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Opinion Column

Yeah, Those Emergency Rooms Are Crowded

Almost everyone understands that our emergency medical care system has real problems. Yet a surprising number of people, on many sides of the policy debate, wrongly view reducing emergency department use as a key measure of health reform’s success. To many liberals, crowded ERs exemplify a lack of access to basic care — a lack of access which ironically results in more costly care. To many conservatives, those same crowded ERs exemplify patients’ expensive and irresponsible misuse of scarce medical resources.

Although these arguments reflect very different ideological perspectives, they actually reflect surprising agreement on several things: Inappropriate, avoidable, or excessive emergency room use is unduly costly; health reform could and should reduce such use through some combination of incentives and the provision of alternative services; and reforms that reduce emergency care could therefore save a lot of money through the provision of more cost-effective care.

These arguments contain some element of truth. Yet they leave an overall impression that misidentifies the true problems facing our emergency care system. The real problem is not overuse. Rather, the problem reflects our lack of a financial and administrative infrastructure to properly support emergency care.

Why is the conventional view so wrong? For one thing, “inappropriate” emergency department use turns out to be less costly and harder to define than you might suppose. Patients seek emergency care for all sorts of reasons. Some are frightened by ambiguous symptoms. Some are sent by their primary care doctors, perhaps out of concern that this is a true emergency or because the required tests can’t be administered and read during the normal schedule. Other patients don’t like their regular doctor or are embarrassed to admit that they haven’t been taking their medications. Some just want a warm and safe place to sit.

True, emergency room use can be reduced by imposing stringent financial constraints on patients. Unfortunately, this approach reduces appropriate use, too, with sometimes deadly or frightening effects.

The above is pretty standard fare in health services research, as is evidence suggesting that universal coverage might actually increase both appropriate and inappropriate emergency department use. Notwithstanding this evidence, policymakers and voters seem determined to regard reducing ER use as a touchstone of the health care reform effort. This misguided focus provides a poor guide to health policy. It also makes it harder to nurture a realistic public conversation about what we should really do to make ERs effective and financially sustainable, given the ways that patients will actually use them.

People are right that something must be done to align the supply and demand for emergency care. ER’s are indeed overcrowded. At the same time, many hospitals are closing these centers. Predictably, average wait times are creeping up, sometimes to dangerous effect. More often, hospitals cannot provide the timely and humane care that each patient deserves.

In part, this problem arises because so many patients do present with complaints that could be addressed more cost-effectively in other settings. A recent study suggests that perhaps one-fifth of all emergency room visits could be managed at urgent care centers and retail clinics, at an estimated savings of $4.4 billion. We should realize, however, that these behaviors are hard to change.

In the scheme of things, $4.4 billion is small change in the context of 120 million emergency room visits every year, let alone our $2.6 trillion medical care system. Heavy-handed efforts to reduce ER use are likely to bring unintended, negative effects. They also divert attention from the most serious problem associated with this heavy use: the likelihood that patients are receiving poor medical care.

Of course, we can be more creative in developing attractive venues for well-managed primary care — efforts the health law appears to promote. We must modify emergency departments themselves to more effectively and efficiently meet patient care needs. A more sound approach would place less emphasis on influencing patients’ behaviors, and more on making our emergency care system financially and organizationally sustainable, given the patients who are actually likely to show up.

Although hospitals don’t always like to talk about this subject, inappropriate or excessive ER use are not the only or the most financially burdensome challenges facing our network of emergency care. These departments are the chink in the armor in allowing the uninsured and underinsured access to costly, often-unreimbursed services.

When hospitals lose money on emergency room patients, when they fear they will have to admit people they can’t afford to treat, or when these patients simply overwhelm the capacity of hospitals to provide such care, care will be rationed by waiting time or by other means which are not always pretty. This isn’t the fault of any specific hospital. It is an inherent problem of a system that must serve millions of uninsured people.

I have a modest proposal. By all means, let’s build primary care options and medical homes that provide effective and attractive alternatives to emergency care. Let’s find and finance alternative chronic care models that reduce the need for certain avoidable forms of emergency care. Let’s experiment with urgent care models that might lighten the ER load. Along with these efforts, let’s also make sure that emergency department’s receive-through insurance and through other means — proper supports for the care they deliver.

Then let’s let the volume of emergency care be what it’s going to be. We’d make better policy if we spent a little less time and energy trying to coax patients out of the emergency room, and spent a little more time and energy making sure that the system effectively treats the people who still come.

Whatever we do, two things are clear. We need more capacity for emergency care. And whether or not we build it, the patients will come.

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