Those in and outside the health care system often blame patients for their nonurgent ED visits, labeling them medically illiterate. Some, despite all the evidence, point to this as the cause of emergency department crowding.
As emergency departments brace themselves for the onslaught of the newly insured anticipated to come with the Patient Protection and Affordable Care Act, new studies indicate that the answer may be easier to define but more difficult to solve.
The simple answer is that many patients lack timely access to primary care or clinics. Faced with symptoms such as pain or fever, they go where they know the door is always open.
Sixty-five percent of the adults in one study, which was reported at the recent annual meeting of the Society for Academic Emergency Medicine, said they came to the ED because they were suffering from what the researchers called a high-acuity problem. And an astounding 78.9 percent reported at least one problem in accessing care, said Adit A. Ginde, MD, MPH, an assistant professor of emergency medicine at the University of Colorado School of Medicine and Epidemiology at the Colorado School of Public Health.
The researchers evaluated responses from 4,606 participants in the 2010 National Health Interview Survey who had sought care in an emergency department in the past year, and 83.9 percent of those who did not have a high-acuity issue said they sought ED care because of one or more barriers to obtaining regular care.
The investigators, after adjusting the data for covariants, found that those who reported a high-acuity problem as the reason for the ED visit were pretty much the same whether or not the patient had insurance. Instead, the differences lay with access to care. Patients with Medicaid only, those with Medicare and Medicaid, and those without insurance were more likely to have at least one problem accessing care compared with those who had private insurance.
Dr. Ginde, also an associate director of the Colorado Emergency Medicine Research Center, said he and his colleagues anticipated that Medicaid patients would be less likely to say they thought they had a true emergency, but that proved wrong. “When we adjusted for co-morbidities, they were as likely as those with insurance to say they had a truly emergent issue. From a patient perspective and a prudent layperson standard, they perceived that they had a true emergency and often may have called a primary care office only to be told to go to the emergency department,” he said.
Jennifer Wiler, MD, MBA, an assistant professor of emergency medicine at the University of Colorado School of Medicine and an author of the report, said providers do not view all types of insurance equally. “Medicaid is different. Access to care is different for Medicaid, Medicare, and private insurance,” she said. “One barrier for Medicaid patients in a lot of states is that the cost of delivering care is higher than the payment. Until we fairly pay providers for caring for these patients, it's always going to be challenging.”
The Affordable Care Act is a great first step to expand insurance coverage to Americans, Dr. Ginde said, but no parity exists among the types of insurance. “It's not the silver bullet, but it's an important but small step,” he said. “Medicaid patients, even if they have a designated primary care provider or a medical home, have greater difficulty in accessing those providers for acute care needs. There is no chance of getting a same-day or next-day appointment. You could argue that they don't need emergency department services, but they do need acute care services, and if they cannot get them, they go to the emergency department.”
Dr. Ginde said just providing insurance is not going to be enough to fix the system. “With the Affordable Care Act and infusion of new patients into an already overtaxed primary care system, we will see new surges in the emergency department,” he said. “It should be accompanied by true access.”
He advocated for medical homes, though he noted that maintaining that contact can be difficult. “If a patient jumps around because he or she is told, ‘You can't come here anymore; you should go there,’ then there is inconsistency, and they are more likely to end up in the emergency department.”
Focusing on nonurgent visits to the emergency department may be counterproductive to solving these overarching problems, said Jesse M. Pines, MD, MBA, the director of the Office for Clinical Practice Innovation and a professor of emergency medicine and health policy at the George Washington University School of Medicine and Health Sciences. Studies that look at whether a patient's visit was urgent show, of course, that what seems urgent to patients may not be to a trained physician. “A better classification is low acuity,” he said.
Nonurgent use is driven not just by barriers to care and lack of insurance, Dr. Pines and colleagues found in a recent study. (Am J Manag Care 2013;19:47.) A systematic analysis of 26 articles looking at nonurgent visits revealed that none used the same criteria to define nonurgent, they noted. The percentage of visits considered nonurgent ranged from eight percent to 62 percent. “The limited evidence suggests that younger age, convenience of the ED compared with alternatives, referral to the ED by a physician, and negative perceptions about alternatives such as primary care providers all play a role in driving nonurgent ED use,” they wrote.
Dr. Pines cautioned that the issue is vastly more complicated than whether the patient has insurance. Is the setting available in a timely manner? “In a lot of cases, it is not. Someone calls a primary care doctor, and is told to wait two weeks for an appointment,” he said. And sometimes the setting does not have the resources to care for a particular complaint. “For a lot of things, patients don't know what's an emergency, what's urgent, and what can potentially wait,” he said. “Any complaint can be potentially life-threatening.”
That is backed by a recent study by Maria Raven, MD, MPH, an assistant professor of clinical emergency medicine at the University of California-San Francisco, that showed the chief complaint and the discharge diagnosis are often different from one another. (JAMA 2013;309:1145.) “Among ED visits with the same presenting complaint as those ultimately given a primary care-treatable diagnosis based on ED discharge diagnosis, a substantial proportion required immediate emergency care or hospital admission. The limited concordance between presenting complaints and ED discharge diagnoses suggests that these discharge diagnoses are unable to accurately identify nonemergency ED visits,” the study's authors wrote.
Dr. Pines pointed out that many studies have shown that crowding is not an issue of low-acuity patients but a hospital-wide problem that has high-acuity patients boarded in the ED until a bed opens up. The problem then becomes that low-acuity patients usually pay more than the cost of care while high-acuity care can cost more than the charges. “If you starting taking the low-acuity patients out of the emergency department, you could have an adverse effect on hospitals. The solutions may backfire, and you end up increasing costs. If the goal is to reduce health care costs, there are so many other ways to do that more effectively than reduce low-acuity visits to the emergency department,” he said.
Dr. Ginde agreed that quick fixes will not be effective. “We need a comprehensive approach that is patient-centered,” he said.
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