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ER overuse may be a myth

Kevin | Physician | March 31, 2010

Overuse of the emergency department is commonly discussed during the health care conversation. Especially with the lack of primary care access shunting patients with seemingly routine symptoms to the ER.

But is this a myth?

That’s what two emergency physicians contend in a piece from Slate.

The emergency department is functioning just fine, they say: “Just 12 percent of ER visits are not urgent. People also tend to think ER visits cost far more than primary care, but even this is disputable. In fact, the marginal cost of treating less acute patients in the ER is lower than paying off-hours primary care doctors, as ERs are already open 24/7 to handle life-threatening emergencies.”

“Unnecessary” emergency use is no different from the perceived waste in other medical specialties; like heart procedure overuse in cardiology, vertebroplasties for compression fractures, or the knee surgeries in orthopedics.

Perhaps it’s not fair to single out the ER.

But I am curious to see what the next few years will bring. As we add 35 million new patients to an already overburdened primary care system — where patients already wait up to 2 months for an appointment — we’ll see whether the numbers of discretionary visits to the emergency department will overwhelm the system.

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Tagged as: Emergency, Hospital, Primary care

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  • Dr.Nick

    Cost in health care is difficult to parse to begin with. Just because the hospital or doctor’s office writes numbers on a bill, do they have any basis in reality? An MRI does not really cost what they cahrge- that machine is amortized pretty early in its life, they just need to cover staff and maintenance costs. There’s a break even point of time after which MRI will become a cash cow.

    The hospital charges whatever they want to charge, and the insurance companies pay whatever they’ve agreed to pay. Woe be to the poor slob who ends up at a hospital or office without a participating insurance company- he or she will be taking a licking.

    But the ER point is a good one. Everyone in the ED is salaried. The marginal costs of treating less urgent patients SHOULD be pretty minimal. It needn’t even effect the flow that badly, as in busy times, the less urgent cases will be waiting a long time.

  • family practitioner

    Sorry, I do not buy this.
    If the actually number is only 12 percent, then that is still 12 percent too much.
    The issue is not just that they are in the ER unnecessarily, but once there they are more likely to get a work up, ie CXR and labs, and even admitted.
    I see many copd exacerbations and cellulitis cases in my office (just 2 quick examples) that are treated successfully on an putpatient basis; I know full well that if those patients went to the ER, they would be admitted.
    However, I do not want to blame the ER completely (although I see many ads bragging about a short wait); the patients are culpable due to their “I am important, everything is urgent, and I cannot wait mentality”. Also doctors offices, especially specialists, are very quick to tell patients to go to the ER if they happen to call at inopportune times.
    By the way, urgi care is not the answer. I moonlight at an urgicare center, can see 40-50 patients there on a Saturday, and feel that around 80 percent do not need to be seen at all, or should at least wait for their pcp to be available. But those health care consumers can be quite demanding…

  • Marc Gorayeb, MD

    My daughter went to the hospital ED down the street from her apartment for treatment of a 1.5 cm curvilinear laceration to the dorsum of her finger caused by a glass that broke while she was washing it. No tendon injury. No tests. Simple repair by a physician’s assistant. Never seen by a physician. Hospital charge (total charge) was approx. $1000, reduced by contract with insurance provider to about $300. Had she been uninsured, she would have been required to pay $1000. What about it, family practitioners; isn’t this something you could have fixed in the office for less than $300? By the way; the wound dehisced its sutures within about 4 days, and it healed just fine by secondary intention. This is anecdotal, but I assure you that ED care is outrageously expensive compared with care provided in a family practitioner’s office. I know; I am an emergency physician.

    • rezmed09

      Anecdotal? How about a syncope visit to the ER in a healthy 20 YO? guess how much? Head CT, monitor, EKG, Labs and an H&P… $11,000!! For 4 hours of care. Good care, mind you, but still, $11,000. It probably cost $1000 to provide the same care at a VA.

      Insurance only paid $1300. Yes, the real losers are the uninsured who will be hounded to pay all or nothing.

  • http://glasshospital.com John Schumann, M.D.

    The Slate article does a fair job of debunking the myth. Yet the simple fact remains that the ER proffers a simple message:

    “We’re always open, and we can’t turn you away.”

    The clarity of this is obviously preferable to the many patients who choose the long waiting times for the certainty of being seen instead of the long delays and carefully proscribed time slots to see doctors in offices.

