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Inappropriate ER use across the board

Charlie Baker is the president and CEO of Harvard Pilgrim Health
Care
. 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.

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Sports FlooringjamesdJayDr. JayLuontaistuote Recent comment authors
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Sports Flooring
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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.

jamesd
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jamesd

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… Read more »

Jay
Guest

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… Read more »

Dr. Jay
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Dr. Jay

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.

Luontaistuote
Guest

“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.

J Bean
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J Bean

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… Read more »

bev M.D.
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bev M.D.

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… Read more »

Bret
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Bret

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… Read more »

MG
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MG

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… Read more »

rbar
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rbar

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… Read more »

Norma
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Norma

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.

Peter
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Peter
Peter
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Peter

“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… Read more »

docanon
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docanon

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.… Read more »

tcoyote
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tcoyote

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… Read more »