Google “ER expansion” and after you get past a few articles on endoplasmic reticulum, you will find many links about hospitals in all parts of the country building new, larger emergency departments.
Everyone knows that most EDs are overcrowded and waiting times are long. Here are just a few of the many reasons.
A paper describing the results of the now-famous “Oregon experiment” appeared in Science. It showed that Oregonians who received Medicaid in a somewhat randomized way (a lottery) utilized the ED 40% more than those without Medicaid.
Dr. Anthony L. Komoroff reviewed that paper for the New England Journal of Medicine Journal Watch and asked, “But why did these patients go to the ED and not to a primary care office? Despite the earlier finding that coverage increased outpatient use, many of these newly insured patients probably had not yet established relationships with primary care physicians. If so, the excess ED use will attenuate with time.”
I’m not so sure. A decrease in ED use will only occur if those patients can find primary care doctors who will accept Medicaid, which is not necessarily a given. Late last year, the New York Times reported that 69% of doctors nationwide accepted Medicaid, with a range of 40% of MDs in New Jersey to 99% of those in Wyoming.
A recent survey by the health care consulting firm Merritt Hawkins found that in 15 urban markets, only 45.7% of physicians accepted Medicaid.
Why are some physicians reluctant to see Medicaid patients? Dr. Peter Ubel listed several reasons. Reimbursement rates are poor, averaging about 61% of what Medicare (not exactly Rolls-Royce coverage) pays. Because that is an average, some states have even lower rates. Many doctors complain that Medicaid is slow to pay and requires excessive paperwork. Medicaid patients often have complicated problems that require more time than most patients.
A post by blogger Dr. Saurabh Jha discussed the issue of EDs acting as primary care physicians for many patients who find it convenient due to EMTALA regulations: patients must be seen whether or not they have appointments. Dr. Jha also noted that even though patients have much better access to primary care physicians in the UK, EDs there are just as crowded as those in the US.
The RAND Corporation recently reported that 41% of patients with a complaint not related to an accident or injury contacted a doctor’s office before they went to an ED. Of that group, 82% were told to go to an ED rather than a doctor’s office. Of the patients who didn’t try to contact a doctor before going to an ED, 86% said they had no other options for treatment.
With more people joining the ranks of the insured, the problem of ED overcrowding will likely get much worse. Is enlarging existing EDs going to solve the problem?
In an excellent 2008 book called Traffic, author Tom Vanderbilt explained what happens when new highways are built or extra lanes are added to existing roads. Rather than relieving traffic congestion, more highway capacity simply resulted in more people driving. He called this phenomenon “induced travel.”
Will the expansion of emergency departments lead to “induced ED visits”?