s have become one-stop shops, assuming that you're willing to lie on a foam stretcher in a hallway for eight hours.

Low co-pays push patients in the same direction. The RAND Health Insurance Experiment in the 1970s showed that patients use more health care (even if it doesn't make them healthier) when they don't bear much of the cost directly. In the E.R., a single $100 co-pay may feel like a relative bargain compared with the alternative: fees for multiple trips to the doctor and testing centers, hours on the phone arranging the whole process, and days of missed work.

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If you are uninsured, it's even more rational to get your care in the E.R. Federal law requires a screening exam and treatment for any patient who shows up, regardless of whether they can pay. And hospitals, after a string of negative press reports, are less likely than ever to aggressively pursue patients for delinquent medical bills. In contrast to ERs, primary-care clinics routinely fail to provide urgent appointments for patients who are uninsured, even if they have a serious condition or are willing to pay cash for their visit.

The problem, of course, is that societal health costs end up higher because of E.R. overuse. This is because many conditions can be prevented through health maintenance programs, like managing blood pressure or cholesterol, which E.R. doctors don't do. Instead of the relatively small costs of seeing the doctor and taking a generic blood pressure pill, we foot the bill for expensive, high-tech services when the uninsured with no preventive care develop strokes and heart attacks.

Ultimately, it doesn't take a genius to outline a cure for E.R. overuse. We could start by changing the incentives to line up with rapid access to urgent primary and specialist care. This could be achieved by developing reportable standards for acceptable waiting times for appointments. Next time you call the dermatologist and they say, "We'll see you next summer," you could cry foul. We also should restructure the payment system for primary-care doctors so they won't go belly up if their schedules aren't 100 percent booked, given how little they're paid per patient. They should get paid for those after-hours calls. Then there are fixes on the E.R. side: Some emergency rooms have considered taking steps to try to change the law on medical screening exams and triage, so that some E.R. patients could legally be sent away without seeing a doctor as long as they could get to see a primary-care doctor within 24 hours. Another promising idea is to send patients with nonemergency conditions directly to affiliated primary-care clinics without a complete E.R. work-up. But this would only work if clinics made room for E.R. patients, who may or may not have insurance.

For now, if you're stuck in the E.R. with a real emergency (like chest pain that you think might be a heart attack) and you sit down next to a guy with a clearly minor problem (like a sprained pinky), just remember that he may be making as rational a choice as you are. The problem is a lot bigger than his aching pinky and the pain in your chest.

Zachary F. Meisel is a practicing emergency physician, a Robert Wood Johnson Foundation clinical scholar at the University of Pennsylvania, and a senior fellow at the Leonard Davis Institute of Health Economics.

Jesse M. Pines is a practicing emergency physician and an associate professor of emergency medicine and health policy at George Washington University in the Center for Health Care Quality.

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