Inappropriate ER use across the board

Charlie Baker is the president and CEO of Harvard Pilgrim Health
. This post first appeared on his blog, Lets Talk Health Care.

A few months ago, the New England Healthcare Institute (NEHI) issued a report on non-urgent use of Emergency Departments. It didn’t get that much public attention, which is too bad. It offered some interesting insights.

First of all, inappropriate — or non-urgent — use of the Emergency Room was not limited to uninsured populations. It showed up across the board. People covered by private insurance, Medicaid and Medicare were just as likely to use the ER for non-urgent care as people without health insurance. About 20 percent of all ER visits by privately insured and Medicare patients were for non-urgent purposes. About 24 percent of all ER visits by Medicaid beneficiaries and people without any insurance were for non-urgent purposes.

Second, another 25 percent of all ER visits for each group were for primary care treatable/preventable maladies. In other words, almost half of all ER visits were either for conditions that could have waited at least 24 hours to be addressed, or could have been solved in a doctor’s office.

Hmmm … We all read stories all the time about how crowded the ER is at many local hospitals, and the burden this puts on the care delivery system. We usually assume this is due to inappropriate use that’s driven by uninsured people seeking the only source of open access care that’s available to them. We also assume, correctly, that this is a pretty expensive and inefficient use of health care delivery resources. ER’s typically cost about 2 to 5 times more than a physician’s office to treat non-emergency conditions.

National statistics put the cost of treating non-urgent conditions in ERs at about $21 BILLION. In 2005, non-urgent care in the ER in Massachusetts cost about $1 Billion — or around 40 percent of all ER charges.

These stats, all by themselves, make Minute Clinics and their various clinical incarnations a no-brainer. How can anyone who believes that health care costs are too high look at this data and presume that a Minute Clinic is a bad idea?

But these data also illustrate the limits of a care delivery system that’s built increasingly on a specialty care model. If 70 percent of all physicians are specialists and only 30 percent are in primary care — and some 40 percent of what goes on in an ER belongs in the office a primary care provider, something is wrong. NEHI is discussing a demonstration/research project they will do in conjunction with the Institute for Healthcare Improvement and some of the IHI’s member hospitals and physicians to figure out if there’s a better way to handle the delivery of non-urgent care.

16 replies »

  1. naturally like your web-site but you have to check the spelling on quite a few of your posts. Several of them are rife with spelling problems and I find it very troublesome to tell the truth on the other hand I will definitely come back again.

