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The black hole known as the emergency room

Spend enough time in healthcare circles and you will find that folks talk a lot about the “ER”. Yes, the emergency room, one of the most costly places to receive healthcare services in the entire US healthcare system. From the NYT:

“Emergency room bills are notoriously high and perplexing; patients often are left feeling like captives who have few alternatives. It is impossible to know how much the services will cost when you walk in the door. The hospital bill, which arrives weeks later, may include seemingly inflated charges for things like Tylenol or an M.R.I. Doctors who treated you may send their own separate bills, further complicating the payment process.”

When articles have titles such as “The emergency room bill is enough to make you sick” and “The bizarre calculus of emergency room charges” it begins to make one curious why this one part of our delivery system gets so much attention and has such confusion around its cost.

If one looks at the Agency for Healthcare Research and Quality (AHRQ) Medical Expenditure Panel Survey (MEPS) data, the average expenses for folks who had one or more visits to the ER were $1318 in 2009. Median cost was $615, and for people 45 – 64, the cost was significantly higher than the average ($1696). The uninusered were by far the costliest in the ER (on average $1397; 37% paid out of pocket for these visits compared to Medicare patients who pay 4% to 6% out of pocket). Kids under age 18 were in the $465 to $469 range. These data can be seen here on the MEPS site. While these numbers may seem small in comparison to the trillions spent on healthcare, they definitely add up (how many million are uninsured??).

So let’s take a step back and look at the emergency room itself, and why services in this setting are so important. From Wikipedia:

“An emergency department (ED), also known as accident & emergency (A&E), emergency room (ER), emergency ward (EW), or casualty department is a medical treatment facility specializing in acute care of patients who present without prior appointment, either by their own means or by ambulance. The emergency department is usually found in a hospital or other primary care center. Due to the unplanned nature of patient attendance, the department must provide initial treatment for a broad spectrum of illnesses and injuries, some of which may be life-threatening and require immediate attention. In some countries, emergency departments have become important entry points for those without other means of access to medical care.”

It likely goes without saying that there are various times in our lives when we need emergency healthcare services. And make no mistake, many times access to these services saves lives – this is why we have a portion of our system that can take care of emergencies. However, “it’s quite typical for a patient to enter the ER with symptoms indicating a serious medical condition but leave with a diagnosis that sounds anything but urgent. Imagine, for example, the common scenario of a 50-year old man with a heart condition who comes to the ER complaining of crushing chest pain but, after a medical work up, is found to be suffering from indigestion.”

And this is the heart of the problem with emergency room services – because of their nature to assess, treat (if appropriate) and be readily available, they become one arm of the system that has the potential to be misused or overused. ER services do not require planning, in fact, this is counter to their function. ER services are for health emergencies; those unpredictable events that you cannot anticipate happening.

If I have no health insurance, I am likely to not see my primary care physician for prevention, chronic disease management and health behavior change. If I have no health insurance, I am likely to let some of my health problems “go” as I don’t have the resources to pay for an office visit (nor am I likely to ask how much the services I receive in an office visit will cost). To this end, the ER becomes my safety net; a place where I can always turn if it gets bad enough for me to really worry. As the classic RAND health insurance experiment showed, “patients use more healthcare (even if it doesn’t make them healthier) when they don’t bear much of the cost directly. In the E.R., a single $100 co-pay may feel like a relative bargain compared with the alternative: fees for multiple trips to the doctor and testing centers, hours on the phone arranging the whole process, and days of missed work.”

And this is what is happening throughout the country. Or is it? No doubt, the ER has become an over-utilized service that remains a high driver of healthcare cost, but when happens when we break down the data and look at who is actually using the ER services? What do we find?

Well, surprisingly many of the folks showing up in the ER have insurance. From Slate: “In fact, the uninsured don’t even use the E.R. any more often than those with insurance do.” The authors point out that one study showed that the “increased use of the ER over the past decade (119 million U.S. visits in 2006, to be precise, compared with 67 million in 1996) is actually driven by more visits from insured, middle-class patients who usually get their care from a doctor’s office” than from the uninsured.

So what is about us that even when we have access to traditional healthcare services, we still look to the ER for the answer?

I think the answer is twofold.

First, there is an information issue. Many times the information written about me stored on an electronic medical record may not be accessible to the person it matters the most to (me). I may only know what I remember from my office visit, and in the face of a health emergency, may forget all this anyway. While it remains to be seen how much personal health records and access to our health data will help decrease ER misuse, there is something there worthy of examining. We must have better access to our own health information.

Second, we must work on changing our attitudes on healthcare from “instant gratification” and “reactive” to a more “planned and informed” or “proactive” approach. The easiest example of this is that oftentimes it is easier to take a pill than do a more complicated routine of multiple health behaviors. The pill “gets it done” fast with little or no effort on my part. The same can be said for the ER. The ER is there, easy for me to access, and therefore why worry about that nagging pain in my chest? If it gets any worse, I can always go to the ER (please note, these are just examples and I do realize that nothing is as simple as I am making it). There is an underlying attitudinal change that must occur in healthcare prior to us seeing behavior changes in the healthcare system.

As more innovative healthcare programs emerge, many of them are choosing to focus on decreasing ER utilization as one way to drive down overall healthcare costs. These programs should be encouraged and will likely yield many positive results; however, we must start to look at some of the underlying issues at play here and consider the “why” questions. Why are patients using the ER in the first place? Why do we keep so much of the information about the patient in a place the patient cannot use it? And the list goes on and on.

The black hole known as the ER will eventually become anything but a black hole. Trends in healthcare spending simply will not allow for patients to continued to be “sucked in” to this setting at the level they are now. This will change, and it is time for us to consider how to change it.

What has your experience been with the ER? Why do you believe these services are so often over used?