What's the Big Emergency?Zachary F. Meisel and Jesse M. Pines take readers' questions about E.R. abuse and its culprits.

(Continued from page 2)

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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.

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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.

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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.

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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.

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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.

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