Less Primary Care Yields Higher Volume in Emergency Rooms, New York Times Reports

Lack of access to primary care physicians, especially among uninsured Americans, has contributed to a rise in emergency room visits, the New York Times reports in a front-page feature. Although the managed care movement was intended to decrease emergency room patient volumes through "better use of family doctors," low insurance reimbursements for primary care physicians have either driven physicians out of the field or forced them to cut out late office hours or weekend appointments, when emergency care is most frequently sought. As a result, emergency room visits have risen 6% to 8% in the past year, and according to a recent study by the Commonwealth Fund, three out of four emergency room visits in New York City are nonemergencies. Jeff Spartz, CEO of the Minneapolis, Minn.-based Hennepin County Medical Center, said, "The reimbursement in primary care is pathetic. It really frustrates us because we would like to be aggressive about prevention and early intervention, but the financing doesn't work." In addition, the increasing number of uninsured residents has contributed to the problem. Uninsured residents "have little choice but to get even the most routine care in emergency rooms, which by law must treat every patient who shows up," so cities with large uninsured populations are facing the worst crunch. In addition, the Commonwealth Fund study found that the majority of patients using the emergency room for primary care were not those with the "worst insurance, but those who lived in the poorest neighborhoods, where there were few doctors and more language and cultural barriers." Commonwealth study co-author John Billings said patients were "frustrated with long waits and inaccessible doctors," adding, "Patients are not happy with the primary care system. The hours are no good, waits are too long, and the people are rude. We have designed a health care delivery system more or less for the convenience of the system, not the patients." Meanwhile, some hospitals are capitalizing on the trend toward emergency room use, expediting the triage system and reducing waits to compete for business. The Times reports that in regions "where hospitals still compete for business, like New York City, and in areas with large numbers of uninsured residents," hospitals are learning to accept and embrace the deluge of patients. Hospitals are luring patients by creating a "private doctor's office" feel in the ER, with short waits and free coffee. Manhattan-based St. Luke's-Roosevelt Hospital has implemented several steps to improve emergency room services, reducing average waits from an hour and 15 minutes to 22 minutes by streamlining the admission process. Other hospitals are marketing their emergency departments by distributing free movie passes to patients who wait longer than 30 minutes to see a doctor and providing patient advocates to help patients cope with "non-medical problems," such as locating family members or providing help with daily tasks. However, though hospitals traditionally profit more from emergency room visits than clinic visits, insurance companies have gradually lowered reimbursement for emergency care by "downcoding," or paying a fee for the diagnosis "rather than the medical tests that reach that conclusion." The Times reports that downcoding would become illegal with the passage of the patients' bill of rights currently languishing in Congress. Meanwhile, the emergency room quandary has not gone unnoticed in the presidential election, with Vice President Al Gore criticizing Texas Gov. George W. Bush's (R) "problems with the uninsured" in his home state. In defense, Bush said in the second presidential debate, "[Texas has] spent $4.7 billion a year in the state of Texas for uninsured people. And they get health care. Now, it's not the most efficient way to get people health care," a likely reference to emergency room care, the Times notes (Steinhauer, New York Times, 10/25).