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Why the ER is so crowded

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A new study in Health Affairs "analyzed 354 million annual visits for acute care from 2001 to 2004" to see how many were taking place in emergency rooms and how many were ending up with primary care doctors. We want, of course, for the primary care doctors to be receiving these visits: They're cheaper, they know the patients' medical histories better, and fewer non-emergency cases in emergency rooms means more room for actual emergencies. But many of them are ending up in ERs:

* 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.

One of the big problems here is time: Primary care doctors don't have much of it, and what they have is generally between 9 a.m. and 5 p.m., Monday to Friday. Patients also don't have much time, but what little time they do have is between 5 p.m. and 9 a.m., Monday to Friday, and then the weekends. Emergency rooms have long waits, but at least you can schedule when you're waiting for a time when you're not supposed to be working.

I'd also note these sentences, which pose a problem for the view that in America, all care is speedy and convenient because we don't live in a socialist hellhole: "One survey reported that 87 percent of primary care practitioners in the United Kingdom and 95 percent in the Netherlands manage patients after hours without referring them to emergency departments. In the United States, only 40 percent of primary care practitioners see patients after hours."

Related: An emergency room doctor tells you when you need to go to the emergency room.

By Ezra Klein  |  September 7, 2010; 1:02 PM ET
Categories:  Health Coverage  
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Comments

But, but, but, I thought Obamacare was going to end unnecessary emergency room visits! Wasn't that supposed to deliver huge cost savings?

Anyway. Large group practices have physicians on duty or on call after hours and on weekends. If you choose the correct provider, you will not have to go to the ER except for a true emergency. Better hurry up and find one now, though, because they may not be taking new patients for much longer.

Posted by: bgmma50 | September 7, 2010 1:22 PM | Report abuse

One of the problems is that, from my experience, people don't know there is an alternative to PCP vs. ED. In many areas there are such things as "urgent care" walk-in clinics that are open on off hours (though not 24) like the weekends... where you can get treatment for stuff that needs immediate attention but that isn't serious enough to warrant a trip to the ED.

Posted by: JWHamner | September 7, 2010 1:23 PM | Report abuse

I know med students seem to want to go into speciaties where they get lots of money and don't work long hours, but can't we incentivize the types of stuff we want pretty easily?

If a med student agrees to work in a primary care facility for 10 years the government will pay for some large percentage of med school. If they leave primary care before then they're on the hook for the loans. If they work in a facility that provides primary care beyond 9-5 Mon-Fri, they get some other percentage of their loans forgiven.

Posted by: MosBen | September 7, 2010 1:32 PM | Report abuse

"One of the big problems here is time: Primary care doctors don't have much of it, and what they have is generally between 9 a.m. and 5 p.m., Monday to Friday. Patients also don't have much time, but what little time they do have is between 5 p.m. and 9 a.m., Monday to Friday, and then the weekends."

So is new Health Care Law giving financial incentives in reimbursements when a PCP sees patients after hours?

Routinely doctors in private practice in India see patients after the normal work hours. It is only in this country (I guess may be in Europe too) where patients have to tailor their visits as per the timing of doctors by keeping aside their day jobs. Perils of Socialistic system?

Posted by: umesh409 | September 7, 2010 1:32 PM | Report abuse

@bgmma50:
"But, but, but, I thought Obamacare was going to end unnecessary emergency room visits!"

Not even I, a certified Obot, thinks the ACA is powerful enough to travel back in time to fix data from 2001-2004.

Posted by: JWHamner | September 7, 2010 1:34 PM | Report abuse

Health Savings Accounts and high deductible insurance policies will cut down on emergency room visits. When people have to pay for their own care, they will only visit the expensive emergency room when there is a real emergency. As major companies start switching to these types of plans in the next few years, you will see the statistics for emergency room follow up visits decrease. Market forces will solve this problem.

Posted by: cummije5 | September 7, 2010 1:36 PM | Report abuse

We don't call doctors after hours. When we speak to a doctor, regardless of situation they say "if you're uncomfortable with the situation, go to the ER", it's a cop-out so they don't get sued. And makes it useless to try and communicate with them out of office hours.

Posted by: kolbkl | September 7, 2010 1:46 PM | Report abuse

"Not even I, a certified Obot, thinks the ACA is powerful enough to travel back in time to fix data from 2001-2004.

Posted by: JWHamner"

You missed the point, JWHamner. Unless there is a provision buried deep in the bowels of the thousands of pages of Obamacare that will cause primary care physicians to see patients after hours and on the weekends, people will continue to use the ER just as they always have. There is nothing, zero, zip, nada, in Obamacare that will magically change those statistics from 2001-2004. So, once again, it fails to live up to it's billing.

Or did I miss something?

Posted by: bgmma50 | September 7, 2010 1:59 PM | Report abuse

@bgmma50:
"Or did I miss something?"

You missed something:

"Uninsured patients received more than half their acute care in emergency departments."

The fact that there will still be an issue with after hours care does not mitigate the fact that the ACA will reduce ED visits by insuring the uninsured.

Posted by: JWHamner | September 7, 2010 2:12 PM | Report abuse

wait so are we supposed to be surprised that doctors in the US are more "businessmen and women" than doctors in Europe?


Actually the most startling figure to me is that one in 3 Americans had an ER visit in the year that the statistics were based upon. I wonder how that compares to the other countries?

For my own example we specifically chose our children's pediatrician because they have office hours on the weekends. Sure they're good doctors but there are better pediatricians that we've researched but when you couple the availability with the quality of the doctor it made the choice easy for us.

