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Why Reduced ER Use Isn’t Always the Best Indicator

28 Jul

In making the case for health care reform, inappropriate utilization of emergency rooms is frequently cited as an example of our inefficient system and an important factor behind the staggering cost of U.S. health care. At first, the logic makes sense: emergency rooms have to treat people, so the uninsured often turn there for care, including primary care, which is very expensive to provide in an emergency room, and would be much better treated in a private doctor’s office. Give people access to affordable health insurance, and they will no longer have to head to an emergency room when they get sick, which will translate into less crowded ERs and a lower national health care tab. There’s just one problem: It doesn’t work that way.

Opponents of health reform who suggested during the rhetorical back and forth over its passage that universal coverage would lead to long waiting lines were somewhat correct. It isn’t likely that the change will be measurably noticeable at your physician’s office, but it is very likely in the ER waiting room. The reason is simple: people go to the emergency room for a host of reasons that have nothing to do with their insurance status. Among these reasons are low health literacy, a health care system that is often complicated to navigate and inaccessible for people who can’t get off work during typical business hours, and a lack of continuity of care that arises for its host of reasons. Waiting to be seen in the ER is no picnic, but for many people it is a more easily understood process than trying to get a referral to a specialist from their primary care physician–assuming they even have one.

So, if we give people insurance, we might actually see an increase in ER visits, because one of the primary reasons people might have avoided going to the ER (cost) will have been largely removed. In fact, we can take a look at Massachusetts, where ER visit rates haven’t dropped despite near-universal coverage as evidence of this. Does that mean that we shouldn’t have bothered to increase insurance coverage? Absolutely not. Having insurance is an important component of reform–it’s just not the only thing that matters. The system needs to be reformed in other ways too. That means focusing on the non-insurance barriers to health care access–things like transportation, translation, on-site child care, after hours appointments, same day appointments, electronic medical records that follow the patient, and so forth. These types of “enabling services” are actually one of the things that the well-respected and high-performing community health centers provide that set them apart from other health care providers.

What we need are more intermediaries–places like urgent care centers, and community health centers that can “fill the gaps” between the emergency room and traditional private practices. And all of these people need to be able to talk to each other. Until these types of changes are made to the health care system, people will continue to go to the emergency room for non-emergent conditions–even if they have insurance. We should anticipate that, because if we fail to do so, there are many opponents of health reform who will suggest that the lack of improvement in this single measure is indicative of reform’s failure. The truth is, reduced ER use isn’t always the best indicator of whether or not health reform is working. It can be. It can tell us how well people are able to navigate our system and how well the various parts work together. But it doesn’t reflect well the effects of increased insurance coverage. Harold Pollack, a professor at the University of Chicago, provides a more detailed look at the issue, which is well worth reading.

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2 Comments

Posted by on July 28, 2010 in Uncategorized

 

2 responses to “Why Reduced ER Use Isn’t Always the Best Indicator

  1. JCS MD

    July 29, 2010 at 10:57 am

    Why is the answer always "we need more"?Why is there the perceived need for more providers to get between the patient and their primary care physician?Why not bolster the infrastructre that already exists, rather than create entities that drive up cost through higher fixed capital expenses?How do more venues for care make the system more 'understand'-able?Low margins in primary care practices reduce or eliminate the financial incentive (read: viability) to 1) hire more providers for extended hours, 2) provide translator services, 3) provide non-face-to-face care that would obviate the need for some visits.Pay for extended hours visits that have proven to reduce ER visits. Pay for internet-based translator services that eliminate communication barriers. Pay for e-visits and telephone calls that eliminate the need for sitters. Pay the people that have already have a roof and a parking lot as fixed capital.Creating positive interaction between providers and patients requires that we 'enable' all parties, not simply adding more.As for the transportation… I'll bet in this down economy, you can get some pretty good bulk rates from the cabbies.

     
  2. Michelle W

    August 5, 2010 at 3:03 pm

    I think you've hit on a likely suspect in terms of ER utilization. When I was in middle school I broke my arm on a class field trip. Because my mother wasn't working at the time, she was able to drive over, pick me up, take me to our pediatrician for an examination, and pick up a referral to an orthopedic specialist we'd been to for past problems, all without going to the hospital.Had she not been able to do so, the school would have had to call 911 to take care of me. I'd have been taken to a hospital that didn't have any of my records, and waited to be treated by those unfamiliar with my medical history. Then I'd have had to travel a greater distance for continued care. Obviously it was better to be treated by the doctor I already had a history with. But it all relied on my mother having the time and wherewithal to get me through the medical process.

     

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