ER utilization shouldn’t be a measuring stick for health care reform

Mitt Romney’s “let them eat cake” comments on 60 Minutes serves to illustrate how badly both sides of a political debate can confuse an issue. In 2010 he criticized emergency room care as a potential  loophole used by people to get “entirely free care” while avoiding having to pay for health insurance and in his book No Apology, the Governor outlined the idea behind Massachusetts health care reform as “redirecting” the costs of expensive hospital care towards helping the uninsured pay for health insurance.

But in the 60 Minutes interview Gov. Romney appears to have reversed himself by emphasizing the fact that emergency rooms provide care regardless of a patient’s ability to pay while appearing to back off on the idea of universal coverage.

In my state, we found a solution that worked for my state. But I wouldn’t take what we did in Massachusetts and say to Texas, “You’ve got to take the Massachusetts model.”

Why? Texas has the the highest rate of people without health insurance coverage in the country. Are the uninsured in Texas somehow different from the uninsured in Massachusetts? No. But, Texas also has far more conservative and Republican voters than Massachusetts and the uninsured largely vote Democratic so screw them. Ergo, universal health care is fine for Massachusetts. Everyone else gets miniature American flags. At least Mr. Romney is consistent in abandoning or reversing his positions to pander for votes.

Still, using emergency room utilization as a measuring stick for health care reform appears to be dubious at best. The liberal mythology is that the uninsured flood emergency rooms for all aspects of their care but this is simply not supported by the evidence. The reality is that the uninsured make up only about 15% of all ER visits. The vast majority of patients who visit an ER have government insurance coverage and Medicaid beneficiaries under the age of 65 utilize the ER far more than those under 65 who have private insurance.

The reason for the relatively low ER utilization by the uninsured is that an ER visit is not “entirely free” as Mitt Romney says and most of  the uninsured are not immune to the financial impact of very expensive ER care. They tend to avoid the ER unless and until absolutely necessary, i.e. a true emergency.

The other side of this coin and the other part of this mythology is that increasing the number of insured patients will reduce overall ER utilization. Actually, health care reform has the seemingly paradoxical potential to increase ER utilization. There are several reasons for this and much that depends on demographics. While many of these newly covered patients tend to be poorer, have more health problems, and more unhealthy lifestyles, they also tend to live in areas that have poorly designed primary care infrastructures. They live in areas where primary care providers are few and overwhelmed with patients and where there are few if any urgent care or after-hours clinics. The net result is that this population is chronically undeserved, has decreased access to primary care, and where often the only viable option for timely care is the emergency room. If you remove the financial disincentive to visit the ER then this newly insured population can and will visit the ER more often.

There is already some data from Massachusetts that suggests that this is the case with health care reform. Researchers from Harvard found that the total number of ER visits at 11 Massachusetts hospitals increased 4% after the state required all individuals to be covered by health insurance in 2008. Liberals tried to spin this by pointing out that there was a decrease of 2.6% (4% in a Blue Cross Blue Shield study)  in the number of previously uninsured patients using the ER for “low severity” problems.  But given that 400,000 newly insured patients entered the system during this time these numbers seem oddly small. The reason for such small changes in ER utilization may be that any decreases in ER visits by newly insured patients who obtained their care in the community were offset by increased visits by newly insured patients for whom the ER is the most viable source of care.

ER utilization is more likely to be impacted by the quality of the local community’s assess to primary care than its percentage of uninsured patients. Unfortunately, neither ObamaCare nor RomneyCare legislation has addressed this issue. Medicare and Medicaid routinely reimburse far more for an ER visit than an office visit even for something as basic as an ingrown toe nail or a minor injury. The financial intensive is skewed towards pricey ER care (follow the money) while outpatient primary care offices concentrate on high volumes of lower complexity patients (medication refills) and anything more urgent or complicated is referred to the ER.

The ER is not the appropriate battleground nor measuring stick for the need for or success of health care reform. Not unless both sides are willing to admit that their financing and reimbursement schemes are deeply flawed and part of the problem rather then the solution.

Chris Rangel is an internal medicine physician who blogs at

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  • buzzkillersmith

    Dr. Rangel,
    The government needs to incentivize us to keep our pts from going to the ER. We should be able to see them 24/7 and be subjected to beatings and bread-and-water rations should these little stinkers darken the ER’s door with such foolishness as ear infections, bleeding and high fevers. You’re a doctor. Get to work I say. YOU need to be the ER. Cowboy up. Sleep and family life are for wimps. If we want to save this country some money, we need to get divorced and forget the names of our children.

    • Margalit Gur-Arie

      Here is a better solution: pay $200 for a primary care visit between 7 pm and 12 am, and $300 between 12 am and 7 am. How many primary care offices will decide to stay open “after hours” and at all hours? How many young doctors going into hospitalist careers in their search for balanced lifestyles will be trading that choice for primary care?

      • buzzkillersmith

        $200!! Whadda think we’re dermatologists around here? Sign me up! Early retirement here I come.

        Check out the typical E & M payments, Margalit. I for one get paid a lot less than you think I do.

        • Margalit Gur-Arie

          I know exactly what you get paid.. :-) Hence my offer you can’t refuse….

          • buzzkillersmith

            The real tragedy here is that you do not run the insurance industry in this country. I’d vote for you were it an elected position.

    • rswmd

      We used to open our office for a couple hours in the morning on Thanksgiving, New Years, July 4th, etc. We’d see 20 acute problems, pay the staff double, and collect a “holiday service” fee from the insurers. Then the big boys said they wouldn’t pay the fee, and we replied that we’d send all the patients to the ER at 10x the cost. I have written replies from our three largest insurers that they’d rather pay the ER charges. They took a win-win-win situation, and turned it into everybody loses.

      That was a real eye opener.

      • buzzkillersmith

        Weird, isn’t it. When jockeying the same-day part of our clinic I have seen pts in for head trauma who have failed the New Orleans and/or Canadian criteria and have needed a CT. Low risk, but you gotta do the CT. You know the score.The hospital is close by and heck I can order a CT and call neurosurgery for a bleed as well as the ER doc. No way, says insurance. They won’t pay for a CT unless ordered in the ER.

      • Margalit Gur-Arie

        Is this true also for Medicare/caid?

        The private ones have no reason to cut costs of items that can be attributed to MLR, i.e. all patient care. The more they pay, the more they charge, the more they get to keep….

  • helix400

    As long as the costs are obscene, it’s going to be a measuring stick. My wife had kidney stones over the weekend. This resulted in two ER visits (7 hours in total). Standard service, some morphine, a couple of images and blood tests, urine samples, and she was out. I just got the bill, $28,000.


    As much as people want to point fingers at the underlying causes, the ER will always be a measuring stick when a routine problem costs $28,000 to manage.

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