  2. As an ER physician for 20 years I cannot not remember one of those years when this arguement wasn’t going on. The same information, same arguements, same myths, same propaganda and nothing changes. About the only thing most will agree on is the problem is geting worse, 119 million ER visits and counting. Ran across this in some research. Only questions are, could the computer wizards supply the national health net, will congress debate and past it, and will the people in each county be smart enough to vote for it. You could start with Mass. Wonder what the NEHI thinks. The numbers are correct as far as I can tell for construction, capacity and savings.
    National Access to Episodic Health Care Act
    (Introduced in House & Senate)
    S 2009 IS
    H 2009 IH
    111th CONGRESS
    1st Session
    S. 2009
    H. 2009
    To put forth a granting mechanism, provide funding for construction and establish parameters for basic levels of service in the first national interconnected Episodic Health Care System for all the people of the United States.
    In the House and Senate of the United States
    January 31, 2009
    Ms. RS and Mr. DS (for themselves) introduced the following bill in the Senate; Ms. RR and Mr. DR (for themselves) introduced the following bill in the House; read twice in each chamber and referred to multiple select committees in both houses.
    A BILL
    To put forth a granting mechanism, provide funding for construction and establish
    parameters for basic levels of service in the first National Interconnected Episodic Health
    Care System for all the people of the United States.
    Be it enacted by the Senate and House of Representatives of the United States of America in
    Congress assembled,
    This Act may be cited as the ‘National Access to Episodic Health Care Act’. (NAEHCA)
    Congress makes the following findings:
    (1) Americans are expected to spend $2,600,000,000,000 on health care in
    2009, up from $1,900,000,000,000 in 2005 and projected to continue at.
    6-7% increase per year for the foreseeable future.
    (2) US emergency rooms had 115,000,000 visits in 2005, 12% were
    admitted to the hospital. 101,200,000 visits were not admitted.
    Expenses paid by all payers for care rendered in all emergency rooms in
    United States for patients seen and discharged, (not admitted to the
    hospital) are expected to exceed $40,000,000,000 in 2009, up from
    $17,313,000,000 in1999. These figures do not include administrative costs.
    (3) Despite this large influx of funds, the number of people who leave the
    U.S. emergency rooms before seeing a provider have increased by 75% in
    the last 8 years to 2,300,000 people per year. Of those 2.3 million people,
    4% were estimated to need admission to the hospital at the time of their
    (4) A rapidly increasing practice in US hospital emergency rooms exists
    where the presenting medical acuity of a patient is declared non-emergent
    and they are “triaged out” of the emergency room to seek health care in
    another venue. Many of these patients, for various reasons, do not have
    the means to seek care in another venue and must wait until their
    conditions worsen to receive care.
    (5) 158,000,000 Americans are covered by employer-sponsored health
    insurance and another 14,000,000 buy their own individual health
    insurance. Rising health insurance costs jeopardize the ability of
    employers, employees and individuals to maintain coverage and is
    potentially a public health risk to the citizens of the United States.
    (6) One in every 6 people in the United States, or approximately 50,000,000
    Americans, (Equal to the population of England or the number of all Americans west of the Mississippi River minus Texas, California, Washington and Wyoming) lacked health insurance in 2008. This number is expected to increase as health care costs rise. Excess numbers of death in this population due solely to the lack of insurance and therefore access to adequate care is estimated at 18,000 citizens per year.
    (7) The Medicare program under title XVIII of the Social Security Act
    (42 U.S.C. 1395 et seq.) provide health insurance to 44,200,000 elderly
    and disabled Americans in 2008, while the Medicaid program under title
    XIX of the Social Security Act (42 U.S.C. 1396 et seq.) provided care for
    59,000,000 low income children and their parents, pregnant women and
    low income elderly individuals in 2008. Federal and State government
    expenditures for both programs were approximately $682,000,000,000.
    Out-of-pocket expenditures, secondary insurance/pension payments and
    other third party payments contribute another $380,000,000,000 in this
    population. Future financial projections show the Medicare Act will fall
    into insolvency by 2018. Medicaid will push the States into larger
    unsustainable budget deficits.
    (8) Approximately 85% of the U.S. citizens will experience a health expense
    this year. One out of seven Americans (44 million people) will seek care
    in a US hospital emergency room in 2008. Millions more pay for their
    episodic health care in urgent care centers, retail clinics, community
    health centers, and primary physician offices. Medical expenses paid
    out of pocket by U.S. citizens is increasing every year, especially for those
    age 65 and over.
    (9) At the present time no national system, with or without an interconnected
    electronic medical record system, exists to provide episodic care to all the
    citizens of the United States regardless of their age, insurance or economic
    (10) Secondary to the previous findings, future demographics and financial projections, Congress finds that health care in the United States of America, as presently delivered, demanded and paid for is not sustainable. Health care costs directly limit job creation outside the health care sector, inhibits America from competing in the global economy; threatens the solvency of individuals, families, companies, and pension funds. Government health care costs place catastrophic financial burdens on local, state and federal governments. Costs for health care and indirectly access to care place the lives of Americans in unwarranted and avoidable danger. Health care costs have become a threat to the National economy. Secondary to these findings et al., health costs are considered by Congress to pose a threat to the security of the United States of America.
    (11)The establishment of a National Episodic Health Care System, whose
    electronic medical records are totally interconnected, is deemed vital to
    the health and financial security of citizens of the United States and
    in the National interest.
    The purpose of this Act is:
    (1)To establish a funding mechanism and protocols where every county in the United States may petition funds from the Federal government for the construction of State-of-the-Art Urgent Care Centers.
    (2)Establish the basic levels of service each individual center must provide
    to the people residing in said counties. The centers need not be limited to
    the established levels of service, but must provide them to obtain funding.
    Paramount among the requirements will be the willingness of the
    participating counties to have their centers’ ELECTRONIC MEDICAL RECORD SYSTEMS interconnected with all other participating counties in the United States and that all the citizens in one participating county be able to access the centers in another participating county when circumstances dictate.
    (3) To establish funding for the various federal agencies to monitor the
    National EMR grid such as; CDC, FDA, NIH et al.
    (4) For the people: (not limited to, but including)
    (a) Freeing citizens from financial concerns in seeking their
    episodic and urgent health care.
    (b)Provides people options where to receive episodic care no matter where the need may arise for themselves or their families anywhere in America.