    Read more here:
    http://glasshospital.com/2010/01/07/the-mystic-portal-awaits/#more-10

  • alex

    It’s not a myth and anybody who’s ever worked in an ED knows it. It’s not that people are going there for the wrong reasons, it’s that in America everyone gets a (literally) million dollar workup. The fact that other countries have perfectly fine patient outcomes WITHOUT doing this is all the evidence necessary to see that American ERs vastly overtreat. And yes, it’s a systemic problem not the fault of any individual doctor, so we don’t need the discussions of malpractice, defensive medicine, etc. The ED system simply needs changed in all respects.

  • ninguem

    I’ve worked in urgent care clinics. I hate them; fortunately others like that line of work. I do notice many people in urgent care who have primary care docs. They’re in urgent care on, say, a Tuesday at 9-AM with a sore throat. Why aren’t they in their doc’s office? It’s not a weekend, not 9-PM, it’s 9-AM.

    They tried. They called. First thing in the morning. They get told they can’t be fit in for the entire day. Next opening is three weeks. For an urgent visit. They will either be better spontaneously, or dead, in that time. “Do I feel lucky?”

    So they’re in Urgent Care, at twice my office fee. Literally twice; it’s like they took my fee schedule and multiplied everything by two.

    Can’t say as I blame the patient. The primary care docs in question, all too often nurse practitioners anyway, and they’re in the big corporate settings where they’re not allowed to make management decisions.

    My office, I get them in. I don’t care if it runs me into lunch or past closing. Get the job done. Then again, I’m solo.

    Benefit for me, besides money, is my patients know they can see me the next day almost always, so they don’t call at 3-AM. My patients almost never call me after hours. They don’t need to. My patients get good service, I sleep at night, and I get paid. Win-win.

  • http://ghc.org Michael T, MD

    Many good hospitals have both a Trauma ER as well as a fast track urgent care system as well.. The real problem if that primary care providers haven’t moved to a scheduling system that leaves the majority of their appts open each day and patients are poorly informed about when they should go see a provider.. Wait I see an APP for that coming.. . There is also rarely and discussion of the wide variance in practice patterns across the US. There is less a shortage of primary care doctors and more an over-use of their taletns when a nurse or nurse PA could handle most visits.

  • Amy

    I keep hearing everyone talk about using midlevels to see the colds, sore throats, etc (the easy stuff) and leave the complicted cases to the doctors. The problem with this is that it can be absolutely draining to see those complicated patients all day long. And the fact is is that there is not THAT much difference in the reimbursement for a cold and a 80 year old lady with SOB and a history of CHF, COPD, and uncontrolled diabetes. If we give all the midlevels the easy stuff, They will be making twice as much as MDs and with 1/10th of the stress and liability.

  • Surgical resident

    Marc,

    I’d be pretty nervous having an FP sew up a hand lac……

    Just my opinion.

    • Joseph W. Blackston, MD, JD, FACP

      Nervous? no offense, but WHAT surgical residency are you working in? I’ll bet you dollars to donuts your orthopedics teaching service, your surgical service, your plastic surgery service, your GI service, AND even your neurosurgery service employs Nurse Practitioners or other “mid-levels.” Nowdays, the NP’s do all the patient management, H&P’s, discharges, etc. while the physicians in training do the procedures.

      I’ll bet your tune will change when you are out in private practice, and on call at your local hospital, and the ER doctor calls you to say “I need for you to come in and sew up this 1cm lac on the dorsum of the hand”??

