State of Emergency

A recently produced New York Times video documented the alarming day-to-day operations of an inner-city Oakland hospital emergency room. The un-narrated short film is a montage of clips of patients waiting in long lines to receive care and hospital employees juggling patients from bed to bed and directing ambulance and waiting room traffic. This hospital is a “safety-net hospital” that primarily services the lower class and largely unemployed urban population of the Bay Area. Many of the patients explain that they are uninsured and are looking for medical attention for an assortment of ailments from back aches to knee problems to sore throats.

The video highlights one of the biggest challenges of the American health care system: overcrowded emergency departments. According to the video, safety-net hospitals receive more than 16 million emergency room visits each year, and for this Oakland hospital, half of them are for non-acute conditions. The obvious problem here is that uninsured individuals have no other option for health care. Under the Emergency Medical Treatment and Active Labor Act (EMTALA), most hospitals are required to perform minimal screening and stabilization procedures for every individual that comes through the door regardless of insurance status. This ultimate safety net prevents people from bleeding to death on the sidewalks outside of hospitals, but as the video adeptly explicates, it also subverts incentives for individuals to seek insurance and leads to unnecessary crowding of ERs.

The Patient Protection and Affordable Care Act (PPACA) is intended to help tackle this problem by extending Medicaid benefits, encouraging preventative care for acute conditions, and opening more urgent care facilities in over-populated areas. Surprisingly the problem won’t go away by simply providing insurance to the uninsured. One recent study showed that ER usage in Massachusetts increased by 7 percent after the 2006 legislation that dramatically increased the number of insured individuals throughout the state.

Recent trends suggest that Americans are increasingly inclined to seek care for acute conditions at the emergency room rather than from primary care doctors. One Health Affairs study states that only 42 percent of the 354 million annual visits for acute care are made to a patient’s personal physician, and 28 percent of the remainder seek care first at the ER. It seems that every year, more Americans would rather use emergency facilities than go to their own doctor first, even if they have good insurance.

What accounts for this startling trend?

1) People seem to think that emergency facilities are safer and have more advanced care, especially since they are connected to hospitals with specialists. It’s true that ERs have access to more advanced medical equipment than primary care doctors. However, primary care physicians can usually treat a condition more quickly and at a lower cost since they have access to a patient’s medical records and are not incentivized to increase traffic to specialists. Even if there is a medical problem that needs specialized care, individuals that are sent to specialists by their doctors often have first priority over ER patients that are not referred.

2) Doctor’s have busy schedules. One of the trends that is pushing the overuse of ERs in recent years is that primary care physicians are slowly dwindling in number as the profession moves to consolidated hospitals and specialization. This leaves family and community doctors with tight schedules and shorter hours. Many Americans complain that doctor appointments need to be made far in advance, and it’s hard to get same-day care anywhere besides the ER. Many acute conditions also need to be treated after normal office hours. 87 percent of primary care practitioners in the United Kingdom and 95 percent in the Netherlands meet with patients after-hours, but only 40 percent of doctors offices in America are open late.

Why should we be concerned about increasing ER use? Plain and simple, ERs are not meant for treating our everyday medical needs. More than half of our acute care treatments are done by someone other than a primary care doctor. This creates problems with keeping medical records consistent and fostering an accountable culture of doctor-patient relationships. Emergency rooms like the one shown in the video want to get patients in and out as quickly as possible, and therefore do not give the highest quality care. A Robert Woods Foundation study links overcrowding of emergency facilities to lower health care quality and patient safety.

This is a potential area of reform that can’t be viewed lightly. The sooner we get patients back to their doctors, instead of sitting in line at emergency departments, the sooner we can improve the American reputation of high-cost, low-quality care.