Drs. Zachary F. Meisel and Jesse M. Pines were online at Washingtpost.com to chat with readers about why so many people who are not urgently ill or injured go to the emergency room. An unedited transcript of the chat follows.
Dr. Zachary F. Meisel: Hi everybody. Zack Meisel here ready to chat.
Alexandria, Va.: The ER eventually will be split into emergency and routine areas. Just don't call the routine part universal health care.
Dr. Zachary F. Meisel: Many ERs do just this—they have urgent or walk in sections for low acuity patients. However, the biggest issues are for patients with, say belly pain, who could have a minor or a major issue. By definition going to the ED automatically means by some standards that the patient thinks its an emergency and it has to be treated that way, at least at first.
Jersey City, N.J.: What are the main reasons people choose to go directly to the ER? Is it because of the convenience, or is it to save money??
Dr. Jesse M. Pines: Zack and I had mentioned in the article the main reasons that people go to the ER. The first is that they really need ER services, like they are having a heart attack, a stroke, or have just broken their leg. Another main reason is that they are worried they might be really sick, and they either can't schedule an urgent visit to see a doctor, can't get a hold of their doctor by telephone, or don't have a doctor altogether. One of the reasons that people don't have doctors is that they are uninsured. However, our article stated that the uninsured are just as likely to use the ER as the insured, indicating that it is more of an urgent access issue than an uninsurance one.
Washington: I am frustrated by the current state of our medical community. In the past six years I woke up twice with a blistering earache that made me dizzy and was flat-out painful. Just last month I woke up with the worst sore throat I ever had in my life—something so painful I couldn't speak. In all three cases I woke up on a weekend. I called my different doctors' emergency lines and got no response. Nothing. I called the hospital referral line, and to this day I haven't received a call back from them—they clearly ignored my message.
In all three cases after a period of a few hours where I made multiple calls, I just drove to the emergency room or urgent care facility and got my ears or throat looked at. In the case of my sore throat, it was really strep. If the medical community really cares about lessening emergency room visits, then they have to be in business on Saturday and Sunday for full days—until 6 p.m. or 7 p.m. If not, then what alternative do I have to ER or urgent care? Really, what?
Dr. Jesse M. Pines: Access to care when you need it is a major problem in the U.S. which is what drives people to ERs when they may have better been served in a primary care environment. I agree that a potential solution would be extended hours for clinics.
Dr. Zachary F. Meisel: I think the answer is that of course you should go to the ER if you are really worried or in severe pain. However, there was a chance that a private doctor's office could have made an intervention that helped without sending you to an emergency dept. Consumers should have a way to assess if their primary doc's offices will be responsive at off hours or for urgent follow up. This type of transparency could be used to incentivize primary care providers to come up with systems to handle situations such as yours.
Philadelphia: Decades ago, Philadelphia used to have free health clinics. Obviously they weren't profitable, but they served a large community. Should and could free health clinics ever return to the degree they used to exist?
Dr. Zachary F. Meisel: In Philadelphia there are a number of places for people to go for free or reduced fee care—they are either run by the city department of public health or are private clinics with federal dollars that help support indigent care.
Dr. Jesse M. Pines: I'm not sure whether it is true that free clinics are unprofitable. But it is true that increased availability of free clinics may reduce the demand for ER services. However, people often come to the ER because we can provide more services that free clinics, like CTs, intravenous medication, and access to specialists.
Laurel, Md.: Seems to me I've read a lot of illegal immigrants are abusing the ER, and I don't think by law you can turn them away, but it's unfair to the people who pay insurance. They get pregnant and have babies for free.
Dr. Jesse M. Pines: We cited several studies in the article that show that ER use is actually more common among those with insurance which mirrors the general population (i.e. more are insured than uninsured). And that the uninsured immigrants that you refer to are not actually disproportionate users of ER services overall. Immigrant use of ERs may be more dependent on the number of immigrants in the community than their individual healthcare seeking behavior.
Dr. Zachary F. Meisel: I agree. A good source for information about who is using the Emergency Departments is the National Hospital Ambulatory Medical Survey. It's easily available online and can answer some of these questions.
Harrisburg, Pa.: How much is the shortage of health care professionals contributing to the increased use of emergency rooms?