    (c) Allow greater freedom and choice in how Americans wish to
    secure and pay for their and their families overall health insurance
    (d) Reduce their out of pocket health expenditures.
    (e) Provide greater communication between their primary care
    physicians and urgent care providers.
    (f) Establishes centers for information on; health care, points of access
    to care available in their own counties of residence, their illness,
    evidenced based care, health insurance, health literacy and
    pharmaceutical information.
    (g) Decreased morbidity and mortality.
    (5) For the providers: (not limited to, but including)
    (a) Better patient care with detailed patient visit reports in their
    offices by e-mail or fax within 24 hrs of their patients visits
    to one of the centers anywhere in the US.
    (b) Relief of after hours patient care.
    (c) Assistance with their patients P4P accounting system.
    (d) Improve Hospital revenues on admitted patients from centers
    with direct admission and accompanying preliminary testing.
    (e) Decreased uncompensated care at every level.
    (f) Decompression of Emergency room traffic
    (g) Decompression of Federal Qualified Health Center traffic.
    (h) Dissemination of evidenced based health care information,
    advertising of physician office services, scheduling appointments,
    and increasing their patient base.
    (i) Assist new physicians and health care workers in paying off their
    medical education debt.
    (6) For the Payers: (not limited to, but including)
    (a) Conservative estimates of 40% saving ($24,000,000,000) on
    Emergency room cost per year the first year of full participation.
    (b) Greater control of healthcare inflation, at least in this sector of
    health care, providing greater savings every year.
    (c) Allow greater creativity in insurance packaging/offers to US
    Citizens making health insurance less expensive to all.
    (d) Dissemination of insurance information.
    (7) National Security
    This program establishes the first National Interconnected Health
    Grid where one currently does not exist.
    A National interconnected health care grid enables multiple
    federal and state agencies to monitor for outbreaks of disease from all
    causes, drug reactions and public health research. Such a system
    allows greater response to man made and natural disasters, rapid
    vaccination and information dissemination.
    Services provided and basic specifications of each center to be constructed
    locally and funded by Congress include but not limited to:
    (1) Building shell and floor plan:
    (a) Waiting room with space available for information Kiosk.
    (b) Reception area.
    (c) 8-10 examination/procedure rooms.
    (d) Provider dictation/information center.
    (e) X-ray room generator and digital processor room with internet capabilities.(PACS).
    (f) Medical Laboratory with a laboratory information system.(LIS)
    (g) Adequate storage and refrigeration space.
    (h) Staff room.
    (i) On site self contained electrical generator capability so site may
    continue full functional capacity in the event of power loss for
    any reason.
    (j) EMR soft & hardware:
    Must be capable of but not limited to the following:
    (1) Each center must be “paperless” with on/off site storage
    of files.
    (2) Patients should be able to register electronically at the
    Centers and from home via the internet if they desire.
    (3) Real time wait to be seen times posted on the internet.
    (4) Electronic dictation and records, voice activated preferred but not necessary. Must be wireless.
    (5) E-prescription services.
    (6) Visit copies sent via e-mail or fax to whoever the patient authorizes.
    (7) Laboratory and x-ray information systems.
    Results must be able to be viewed over the internet by
    (8) Real time data mining capabilities.
    (9) Connected to local hospitals’ and Community Health Centers’ patient data systems. Private physicians with EMRs may connect at their discretion.
    (10)All centers must be capable of being tied into the
    National Medical Record system.
    (11)All connections must meet all security requirements.
    (2) Services, including but not limited to:
    (a) All general urgent care services and conditions not requiring
    emergent care, invasive diagnostic testing or invasive
    procedures. Each center will be capable of serving at least 60%
    of the visits currently seen in US emergency rooms.
    (b) All centers must be ACLS/PALS certified and capable for
    adult and pediatric patients.
    (c) Laboratory capabilities, CLIA certified, Chemistry,
    Hematology, Coagulation, Urinalysis and rapid
    screen testing for Strep, influenza, Pregnancy, et al. as
    determined by CLIA.
    (d) Digital X-ray generation and processing with PACS system.
    (e) Direct admission protocols to local hospitals.
    (f) Visit reports including Physician dictation, lab and x-ray
    reports, P4P criteria and status of patient, evidence based
    treatment and follow up information sent via e-mail or fax
    in 24 hours to primary care physician any where in the US.
    Assistance in scheduling of patients from clinic to office
    for appointments. May be done electronically for those
    physicians who wish to connect to system.
    (g) Services provided will be free of charge to all citizens
    currently residing in participating counties. If a covered
    citizen requires care when outside his county of residence
    care will be rendered at no charge if the county in which they
    are seeking care is also a participating county any where in
    the United States. Charges to citizens who resided in a
    nonparticipating county who wish to obtain care in an
    urgent care center of a participating county will pay costs
    . as determined by the county health centers governing body.
    (h)The capacity of each center shall be at least 15,500 visits
    per year unless a waiver is granted.
    Total cost of the program for construction of all centers in the US
    and construction of the national information system shall not exceed
    $10,000,000,000. Program will run over 5 years with $2,000,000,000 available each year for construction. Expected cost for each center is expected to be
    $2,000,000 each if construction is new. Costs maybe reduced if
    centers already existing and meeting all qualifications can be bought
    out right or leased and retrofitted. Counties will be limited in the first round of funding to one center for every emergency department within their boundaries. Specifications for each center shall
    contain the following , but not limited to:
    (a) Capacity of at least 15,500 visits per year, unless waived.
    (b) All service capabilities as stated above and to be determined.
    (c) Located as close to existing emergency rooms in the
    County as possible. (approximately 3,900 emergency rooms
    In the U.S.)
    (d) Conform to local building codes.
    (c) Meet all biological waste disposal criteria.
    (d) Meet all provisions of the American’s with Disabilities
    Act of 1990.
    (e) Meet all energy reduction specifications. Must have on site
    emergency electrical generation capabilities to run
    at full service capacity during usual hours of operation
    for 3 days time.
    Congress and the various federal agencies will be responsible solely for the
    construction of , initial equipping of the centers, connections to the national
    grid and costs for maintaining/monitoring the national health information
    Before funding is granted for construction, EACH COUNTY MUST SUBMIT A PLAN FOR FUNDING THE ONGOING COSTS TO RUN THE CENTERS CONSTRUCTED IN THEIR COUNTY. This is a well known process to all counties in the US and similar to other Congressional requirements for funding similar projects, i.e. Federal mass transit funding. Expected costs to the counties to run all the centers constructed in their county at the specified levels of service and capacity is approximately $25-$35 for each citizen in the county per year.
