If you think the overcrowding in emergency rooms across the country is because of the uninsured, think again. A new study in the Annals of Emergency Medicine reports that of patients who are frequent users (over 4 times a year) of Emergency Departments, the uninsured represent only 15% of those frequent users. Also the frequent ED users were more likely than occasional users to have visited a primary care physician in the previous year.
They also found that most patients who frequently use the ED have health insurance and the majority of users (60%) were white. These findings contradict the widely held assumption that frequent users are minorities or illegal immigrants without insurance.
It is no surprise that frequent ED users tended to be sicker than occasional users and were more likely to be transported by ambulance. Chronic conditions like renal failure, COPD, asthma and sickle cell disease where common along with "pain". In urban areas like Boston and San Francisco, alcohol related visits and psychiatric conditions led to more frequent visits.
The principle reasons given by patients for using the ED included quick service and ability to receive free care. Most patients had Medicare or Medicaid as their primary insurer.
So what does all of this mean? It points to the fact that we do not have adequate chronic care management in this country. It is hard for patients to get in with their physicians when they are sick and they end up receiving care in emergency departments. If they have complicated illnesses, test are often needed and without care coordination in the physicians office it is easier to send the patient to the ED to "get the tests done". Also many patients pay large co-pays or even $thousands of dollars in deductibles if they see their doctor. These fees are often waived if they go to Emergency Departments.
Health care reform can help these numbers or it can make it worse. To make it better, it is essential to support primary care so more can be done in the office. Offices should be open to accommodate working folks and on weekends. This can only happen if we recognize the amount and level of care that physicians can provide in the office and quit short-changing these critical physicians. The concept of "medical home" will work if there are enough resources paid to the doctors so they can utilize nurses and care coordinators. It does no good to use the term "medical home" without paying for the information technology and personnel that are needed to make it work for patients.
Back in the day of capitation I would receive about $95 a year to care for all of the health needs of a patient. (Yes, you read that right...$95 a year). One visit to the ED would cost $1000. I would reflect that that one visit equaled 10 years of my care. It is no wonder that system died a quick death. But it doesn't look like we have learned much as costs continue to rise and patients still have trouble getting the right care in the right place at the right time.