Dr. Jesse M. Pines: While there are shortages across the board for healthcare professionals (nurses, doctors), the major shortage is in primary care physicians. This is because the economics of primary care does not allow them to be paid a large amount per patient they see. As a result, they have to book their clinics at 100% to pay their staff. When clinics are 100% booked, there is little room for urgent patients or extra time to spend with those who are more complex. Most people don't plan on getting sick. Therefore, clinic overflow and more complex patients are directed squarely to the ERs.
Dr. Zachary F. Meisel: There is some debate among economists about the physician supply. In Philadelphia, if you can pay or have coverage you can find good primary care. However, other communities do struggle with primary care shortages. In our Slate piece, we are particularly interested in why patients who are covered and have doctors still choose (or are sent) to come to the ED when they may not have to.
Boston: One thing you story didn't mention is that people get sick at night, on weekends, on holidays. I was recently in the ER for bronchitis. It was Saturday night, and I was having trouble breathing. I got way too much treatment—IV, X-rays, etc, just in case. I often have taken my kids to an ER. They've got a bad earache, it's 9 p.m., and when I call the doctor's office and finally get to talk to a nurse, she always says go to the ER.
Dr. Zachary F. Meisel: Certainly very important to go to the ED if you can't breathe. Whether or not you got too much testing is probably debatable. One consequence of the ED usage for lower acuity issues is that ED docs and staff will treat your condition like an emergency, at least in the beginning (because by showing up in an ER you have declared that you think it is an emergency as well). Also they may not know you or have access to your outpatient records. This will probably lead to more testing.
Dr. Jesse M. Pines: I agree with Zack on this.
Boston: Walk-in quick clinics are just starting to be allowed in the CVS pharmacies around here. Do you think that type of thing, or more general neighborhood clinics, could help to alleviate some of the strain on ERs?
Dr. Jesse M. Pines: Walk-in clinics like CVS can alleviate some of the strain on ERs. However, while the waits may be shorter, they have fewer resources than ERs do. If they need a more complex assessment (like a CT or an MRI), they will need to come to the ER anyway. Or alternatively, if it is not truly emergent, they can see their doctor (if the doctor will see them in a timely way).
The other issue with walk-in clinics is that people have to pay for services up-front at CVS, where many ERs don't require this. So those who have fewer resources may just choose ERs because they may perceive out-of-pocket costs to be lower, even though the bill they get in the mail will certainly be higher.
Dr. Zachary F. Meisel: Also many communities have tried to set up late night walk in clinics/urgent care centers and for many reasons, they have not been able to stay in business.
Seattle: I have been to the ER three times in my adult life: Once for an ankle injury that may have been a break, but it was swollen to twice normal size and had turned purple, once for chest pains that turned out to be two months of un-treated GERD, and once for appendicitis. Were any of these abuses of the ER?
Dr. Jesse M. Pines: These all seem like reasonable reasons for using the ER.
Dr. Zachary F. Meisel: Agree.
Gaithersburg, Md.: I work with a population with severe and persistent mental illnesses. Many of them have difficulty differentiating between acute symptoms of their illness and non-emergencies. At what point would you consider an ER visit appropriate versus abusing the service? (By the way, I work with Jesse Pines' Mother at CBH Health Life Skills.)
Dr. Jesse M. Pines: You take care of a challenging population of patients and I commend you for that. Regarding their ER use, whether it is appropriate depends on what the complaint is. If it is something that can be taken care of in a primary care office (like a sore throat or a cough), you should take them there. If it is something more serious, like a trauma or they are having chest or abdominal pain, they should come to the ER. Say hello to mom for me.
Dr. Zachary F. Meisel: We, as practicing emergency docs, also struggle with differentiating between serious and non-serious problems in patients with mental illness (despite having access to lots of tests and treatments in the ER). So this is not an easy question.
Washington: Doctor availability is a big issue—even with good insurance, I have trouble finding a doctor who can see me today or tomorrow for something that's urgent. I have to wait days or sometimes weeks to get an appointment (and don't get me started on how long I have to sit in the waiting room once my appointment rolls around). In at least one case, during the wait my condition worsened, and I ended up in the emergency room. Insurance companies could save a lot of money by including urgent care centers in their plans.
