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Jul
13
2006

As a proportion of total U.S. health care expenditures, emergency department (ED) costs are small: 1.9% of all expenditures of which 88% are covered by insurance.[1]  If ED costs are so small, relative to the whole pie, what can trends in ED use tell us about the broader health care system?

I believe trends in ED use – patient type, insurance status, etc – are like the canary in the coal mine. They can tell us when there are serious systemic access problems in the health care system.

Across the nation, 62% of EDs are now overcrowded.[2]  As an emergency physician, I have noticed a specific category of patient that gives insight into the problems with our medical care system. Two anecdotes illustrate what I think is currently happening.

A man in his 50s came who had temporarily lost his pharmacy benefit. He had a history of high blood pressure. When he ran out of his meds, he had no money and so he let it go. He presented at the ED with severe high blood pressure and congestive heart failure. We admitted him to the ICU – a life-threatening emergency that could have been easily (and inexpensively) prevented with some pills.

I saw a six year old boy at OHSU not too long ago. He had been playing in the yard where he picked up something that turned out to be discarded drug works and stuck himself with a needle. His mother knew that this was not a life threatening emergency. But there was confusion about whether or not the boy was covered by the Oregon Health Plan (OHP). After four days of trying to get an appointment with the pediatrician – who required proof of health insurance – his mother gave up and brought him to the ED. By then, it was too late to give him treatment to reduce his risk of AIDS and other infections.

These are examples of how access to primary health care is currently compromised. The ED serves as a safety net when patients lack access to primary care elsewhere. These people could have been treated outside of the ED with little cost. But there was nowhere for them to go. Under these circumstances, they were right to come to the ED.

This trend in ED use tells us we need to figure out how to provide better access to primary care for people with or without insurance. Sometimes it is not as hard as we think. One study I participated in a few years ago showed that ED use declined by 20% when primary care providers were open in the evening. Another option is to identify hospitals where EDs are not experiencing overcrowding. What is different about these communities? What can we learn from them?

There is also a larger ramification of this ED overcrowding trend for everyone – insured and uninsured alike. If someone has a heart attack or is injured in a car accident, a long wait can change the outcome for the worse, no matter if they have the best insurance coverage possible. That’s the ripple effect of no access to primary care to everyone.

[1] Tyrance, American Journal of Public Health, 1996
[2] Institute of Medicine, A Shared Destiny, 2003

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Join the dialogue here

Jul 14, 2006 8:45:01 AM
John Norris says

For other discussions on "Rx for Healthcare" about the crisis in the ED please see IOM got it wrong back in June 15, 2006.


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