    Counties without a current hospital or large enough population to sustain running even one center may apply for funding under a variance of the rule and in conjunction with the Department of Health and Human Services.
    Each county must also establish a governing body to administer the centers.
    Revenues collected for the purpose of operating, maintain and administering said centers must be held separately from other county revenue funds.
    Congress has established the following as the role to be played by
    the Federal government in establishing and maintaining the elements
    of this Act. (to include, but not limited to)
    (a) One time funding for construction and initial equipping of the
    episodic health care centers.
    (b) Ongoing funding of various federal agencies for the maintenance,
    monitoring and research of the National health information grid.
    (c) Congress directs the Congressional Budget Office to investigate
    the above Act for cost analysis, budget rules of the Congress and
    long term projections of the effect on health care delivery and costs.
    (d) Congress further directs the multiple various agencies; CDC, FDA,
    HHS, CMS, FEMA, et al, to provide input and comment on their
    roles, estimated funding requirements and implementation on the
    above Act.
    Congress mandates and confers the following requirements and responsibilities
    to the local governing bodies which must be created to obtain funding for
    construction. (to include, but not limited to)
    (a) To maintain the basic levels of episodic care as established by this
    Act. Higher levels of service and additional services may be
    established by the county citizens and governing bodies. These
    additional services will be at the discretion of the county citizens
    and will not constitute an encumbrance on Congress.
    (b) To establish the mechanism for the collection of revenues to
    pay salaries, maintain building and equipment, administer and
    provide to their citizens said level of basic services. The revenues
    collected will be the sole possession of the governing bodies established under this act and the citizens they serve. No state, county or any other local governing entity may make claim to or incorporate into their general funds the revenues so collected.
    Existing estimates of costs to each citizen within the boundary of
    a county to be $25-35 per year. After payment of such fee, persons
    are entitled to care at any center within the county and any center in
    any other participating county in the United States free of any other
    (c) To maintain a listing of citizens residing within the county’s
    borders and therefore eligible to receive care at the centers.
    Said listings must be available to all other participating counties
    to allow reciprocal participation among their citizens. Only
    citizens of the United States will be eligible for care under this Act.
    Foreign nationals and citizens of counties not participating will be
    able to receive care at the centers under the rules, regulations and
    costs to be determined by the local governing bodies.
    As passed by the Congress and sent to the President of the United States for his consideration, comment and approval, this day.
    Ironically, the costs of health care in America are rapidly becoming a leading detrimental
    factor to the health of its citizens, regardless of their age, race or economic status. Every year that passes reveals ever greater costs to the many different payers. These escalating costs result in employers struggling to pay for employees’ health insurance. More of our citizens are going without insurance and basic health care. Local, state and the federal government budgets are reeling under the costs to provide health care to over 1/3 the population of America.
    No matter how you look at future projections of demands and costs for health care, it is
    quite apparent that the present method of supplying and paying for health care in America is unsustainable. America is not alone in this predicament. Costs are accelerating around the world and improved quality is a concern for all nations. Many industrialized countries are grappling with how to meet their populations increasing demand for Urgent Health Care. What the tipping point is regarding the percentage of GDP devoted to health care and a country’s economic viability is unknown. Many feel that it is rapidly approaching in America. For many of our fellow countrymen and their families, the 18,000 Americans that are estimated to die every year because of a lack of health care, that point has already arrived.
    Health care reform in America has been going on for over 100 years. Health care delivery
    is basically the same as it was at the beginning of the 20th centaury although the technology is much more advanced. The third party payment system, employer provider insurance, exploded during and after World War II. State sponsored insurance has been growing for over forty years. These and other changes have brought us to where we are today. The greatest health care in the world, but only if you know how and where to get it, pay for it and hope the system works as planned. Health care in America is not a system by definition, but a piecemeal, nonintegrated collection of payers, providers and information. Even when you have the money and knowledge to access the system a good outcome is not a certainty. Strains on system capacity result in greater amounts of patient misinformation, lack of information and medical error which increase costs, morbidity and mortality regardless of a patients intelligence or wealth.
    Today, with a presidential election looming, healthcare is again coming to the forefront.
    The proposals presented mainly attempt to address the cost of procuring health insurance
    and are divide into 2 main camps. One plan championing “free market” principles and individual responsibility and the other based on “Universal Coverage”. Both are based on good hypotheses and have an emotional appeal to different segments of the country. Both have their deficiencies. Neither addresses the concerns of access and system capacity. They minimally address the information gaps at all levels. Whether they will decrease health care costs is a hotly debated issue. Neither addresses the looming issues on Medicare and Medicaid.
    What role does the “National Access to Episodic Health Care Act” play in the overall plan to provide less expensive, quality health care in America? How will it address the above concerns and what does the NAEHCA do?
    The “Act” as proposed provides the American people, county by county, throughout the United States a choice. There are no mandates of how people would pay for, seek and meet this specific area of their health care needs, their urgent or episodic health care. The demand in America for this type of care has been increasing rapidly over the last 10 to 20 years. This is need for episodic care is evident by the rapidly growing numbers of emergency room visits, urgent care centers and newer retail clinics to meet the demand. Care delivered by these various entities is vastly more expensive then the system proposed by the Act. None of the various providers are interconnected. They also cannot expand their services the way this proposed system would be able to. The Act provides savings and incentives for all parties concerned in providing, receiving and paying for health care.