Dr. Zachary F. Meisel: Reportable standards for acceptable wait times for urgent care appointments might add transparency and benefit patients in the long run. We discuss this in our article.
Dr. Jesse M. Pines: I would agree with Zack on this. The trick to good health care is getting the right doctor in front of the right patient at the right time. There is currently no system to measure this vital aspect of medical care.
The problem is that people often don't know who the right doctor is and they don't know if they are really having an emergency. If there was some mechanism to efficiently triage these complaints (insurance companies could do this), that would probably reduce ER visits because many issues could be addressed in primary care clinics or directly by specialists.
Washington: The main people who abuse the ER are illegal immigrants. They know the hospital can't call ICE or the authorities, and they know there is no way to find them to pay their bills. It's just not politically correct to say ... but it's the truth, and numbers done lie.
Dr. Jesse M. Pines: Take a close look at the article. There is now objective data that really debunks this myth that all of ER overuse is uninsured and/or illegal immigrants that are abusing the system. If you take a close look at the studies that we quote, the numbers suggest a different answer—it is the insured patients who actually have doctors who account for the increases in ER visits.
Dr. Zachary F. Meisel: Right.
Indianapolis: Would you agree that people need to understand that offering preventive care will reduce ER usage overall—that it's worth the investment?
Dr. Jesse M. Pines: Investment in effective preventive care services is certainly less costly than investing in acute care services like ERs and hospitals.
The problem is that preventive care (like getting someone to quit smoking) doesn't pay nearly as well as a cardiac catheterization if someone is having a heart attack. Think from the perspective of a cardiologist: if you spend 30 minutes with your patient discussing smoking cessation, you get paid a tiny fraction of what you get for a procedure.
The system is built based on economics, which often is not beneficial to the overall health of the population and is certainly more costly.
Dr. Zachary F. Meisel: Just telling people to get primary care may not be what changes their behavior. But realigning incentives (and improving information) so that patients and primary doctors can get more benefit by not going to the ER for a non-emergency problem may help.
Princeton, N.J.: We wouldn't have these ER problems if we had an efficient single-payer health care system. Here are some facts about a single-payer system. The federal part of Medicare has an overhead rate of 2 percent (Canada's is 1.3 percent) while private insurers average more than 15 percent. This fact alone causes waste of over $100 billion a year. In addition, the private insurers put tremendous bureaucratic burdens on physicians that waste more than $200 billion a year. Here is a simple example to show what is happening.
Suppose you had $100 to distribute to 10 people. You could give $10 to each person. Alternatively, you could decide that perhaps not every person deserves the money. You could develop criteria to determine the deserving and then investigate the people to see who meets the criteria. If this costs you $75, and you find out that according to your criteria, only five are deserving. You could take the remaining $25 and give each of these five people $5.
That's what we are doing in health care. We spend so much money trying to deny health care to people that it would be cheaper to give it to everyone. The point is that the rules—who gets covered for what—are made by the private insurance companies that have as their sole goal, as good corporations, maximizing return for their stockholders and executives. They are neither interested in efficiency or good health care. If they can save a buck by having a physician fill out a 40-page form, they will do it.
Other industrialized countries have solved this part. They get much better health care as measured by all the basic public health statistics and they pay much less—half per patient of what we pay. Because of the waste mentioned above, we could give Medicare to everyone without limitation, co-pays or deductions, and with complete drug coverage, without spending a penny more than we do now.
Dr. Zachary F. Meisel: There is an active debate in the field about whether universal health care would change the way people use EDs. Clearly, when the ED is one of the few places that uninsured people can get timely care, it will drive them to the ED in higher numbers. But 2 caveats: first, countries with universal care/single payer systems like Canada still have increasing numbers of patients who use the ERs every year. Also, as we point out in the article, patients with good coverage are still driving the increase in ED use.
