Are most emergency room visits really unnecessary?

Health and medicine explained.
March 9 2010 9:39 AM

Are Most Emergency Room Visits Really Unnecessary?

Cracking down on ER use won't save us as much money as you think.

ER.
Do we need to crack down on unnecessary ER visits?

Much of the ongoing health care reform debate has focused on unnecessary health care expenses—specifically, medical bills that rack up without demonstrably improving peoples' health. According to Peter Orszag, the director of the federal Office of Management and Budget, about $700 billion, or 5 percent of the U.S. gross domestic product, is wasted on unnecessary care, such as extra costs related to medical errors, defensive medicine, and just plain fraud. At the center of this discussion are "unnecessary"ER visits for minor conditions—colds, headaches, and feverish babies —that could be handled more cheaply in doctors' offices. If we could only convince patients to take their stubbed toes to urgent-care clinics or primary-care offices instead of ERs, the thinking goes, we could save a load and help fix this whole health care fiasco.

But there are a few problems with this logic. While the past decade has seen dramatic increases in the use of emergency care and ER crowding, ER care is but a tiny portion of the U.S. health care pie: less than 3 percent. The claim that unnecessary visits are clogging the emergency care system is also untrue: Just 12 percent of ER visits are not urgent. People also tend to think ER visits cost far more than primary care, but even this is disputable. In fact, the marginal cost of treating less acute patients in the ER is lower than paying off-hours primary care doctors, as ERs are already open 24/7 to handle life-threatening emergencies. And while we're at it, let's dispel one other myth: Despite the belief that the uninsured and undocumented flood ERs, most emergency room patients are insured U.S. citizens.

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Overall, our ERs are working about as they ought to be. Dramatic news stories attempt to expose the problem of ER "hyperusers," such as the tale of nine patients in Texas, eight of them drug users, who were responsible for a whopping 2,700 ER visits in six years. * But ER abuse like this is the exception, not the rule. Most "frequent flyers"—a pejorative term used to describe patients who stop by ERs a lot—tend to be the very sick, those with severe asthma, heart failure, or diabetes. When these conditions flare up, patients do, and should,come to the ER. ERs are designed to take care of acutely ill patients, while doctors' offices are not.

Of course, a certain number of ER visits can be labeled discretionary—care that won't make a patient live any longer or make him meaningfully healthier. While ER physicians do treat the critically ill and injured daily, much of their care relieves suffering, provides reassurance, and rules out serious conditions. But think about all the non-ER services that are also discretionary, such as many types of spine surgery (which may not have lasting benefits); cosmetic surgery (nose jobs are the ultimate discretionary health care expense); yearly invasive heart tests doled out in McAllen, Texas (but don't seem to make McAllen residents' hearts tick any better); and even some forms of cancer care, where "good" outcomes are counted if lives are extended by a few weeks. Non-ER discretionary care dwarfs the amount expended on "unnecessary" ER visits.

In the end, most who go or are sent to the ER end up there for good reason. ERs are available for people on an immediate basis when primary care schedules are fully booked and doc-in-the-box CVS Minute Clinics don't have the resources to offer treatments beyond antibiotics and earwax removal. Economists who go looking through old records to find evidence of "wasted ER care" are going to discover some well-known pitfalls. Prudent layperson laws say that insurance companies can't deny payment when an ER patient worried he's having a heart attack ends up diagnosed with heartburn.

In July 2007, then-President Bush exclaimed, "I mean, people have access to health care in America. … After all, you just go to an emergency room." He was lambasted for this statement, but there may a kernel of truth to it. ERs are safety net for the United States and really do ensure that Americans always have someplace to go. Having an always-available resource to alleviate pain, make sure your baby is not truly ill, and patch you up after a nasty fall is vital, even if it turns out that your condition wasn't as serious as you feared.

Ultimately, there's no reason to single out the ER as being more unnecessary than any other health care service. Saving health care dollars is about keeping people well and preventing the use of unnecessary medical procedures and tests, most of which are delivered outside the ER. What we should be doing is reducing unnecessary illness related to the culture of McDonald's, Marlboro, and Michelob by making sure people eat their veggies, take their blood pressure medication, and go for regular runs. Preventing people from getting sick will lower the use of emergency care—not by keeping the worried well from coming in but by avoiding the heart attacks and strokes in the first place.

Correction, March 9, 2010: This article originally misstated the time frame of the nine Texas ER hyperusers' 2,700 visits. The visits took place over the course of six years, not one year. (Return  to the corrected sentence.)

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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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