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.

ER entrance. Click image to expand.
Emergency rooms are crowded with patients who don't need to be there

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."

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.

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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