Charlotte, N.C.: Some of what happens in an emergency room happens because the staff's default assumption is that something is, in fact, an emergency. I had what turned out to be—seriously—an allergic reaction to nuts I'd never experienced before. Weird tingling, some swelling and dizziness. I really think that—had this happened during normal business hours my own doctor, who knows I have zero risks for heart issues—it would have investigated as something idiomatic. But the emergency room hears tingling and dizzines and, in spite of the fact that I'm an athletic-looking 40-year-old, starts running cat scans and EKGs and running up a bill of over $5,000. Five thousand dollars. (I've got great insurance and my total co-pay was $50.) But if you're an emergency room doctor or nurse, it makes sense that your assumptions tend toward the catastrophic, doesn't it?
Dr. Zachary F. Meisel: Emergency physicians are trained to take care patients who are well or sick. But because we see more acutely ill patients than primary care providers, we may be more biased by experience to assume a patient is sicker than he may ultimately be. Also, as I said in one of the other responses, when a patient shows up in the ED (or is sent there) we are obliged to treat it as an emergency—which may bring on more testing.
Dr. Jesse M. Pines: Agree. Emergency physicians tend to think of the worse case scenario when they are seeing patients and make sure that all the emergencies are ruled out.
Much like if you show a rash to a dermatologist, he'll say 'rash' but if you show a rash to an oncologist, he'll say 'cancer'.
However, our article stated that the uninsured are just as likely to use the ED as the insured, indicating that it is more of an urgent access issue than an uninsurance one.: But couldn't that simply be because the uninsured wait longer and sometimes just stay sick? And doesn't this increase costs in the long run?
Dr. Jesse M. Pines: Yes, absolutely. When people wait longer to be seen, if it is a treatable illness (like an infection), sometime they end up sicker in the end and require more resources. Same goes when people don't see primary care doctors, they don't get preventive services like blood pressure management and cholesterol lowering which can prevent heart attacks and strokes.
Re: Uninsured using the ER: How many of the emergencies for which the uninsured use the ER were preventable, if they had had insurance? My guess is that "abuse" of the ER isn't the problem; it's that lack of insurance turns molehills into mountains.
Dr. Jesse M. Pines: Agreed. Lack of health insurance certainly makes the health of the population worse because they don't get preventive care. I'm not sure anyone has actually quantified the burden of preventable disease caused by uninsurance.
Menomonie, Wis.: Good morning. I am not sure if this is off-topic, but I often have heard the term, "clinical futility." Do you know what this term means? Thank you.
Dr. Jesse M. Pines: That is somewhat off-topic, but clinical futility refers to when additional resources allocated to a patient's care will not change a poor outcome, for example, when there is brain death.
Re: Laurel, Md.: I did a paper last year on this very subject, and believe it or not, American citizens are the worst offenders in using the ER as their own doctor's office. As Dr. Pines and Meisel stated, it is not just one-sided. If you read something that seems logical but may be considered racist, investigate the statement more thoroughly. There are many sites out there that give a truer picture of what is going on.
Dr. Jesse M. Pines: We certainly know that ER visits are going up—67 million in 1996 and 119 million in 2006 in the U.S. Critical thinking about the topic and getting to the heart of who is using the ER and why will hopefully point us to solutions.
Washington: I work evenings/weekends as a telephone triage/advice nurse for an HMO with urgent care clinics open 24-7. Many callers with non-urgent conditions (e.g. rash unchanged for the past two weeks) want to go there or to an ER because they don't have any sick leave coverage at work, rely on public transportation and an unaffiliated ER is "just down the street," or they "just got tired of [the condition]" and want it fixed now (however unlikely that is). All are frustrating from "the system" viewpoint, but at least I have sympathy for the first two. Any suggestions for how to dissuade the third group from using "urgent" care settings for nonurgent problems, which slow response time for everyone else?
Dr. Zachary F. Meisel: Well first it is great that you have this job—I bet you are able to help people sort out whether or not they need to go to the ER (can you schedule urgent or follow up appointments?) So the answer may be creating more positions like yours and training those who staff it how to do a good job triaging patients by phone. But we still have to convince the patients to use the phone service and not just go to the ER because its there or its cheap. As we mentioned in the article, raising cost sharing for ER use (through higher co-pays) may help (but it won't be popular). However, people are already likely paying for low co-pays through their insurance premiums. So raising co-pays may not actually drive more out of pocket health consumer costs.
Dr. Zachary F. Meisel: Thanks everybody for the great questions.
Dr. Jesse M. Pines: Excellent questions, goodbye everyone.