  • Anonymous

    After reading your blog on ER Overuse, the Slate article and all the comments in both, the only thing that is really apparent is the low level to which the debate on health care in America has descended. The science and yes the truth in health care delivery left the debate along time ago. Fear and money will do that. The authors of the article I’m sure are fine emergency physicians and work at highly respected institutions, but their presentation of current statistics and “facts” in defense of their premise concerning ER overuse borders on conduct unbecoming a physician. I do not make this accusation lightly, there is just too much at stake. I have been an ER physician for 20 years and a medical director of an ER for 10 years. It is inconceivable that these 2 highly educated physicians actually believe what they wrote and they know better.
    The CDC statistic of only 12% of ER patients in the “non-emergent” category to prove that ERs are not over used is irrelevant to the question of, where is the best and least expensive venue to provide patients care. I am sure that at least 30-40% of the patient’s entering GW and U of P’s ERS are sent to the fast track/urgent track section of their ER only they are billed at the full ER level. The expected utilization of services the patients have at triage puts them their. These services could easily be provide at any well equipped urgent care center, primary care office or retail clinic depending on the service capabilities and the patient’s requirements. The fact that they are in your ER and a level 2 or 3 triage does not mean they could not have been taken care of in another venue.
    Their claim that the cost of ER care in America is so small and need not be addressed just isn’t true. The portion of total health care expenses attributed to the ER has been increasing over the last 10-12 years where it is now 4% of the total. If the historical growth rate of ER expenses continues over the next 10 years, America will spend approximately $1.25 Trillion for the decade. The problem is that the growth rate will increase with health care reform by 1-2 % above historical levels which means an extra 125-250 billion dollars wiping out any savings as calculated by the CBO. If you are able to decrease the ER growth curve by 1-2% you would save a like amount, a 250-500 Billion dollar swing. How we alter the ER expense growth curve is the real question.
    The real myth Kevin is that increasing primary care will alter the ER growth curve, but that is another topic.

  • family practitioner

    Increasing primary care can potentially alter the ER growth curve but the public has to be willing to embrace it. Again, I keep coming back to urgi-care, a modern invention that amazingly was not needed 30 years ago. It also seems to not have affected ER utilization; quite to the contrary, it probably has made utilization go up by having patients feel they need to be seen for conditions that perhaps they should be more patient with (bug bites?, sunburn?). What is the difference between urgicare, retail clinics or a fast track at an er other than setting and marketing?

    We also know that er’s are making money off of their fast tracks; that is why they run all those ads.

  • R Watkins

    Look at all the reasons the insurance companies give me not to treat emergency/urgent care patients in my office:

    1. Do i want to do procedures such as a laceration repairs, and get paid only the professional fee, which includes all supplies and follow-up care? No, send them to the ER, where they get paid professional fee, facility fee, supply expenses, and no requirement to do follow-up.

    2. If a patient in my office needs a stat scan or diagnostic procedure, do I want to tie up my front desk for two hours trying to get prior authorization? No, just send the patient to the ER, where the doc can order as many expensive tests as they like.

    3. Do I want to spend two hours with a complicated patient, and risk getting negative reivews because every other patient had to wait? No, just send them to the ER, so I can stay on schedule.

    And on and on . . .

    • Marc Gorayeb, MD

      I understand your points. But don’t you sacrifice the essence of your craft by deflecting the sicker patients, the procedural cases, the risky cases? Isn’t there a risk that succumbing to admittedly oppressive time pressures as a rule rather than exception will ultimately suck the joy and satisfaction out of practicing medicine?

      Many family practitioners don’t even manage the care of their patients in the hospital any more. How do you preserve the bond between primary physician and patient when you are not sheperding them through the toughest part of their lives?

      Isn’t there a point at which it’s not unreasonable to ask how a family practitioner’s practice differs from that of the “mid-level” provider that may be in their employ?

  • Evinx

    First, ERs are a portal into the hospital + hospitals want it that way for a whole host of reasons.

    Second, ER vary dramatically according to locality.

    Third, every doctor’s office phone answering device starts off, “if this is an emergency, hang up and go to the nearest ER”

    Fourth, PCPs oftentimes do not want to +/or refuse to treat emergency type patients – like a child who may be bleeding from the ear or eye, for example. The staff will immediately direct you to the ER.

    Why for all these examples – fear of litigation is a huge driver. for all of the above except the usage differences by locality.

  • Joseph W. Blackston, MD, JD, FACP

    IF “overuse” is a Myth (it’s NOT), then WHY would Medicaid patients utilize the ED at 4 times the rate of patients with private insurance? (this data is from the CDC, not a political mag with an agenda like “Slate”)

    I guess Medicaid patients just have 4 x the “emergencies”? And don’t tell me that it is because they don’t have access elsewhere. Virtually every primary care physician where I live (and work in the ED) accepts Medicaid in their offices. Plus, there are numerous Rural Health and Federally-funded clnics.