    NAEHCA establishes a program where the People in any county in America either through referendum or their elected officials will be able to establish an episodic health care system in their county. The Federal government provides the funds for the construction and capital costs for initial equipment in each center. Each center will on average cost the $2,000,000 to construct and equip. The centers are then turned over to the “governing body” established by the People in each county to run and maintain the centers. Total cost to the federal government for constructing and equipping a center near every emergency room in the country, 3,900 centers, is $7,800,000,000. In 2005, the federal and state governments paid for 51,000,000 visits to emergency rooms alone in the U.S. Only about 19% of the visits required immediate or emergent care. This doesn’t include episodic care paid for in other ambulatory care settings. This one time payout pales in comparison to the savings such a system would generate and the saving would become larger every year. Likewise, all payers of these types of visits would reap large savings by such a program. Private insurers and workman’s compensation insurers would also benefit with large savings. Together they had 48,000,000 visits to U.S. emergency rooms in 2005 of which only about 15% were immediate or emergent. Perhaps a Public-Private partnership to fund the initial construction and equipping of the centers could be arranged since all payers would benefit? Out-of-pocket expenses paid by the citizens of the United States for their ER/Urgent care needs has increased every year, with the elderly making the highest cash payments. When fully constructed the system could easily handle over 60,000,000 urgent/episodic care visits per year and its full capacity approaches 100,000,000 visits per year.
    Other expenses generated and paid by the Federal government would be for the maintenance and monitoring of the national episodic care center health grid. Various federal authorities such as the CDC, FDA and NIH would be able to monitor the grid for outbreaks of illness, drug reactions and perform public health research. Areas of low vaccination rates could be targeted. Populations with low achievement of evidenced based preventative health measures and their primary care physicians could be contacted
    and the quality of their health care increased and physician’s P4P increased. All centers would have internal electrical capabilities for 3 days allowing continued health care during natural disasters, areas important to FEMA and Homeland Security.
    The figure of $10,000,000,000 established by the Act to pay for construction and initial equipment may seem unprecedented. The federal government will pay $1,500,000,000 to close 7% of the hospital beds in New York state alone over the next 4 years. The Genome Project, the sequencing of the human gene structure cost more than $5,000,000,000,000. Estimated savings to all payers in the system approaches $24,000,000,000 in the first year and will increase every year. These savings maybe dwarfed by those achieved through changes in the costs of health insurance, the increased overall health of the American citizen and boost to the overall US economy which will occur as a result of enacting this bill.
    Although a national episodic health care system will provide billions of dollars in savings
    to the various payers of such care, both in direct payouts and processing expenses, the greatest benefits would be to the people of the United States. With such a system in place the citizens of a participating county each pay on average $30 per year, about 8 cents per day. This entitles them to go not only to any of the established clinics in their own counties, but any other clinic in any other participating county and as often as needed. The level of service provided is at least equal to that provide by a hospital based urgent care center. Direct out-of-pocket saving to the public is in the billions of dollars. For $30 per year the person’s episodic health care needs are removed from their overall health insurance costs. This allows them to purchase other health insurance at a reduced cost. Insures would be able to expand and individualize health insurance plans with greater freedom and cost. Such a system alleviates people’s concern for their costs of urgent care. These concerns prevent people from seeking care early on in the disease process and cause unnecessary and more invasive care later on. Those people who still wish to receive their care in an emergency room or other setting may do so but they and their insurance carrier will incur the cost. There are no mandates where people must seek their care. For those people traveling on vacation, business or migrating for the season their episodic care is easily and readily available and at no additional cost except the $30 dollars per year they paid in their home county, providing they seek care in another participating county. The cost savings are only the beginning of the benefits such a system would provide. Availability of health information, direct admission to the hospital if needed, assistance with health and insurance information, increase evidenced based care are only a few. The people in the county may wish to increase the types of services available at their county clinics and by referendum or through their governing bodies provide emergency dental care or psychiatric care. This is health care organized at its most basic level, the county. Money collected does not leave the county but pays for jobs and services in the county. This is not government health care or mandates, but managed by “Governing Bodies” made up of people living within the county.
    Financially, this plan works in every Metropolitan Service Area of the country where approximately 85% of all ER visits occur. (Try the formula in your county). Take the number of emergency rooms located in your own county. Using this as the number of episodic health care centers erected in your county, multiply the number of centers by $1,800,000 which is the amount of money required to run each center for a year. Multiply the total population, number of people living in your county, by $25-$35 which gives you the total amount of money collected in your county each year. The formula works for every county with a population greater than 50,000 in the US. As an example, the nation’s capital will be used. Washington D.C. has 8 emergency rooms. It would cost $14,400,000 to operate the 8 centers constructed. The 2006 population estimate for Washington D.C. is 581,530 people. With each citizen paying $30 per year, $17,445,900 would be raised. This is more than enough funds to run the centers which at a minimum would provide 124,000 visits per year and a capacity approaching 200,000 visits per year.
    Once constructed and connected, the possibilities of providing care, reducing costs and increasing the quality of care to each individual in America and the country as a whole depends only on what the people in each individual county can imagine and are willing to pay for. For the first time in American healthcare, at least their episodic health care, delivery will be directed not according to insurance status or income, or age or employment status, but by all the people in a given community for the common good, much like their transportation needs are coming to be met.
    The future of how we in America plan to provide and pay for health care is uncertain.
    Regardless of the plan that will be implemented, market based, single payer, some mixture of existing plans, or the status quo, NAEHCA and the system that it creates will make the delivery and cost of health care more efficient and less expensive for every single American regardless of their economic or social standing. The Act does not replace providers but enhances their abilities to provide care. These facts hold true for either presidential candidate’s plan or the Patient-Centered Medical Home Model put forth by AAFP, AAP and ACP. If for no other reasons than those, the “NAEHCA” deserves to be debated in the halls and on the floors of Congress.

