What's the Big Emergency?Zachary F. Meisel and Jesse M. Pines take readers' questions about E.R. abuse and its culprits.
Posted Thursday, Sept. 18, 2008, at 4:59 PM ETDrs. 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.
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StumbleUponDr. Zachary F. Meisel: Hi everybody. Zack Meisel here ready to chat.
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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.
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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.
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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.
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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.
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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.
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