  • Jadedmd

    Same girl got a head ct for a headache. It seems like everybody with a headache that goes to the Ed will get a head ct. Can’t say I wouldn’t do the same if I were working the ED i

  • Jadedmd

    Everyday I have evidence that our ED is being overused. one of numerous examples: a 23 yo with gerd kept going every week or two for several months with her atypical chest pain that I was managing as an outpatient, everytime getting a work up. I made monthly follow ups and tring to head her off before next unnecessary er visit at one point made a one week follow up. She still went to er then kept her appt with me later that day. I have several open spots during the day. Plus she’s on public aid. She is not an outlier

  • http://www.linkedin.com/in/achievementstrategies Marie

    I was the Director of Admissions for one of the busiest ER’s on the East Coast. Unnecessary visits? I would put them at 40%, if not higher.

    Families with scabies. Families of five, all with different complaints: sore throat, cough, rash, rash, headache. It almost seemed recreational sometimes, something to do besides sit home and watch TV. Individuals who were seeking narcotics (it hurts here…um…I mean here). Individuals who had had a condition for weeks, but just decided to pop in and have it checked. And they ran the gamut from commercial insurance to Medicaid to Medicare to no insurance.

    These people knew what they were doing. At a doctor’s office they had co-pays to pay, or balances. Doctors could discharge them from the practice if they didn’t pay. If they didn’t pay their ER bill it might ruin their credit, but they didn’t seem to care. They had no intention of paying their bill and they knew we could not turn them away.

    Much of the time, besides wasted utilization, they were total financial losses that cost everyone in the long run.

  • LynnB

    I am a general internist, a dying breed, in a small town . I HATE it when my patients go to the ER because ER don;t manage chronic illness, that’s not what they are trained to do.

    I am really upset when they go to ER because they are waiting for approval (the ER doesn’t NEED approval) for a CT or MRI. That teaches them if they want something within a few days they can go to the ER. Two went this week went because the CT approval was late . One was , of course admitted, the CT wasn’t normal (DUH) and in the second case I spent a half hour on phone and e-mail since “if its important the doctor will call herself” while other patients waited getting it approved because I was sure it was bad news. It was , and we talked, the CA-125 is > 800 and she waited for that lab result at home instead of in a hospital bed , and hospice will help her stay at home.

    I hate it when they go because they don;t want to wait to see me over lunch . I hate it when they go because I told them something they did not want to hear, or because I suggested a visit to the cardiothoracic surgeons at age 94 with critical AS is not a good use of time. I hate it when they lose their insurance, get uncomfortable and go in in for a simple UTI that we would diagnose with a 10 minute visit or a lab without a visit and get a non-contrast CT stone study and IV antibiotiocs.

    Often they unnecessarily get admitted –they have high creatinines (like most patients with stage 4-5 kidney disease) , or high sugars with normal bicarbs and no signs of dehydration,and then they decide they should always go to the ER to be admitted , that I just don;t realize how sick they are, unlike the ED doc who lacks the 10 or 20 year acquaintance and doesn’t have the luxury of a followup next week or next month. . Alternatively they are sent home with new home oxygen and a single shot of IV diuretic to address a 22 pound weight gain and a systolic pressure of 87 ,(yes, this has happened , more than once ) . I have seen them once or twice weekly for 4 weeks, according to the the outpatient record, which is available to the ER . It also shows a constant escalation of ACE’s and beta blockers and diuretics and starting them on spironolactone and maybe adding isordil and hydralazine , over 2-3 months what the heck else can I do?

    Sometimes I feel the ER doc is punishing my patients because he/she is mad at me or at life for whatever reason . The actual fact is that they are trained to treat an acute , or acute on chronic illness , like a chemo patient with sepsis . They are eventually comfortable with the idea incurable illness (what ARE we going to do in the hospital?) , but don;t usually think about what we might do over the next several weeks to make them feel better, even though they aren’t going to feel good.

    What I do is manage people who have one or two or three bad organ systems so they have a better quality of life. I do have 4-5 work-ins every day and work through lunch unless I have a hospital meeting and have been the last one out of the office 90% of the time for 20 years. It’s EASIER than having the ER doc call me and ask me what to do, and then not do it because its not macho enough.

    When I am the hospitalist, I try not to make the ER’s life harder, they think they need to be admitted, fine I will come down (unless the doc is firing patients so fast I can’t get down there to do his job for him) or accept them , not argue. So all you ER guys and gals out there don;t yell at me, but just because a patient is chronically ill doesn’t mean the ER is the best place. In fact, its often one of the worst places.

  • LynnB

    The ER DOESN’T manage chronic illness not DON”T manage it. Sorry multiple timeouts while I ate dinner .

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