  3. We have been working with hospitals for over 2 years on this issue. What we have found is that Medicaid patients are 4 times as likely as commercially insured patients to use the ER for non-emergent care. Uninsured patients are twice as likely to use the ER. Those visits are not occurring in the late night hours as much as you’d expect.
    Our aggregation of clinic availability within the community and the ability to schedule on demand has had a significant impact on lowering non-emergent ER visits.
    Our view is that there isn’t as much of an access problem as there is a connectivity problem. Patients need to know where they can be seen quickly, whether in a convenient clinic or outpatient clinic. Massachusetts is the exception to that statement. There they have a serious access issue.
    More and more clinics are utilizing open block scheduling and that will certainly provide more timeliness for the “on demand” appointment.
    Access for All America is working toward increasing clinic capacity for the medically undeserved through its 1200 community clinics. That will go a long way toward beginning to address the access and connectivity issues.

  4. Why do we put the blame only on the shoulders of the patients? Having been in practice (and fortunately not anymore) for many years, the business and care delivery model of the typical MD offie needs to evolve. No longer can we expect patients to wait in the “waiting room”. Until the average office understands that nothign will change.

  5. “In Germany you can take time off work for medical care without fear of losing your job and generally without a loss of pay.”
    I think it is the same in most European countries, and I think it’s the best solution for both the employees and employers in the long run.

