September 8th, 2010
The busy daytime schedules of office-based primary care doctors, coupled with limited access to primary care services, have led a large number of Americans to seek care in hospital emergency departments, even when the problem may not be an emergency. According to a new study in the September issue of Health Affairs, more than a quarter (28 percent) of visits for acute care—treatment for a new complaint such as stomach pain, fever, chest pain, or cough or for a flare-up of a chronic condition—are made to emergency departments today. In contrast, fewer than half (42 percent) of visits for acute care are made to the primary care doctor.
“More and more patients regard the emergency department as an acceptable or even the proper place to go when they get sick, and the reality is that the ER is frequently the only option,” says lead study author Stephen R. Pitts, an associate professor of medicine in the Department of Emergency Medicine at Emory University School of Medicine. “Primary care doctors have packed schedules and their offices are typically closed in the evenings and on weekends. Too often, patients can’t get the care they need, when they need it, from their family doctor.”
The September Health Affairs issue, released yesterday, contains several articles on the use of emergency departments by nonemergency patients and strategies to reduce this phenomenon. The issue, which also includes a cluster of articles on medical liability and patient safety, was released yesterday at a National Press Club briefing. Video and speaker materials from the briefing will be available soon on the Health Affairs Web site.
The Patient Protection and Affordable Care Act is expected to boost funding for primary care and expand primary care coverage to 32 million Americans who now lack it. But Pitts and colleagues warn that unless coverage expansion is matched by a growth in primary care capacity, visits to already overcrowded emergency departments may increase. The experience of Massachusetts offers a lesson, they add, noting that visits to emergency departments there increased even after insurance coverage expanded because the state was unable to quickly provide enough access to primary care providers.
The study analyzed 354 million annual visits for acute care from 2001 to 2004, using three federal surveys of ambulatory care delivery from the National Center for Health Statistics. The findings:
- Forty-two percent of acute care visits were made to patients’ personal physicians, 28 percent to emergency departments, 20 percent to specialists, and 7 percent to outpatient departments.
- Uninsured patients received more than half their acute care in emergency departments.
- Two-thirds of acute care visits to emergency departments took place on weekends or on a weekday after office hours.
- Stomach and abdominal pain were the most frequent acute care problems treated by emergency departments, while primary care doctors most often saw coughs, throat symptoms, and skin rashes.
In the current environment, a visit to the emergency room allows patients to see a doctor at all hours and benefit from the latest technology. However, the patients often experience a long wait, typically rack up more expensive bills, and are more likely to receive duplicative tests. Patients who often could seek care elsewhere crowd ER waiting rooms and add to the workload of emergency physicians, who account for only 4 percent of doctors in the United States.
Provisions of the new national health reform law could reduce patient reliance on emergency departments for nonurgent health problems, strengthening primary care by encouraging the development of patient-centered medical homes and accountable care organizations and expanding capacity at federally qualified community health centers. These reforms have the potential to decrease unnecessary emergency department visits and reduce associated health care costs. But without an increased supply of primary care providers and incentives for primary care physicians to offer after-hours care or timely access to patients, these provisions will have a limited impact, say the study authors.
Finding A Better Home For Nonemergency Patients
Three other studies in the September issue explore strategies to divert nonemergency patients from the emergency department:
- People with mental illnesses may often be “boarded” in the emergency department until a hospital bed or other care option is available. Vidhya Alakeson of the Nuffield Trust and coauthors highlight opportunities in the health reform law to relieve emergency room crowding caused by psychiatric boarding, such as taking advantage of a new health home option in Medicaid to improve access to and continuity of community-based mental health care.
- Urgent care centers and retail clinics could potentially manage between 14 and 27 percent of all emergency department visits and save $4.4 billion—or 0.2 percent of national health care costs—annually, say Robin M. Weinick of the RAND Corporation and coauthors. These alternative sites could treat patients with conditions such as minor infections, strains, fractures, and lacerations, reducing their waiting time to receive care.
- Eager to reduce unnecessary use of hospital emergency departments by Medicaid enrollees, many states have introduced copayments for nonemergency visits to emergency departments. Results from the first study of its kind by Karoline Mortensen of the University of Maryland suggest that these cost-sharing policies have not been effective and do not reduce enrollees’ reliance on emergency departments.