The Allure of the One-Stop Shop
The real reasons why people go to the E.R. when they shouldn't.
Posted Friday, Sept. 12, 2008, at 7:06 AM
Drs. Zachary F. Meisel and Jesse M. Pine chatted online with readers about this story. Read the transcript.
Perhaps you've heard about the guy who is wrecking the American health care system. He is uninsured, has no major medical problems, and loves the emergency room. He is said to stroll in about once a month to various E.R.s around town for reasons as diverse as a simple cold or an STD check. He usually asks a doctor to excuse him from work and complains if he doesn't get a prescription for narcotic pain medication. The cost of his medical care is unnecessarily high because for his complaints, the E.R. is more expensive than a doctor's office would be. But our legendary visitor doesn't have a primary-care doctor: Why should he, since everything he needs is at the local E.R.?
If you believe the conventional wisdom, the E.R. abusers of our nation are especially responsible for many problems in health care. They fill up E.R. waiting rooms and because they can't (or won't) pay their medical bills, the insured patients who prudently wait for weekday appointments to see their doctors end up bearing the costs of the abusers' in the form of higher insurance premiums. 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. E.R. use by the uninsured is not wrecking health care. In fact, 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. So, the real question is: Why is everybody, insured and uninsured, coming to the E.R. in droves? The answer is about economics. The ways in which health information is shared and incentives aligned, for both patients and doctors, are driving the uninsured and insured alike to line up in the E.R. for medical care.
Asymmetric information is one of the reasons for excess E.R. use—information that doctors have but patients don't. The truth is, many people don't have a good way to judge whether a headache or fever is a true medical emergency. Heralded medical stories may contribute: Think about the coverage about Tim Russert's sudden death from a heart attack right after receiving a clean bill of health from his cardiologist. Now say you're the one feeling lightheaded: How do you know you're not going to just drop dead? All the health information on the Internet can serve only to feed the flames of misunderstanding and worry: Google any symptom, and you find a comprehensive list of the deadly diseases that you may have but probably don't. It's quite nerve-racking, and it drives people who may not need to be there to the E.R.
The way that care in outpatient clinics is organized and reimbursed also sends people to the E.R. when what they really need is to see or talk to their primary-care doctors. Here the problem is that primary-care providers have little reason to tell someone not to seek E.R. care, especially if the complaint is potentially serious and may take a little bit of effort to sort out. Assume a patient calls his doctor about a new symptom. Ideally, after listening on the phone and deciding that it's probably nothing serious, the doctor arranges an office visit for the next day, offers reassurance, and averts an unnecessary late-night E.R. visit. But doctors don't get reimbursed for that call. And what if they tell a patient to wait and something bad happens? Then malpractice lawyers have a field day.
Either way, this scenario assumes that a patient can get through to his doctor. Many come to the E.R. because it's always open. We thank the many doctors who do talk to their patients (even though they don't get paid) and schedule the urgent appointments that keep their patients out of our E.R.s. But they may be more the exception than the rule. The old adage "Take two aspirin and call me in the morning" has been replaced by an office secretary or voice-mail message that says, "Hang up and call 911 or go to the nearest E.R."
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.
Photograph of an emergency room by Robert Sullivan/AFP/Getty Images.