  6. There’s another reason why Germans get their care from their primary care doctors. In Germany you can take time off work for medical care without fear of losing your job and generally without a loss of pay. That makes it a lot easier to go to the doctor during regular daytime hours. I just got off an evening shift in our urgent care clinic and most of the people I saw tonight were there for convenience rather than urgency. Those of us who have always worked in professional careers sometimes forget what it’s like to need a doctor’s note for a sick day or two.

  7. This is a problem which has been well known for a number of years, but just keeps getting worse and worse. I keep asking the same question on these blogs when many of these longstanding problems are repeatedly introduced for discussion – where is the leadership to will a solution into existence? The fragmentation of our delivery system seems to ensure that we will continue to discuss, and discuss, and discuss, most of these problems ad nauseum. I urge people in positions of power and influence such as Charlie to think about an answer to this question of leadership and execution as the first priority.
    Although all the comments make important points on this issue, I think docanon and rbar have hit both the problems and the solution on the head. Patients can’t tell an emergency from a non-emergency, and the media and TV shows have scared them into thinking the most innocuous symptoms may indicate a hidden dire condition. So they go to ER’s “just in case.” Also, primary docs are just as guilty – when a patient calls and describes symptoms, I have seen them tell a patient to go to the ER rather than trying to fit the patient into their schedules. It’s no skin off their noses.
    rbar’s suggestion of putting a 24 hour urgent care clinic right next to the ER is excellent. This way triage occurs by knowledgable people (in the ER), reassuring both the patient and the hospital’s attorneys, and non urgent care is immediately available. If the urgent care physician feels it is a real emergency after examining the patient, he can be bounced right back to the ER immediately.
    Questions of physical space, reimbursement and clinic ownership arise but are certainly not insurmountable. Honestly, I wonder why this solution has not taken hold already – which circles back to the original issue of leadership.
    The bottom line is, don’t try to make the patient the one who determines what is an emergency and what isn’t – it won’t work (already isn’t working) and they are often wrong, in either direction. Sometimes even the ER doctors are wrong – which is why there are wrongful death suits for patients sent home from ER’s.
    The solutions are out there – just have the will to implement them.

  8. I have an HSA combined with the mandatory high-deductible PPO plan. I will always call my GP (or the on-call doctor in the group) before heading to the emergency room.
    Why? Because I don’t want to get charged an arm and a leg for something that can wait until Monday.
    Prices convey information …
    I imagine a common concern is that the high price of an emergency room visit will prevent me from going when I really should. I can at least say in my case that’s unlikely to happen. I think the value of “not dying” is a lot higher than they charge me at the ER.