Transparency (which is non-existent) would help here.

Most insurers websites show office hours of doctors but not many doctors want you to know that they're at their vacation home when your kid has pneumonia.

Posted by: visionbrkr | September 7, 2010 2:25 PM | Report abuse

"The fact that there will still be an issue with after hours care does not mitigate the fact that the ACA will reduce ED visits by insuring the uninsured.

Posted by: JWHamner"

Not if you don't increase the number of primary care physicians in sufficient amounts to serve millions of uninsured...another thing overlooked by Obamacare.

Posted by: bgmma50 | September 7, 2010 2:37 PM | Report abuse

"For my own example we specifically chose our children's pediatrician because they have office hours on the weekends." posted by visionbrkr

As did I, visionbrkr.

Posted by: bgmma50 | September 7, 2010 2:40 PM | Report abuse

JWHammer,

ER visits won't go down until as cummije5 suggest people start getting a clue as to what ER visits cost. If its just $50 to the patient and you can put it on a credit card then these staggering numbers will continue.

A bigger question is how does the US compare when you look at approved ER visits vs other countries even within the socialized world.

What happens when you take your kid to the ER in France or England when he or she has poison ivy? Do they kick you out? Who pays for that?

Posted by: visionbrkr | September 7, 2010 2:43 PM | Report abuse

"As major companies start switching to these types of plans in the next few years, you will see the statistics for emergency room follow up visits decrease. Market forces will solve this problem.

Posted by: cummije5"

I'm curious, cummije5, as to why you believe major companies will make that switch? I would love to see that happen, but Obamacare is all about driving health insurance in precisely the opposite direction.

Posted by: bgmma50 | September 7, 2010 2:47 PM | Report abuse

"I'm curious, cummije5, as to why you believe major companies will make that switch?" - According to Kiplinger.com companies are trying to mitigate their increasing costs by moving to these less expensive insurance plans. (http://finance.yahoo.com/insurance/article/110450/health-insurance-changes-for-2011?mod=insurance-health)

Posted by: cummije5 | September 7, 2010 3:03 PM | Report abuse

Try: doctors have time Monday through Thursday. At least that's what happened to us two weeks ago, when my husband's primary care doctor and orthopedic surgeon were both off on the Friday morning we called them regarding apparent bad infection of an injury that both doctors had seen earlier. At least they conferenced, called back together, and said get to the emergency room. It involved eight hours of waiting and being seen in the ER, and then immediate admission to the hospital. Would a hospitalization have been necessary if either one of those doctors had been in their offices? I'm still not sure (it involved having to be on IV antibiotics for 48 hours until blood cultures came back). But we'd do anything to avoid having to go there again.

Posted by: JJenkins2 | September 7, 2010 3:11 PM | Report abuse

Thanks, cummije5. That's an interesting article.

"Increasing cost sharing for non-emergency care at an emergency room". Imagine that, a solution that doesn't require thousands of pages and dozens of new bureaucracies. Now, if we can simply exempt ERs from the obligation to serve patients who do not require emergency care, we'll have one problem licked.

Posted by: bgmma50 | September 7, 2010 3:38 PM | Report abuse

bgmma50 and cummije5,

if you check with most large employers they're all switching to HSA type plans. Most large insurance companies ONLY offer HSA plans and don't give another alternative. That tells me that this is the only thing that somewhat controls costs. What do hospitals do? Most large ones now have HSA's but also give a higher level of benefit (ie less out of pocket cost) if you use one of their doctors that allows them to control their own costs.

Posted by: visionbrkr | September 7, 2010 3:48 PM | Report abuse

You guys should stop complaining because, one the health care we have now isnt as good as it was supposed to be. also the law has just been signed so give it some time. so if u want to say u have the right to choose tell that to ur congress men or state official. If you do not have insurance and need one You can find full medical coverage at the lowest price by calling 877-882-4740 or check http://bit.ly/9fDY7U If you have health insurance and do not care about cost just be happy about it and trust me you are not going to loose anything!

Posted by: keyshawn8 | September 8, 2010 6:22 AM | Report abuse

I dont know if you are old enough to remeber but there used to be these things called housecalls.When you or your child got sick you would call the doctor and he would come to your house.Even at 3am.

Can you belive that?...Its TRUE!!
Stop laughing..I'm not kidding.They still have them in Europe.You know where medical professionals are forced to do whats best for the patients and not themselves.


THATS why ERs are so crowded.

Posted by: froginapot | September 8, 2010 2:44 PM | Report abuse

We all have a role in helping to control health care costs. Check out http://whatstherealcost.org/info-desk.php?category=common-cents-change

Posted by: ChristineaWithRegence | September 8, 2010 3:52 PM | Report abuse

You guys need to get over this myth that European doctors are making housecalls like the good old 1950s.... yes there are a few who do but the VAST majority of care is provided in clinics and ERs just like in the states.

Find another red herring argument.

Posted by: platon201 | September 8, 2010 9:10 PM | Report abuse

My top reason for joining Kaiser Permanente HMO is that it has urgent care centers which are open evenings and weekends and located throughout the DC metro area. Before joining Kaiser, on several occasions I had a nighttime emergency and spent 3+ hours in an ER queue waiting for care. No more!
I have been satisfied with the care given my health care practitioners,and I like being able to make appointments and order Rx refills on the Internet.

Posted by: ptaylordc | September 9, 2010 8:16 AM | Report abuse

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