  9. I know this seems really simple but three questions:
    These questions should be cumbersome put possible to gather the answers too.
    1. What times were the “inappropriate visits” mainly occurring?
    2. Were the “inappropriate visits” usually for a selective population (e.g., parents with child under say 2 and younger)?
    This one would be also impossible to gather data on useless a small trial is conducted but what is the severity and health status of people at the time they are visiting an ER for an “inappropriate visit.”
    All of these seem rather simple on the face but I would be willing to bet they would shed a ton of light on. They may have already largely been answered too by previous research. Just my thoughts on it.

  10. I think a great part of the problem is what I would call the “impatient consumer mentality” that is particularly rampant in America. A lot of people must have an answer or result NOW, can’t handle waiting for an appointment, test result or therapy.
    I can tell you that in Germany (where I trained and worked in the 90s), there was barely an ER as a concept, and to my understanding, that hasn’t changed. There are PCPs on call for nonurgent issues; for “911” emergencies, there are mobile ambulances staffed with emergency field doctors. If the problem is surgical, you will be brought to the surgical intake unit, otherwise to the medical one (this is also where doctors send patients who need to be hospitalized). There is virtually no “showing up at some facility” to get fulfillment of your medical needs.
    What I think would improve the problem of overcrowding and inappropriate use is to have a 24 hour walk in clinic just next to the ER, and nonurgent patients are just triaged there … and may have to wait.

  11. Well people don’t always get sick between 9 and 5.What we need are clinics opened 24 hours.Another thought clinics could also operate inside hospital buildings with RN’s seeing patients for nonemergency issues.Then the trama centers would not be crowded.

  12. “Is there any evidence that areas (or countries) with more PCPs per unit population have fewer “inappropriate” ED visits?
    I know that when this became an issue in Ontario there were plenty of GPs to handle patients. Now GPs, (especially in rural areas) are getting harder to find.
    My experience in the ER (justified by the way with a finger almost cut off) was that there were people there with sprained ankles or fever – not an ER situation. They just did not want to wait until either Monday or the morning, and use of the ER was just as free as a GP visit. I don’t know what the situation is now or how it’s being handled, but I’m taking a trip back soon and I will find out. Why not Nurse Practitioners in ERs to handle the minor cases?

  13. Interesting post. The idea that we can relieve ED overcrowding by expanding the availability of primary care services has face validity. But I still have to wonder…are there any hard data on questions important to designing a solution:
    1. Patients don’t always know whether their conditions constitute an emergency. They’re also not required to talk to their PCPs prior to going to the ED (to get an opinion on how emergent their condition is). Is there any evidence that areas (or countries) with more PCPs per unit population have fewer “inappropriate” ED visits? Any time-series data from natural experiments?
    2. What’s the optimal rate of “inappropriate” ED visits? It’s definitely not 0%. For how many “inappropriate” ED visits was the appropriateness knowable in advance, and for how many was this only knowable in retrospect. The analogy is operating for suspected appendicitis. If you’re not removing a nonzero percentage of benign appendices, you run a substantial chance of missing the real thing.
    3. In terms of ED access for appropriate use, how harmful are inappropriate visits, as opposed to ED closure by hospitals (a common phenomenon over the past 10 years, due in no small part to the unfunded EMTALA mandate)?
    It might be the case that interventions aimed at shunting patients who present to the ED with “inappropriate” complaints towards hospital-based urgent care clinics would be the best solution. This has the virtue of taking patient behavior as a given.

  14. Of course, the problem as Charlie knows well, is the “belongs in the office of a primary care MD” part. When I called my primary care MD’s office, it was a four month wait for an appointment. When Massachusetts added 300,000 new insured people to the ranks of the insured thru its health reform proposal, guess what?
    Most of them couldn’t find primary care MD’s with open practices.
    When was the last time you spoke to your primary care physician on the phone, or received a response to an email from them? Until this problem gets fixed, and it will probably take the better part of a decade, we’ll have a lot of “inappropriate” ER use from people who merely need a dialog with a knowledgeable health professional about their worrying symptoms. Health reform begins here. . .

  15. This issue is the same for all healthcare systems, single-pay or the U.S. non-system. But in a costly non-organized healthcare “system” like ours it really does add many more dollars. I know the Canadian System had the same issue, people using the ER when they could just as easily wait to see their GP (this was not a wait list issue). What is needed is proper ER triage, but in this “money-is-everything” system I doubt hospitals would want to send the “$$ paying” customers down the road.

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