Insured Patients Using ER for Primary Care

Insured patients using ER for primary care

Victoria Colliver, Chronicle Staff Writer

Thursday, August 7, 2008

(08-06) 18:45 PDT -- Hospital emergency departments, typically the medical providers of last resort, are becoming the only option for insured as well as uninsured people who are unable to get care elsewhere, leading to a record rise in emergency room visits over the past decade, a federal government report found.

Emergency room visits jumped more than 32 percent from 90.3 million in 1996 to 119 million in 2006, the most recent year statistics are available, according to the National Center for Health Statistics, a division of the Centers for Disease Control and Prevention.

"The uninsured have long been more frequent users of (emergency rooms). That's not new. What's new is the rise ... in frequency in visits, and that's occurring in the insured," said Dr. Stephen Pitts, author of the report and a CDC fellow who teaches emergency medicine at Emory University's School of Medicine.

Pitts said the difficulty in getting primary care appointments could be contributing to the rise in emergency room use, particularly by those with insurance or on government programs such as Medicare or Medicaid.

"The likely cause is there are just fewer and fewer primary care physicians," he said. "If you were to get the flu and your doctor says, 'Sure, I'll see you in two weeks,' you may not be able to wait. It's hard for even insured people to get quick appointments and be seen quickly."

While the number of people without health insurance has risen to about 47 million, an increase of more than 5 million since 1996, neither that increase nor the overall growth in population accounted for the overcrowding of emergency departments, the report said.

The CDC did not break down the increased use by insurance status, but a study in this month's Annals of Emergency Medicine confirmed the federal government's findings.

That study found the proportion of emergency visits by the uninsured had not changed substantially between 1992 and 2005, while the number of overall visits went up 28 percent. The survey also found that people in the highest income bracket - in excess of 400 percent of the federal poverty level - accounted for an increasing portion of emergency room visits, while the lowest income brackets remained virtually unchanged.

Dr. Myles Riner, an emergency room doctor at Marin General Hospital in Greenbrae, said he often sees insured patients experiencing delays and hurdles in getting diagnostic tests approved.

Riner said he also sees low-income patients who can't find a doctor who will accept Medi-Cal, the state-federal program for the indigent. "We are the safety net for the safety net," he said.

The rise in emergency room visits comes at a time when the number of hospital emergency departments nationwide dropped to 3,833 in 2006 from 4,019 a decade earlier.

That decrease puts added pressure on the remaining emergency rooms. And California has the lowest percentage of emergency departments per capita - 6.12 per 1 million people, according to Dr. Billy Mallon, president of the California chapter of the American College of Emergency Physicians.

More than 70 California hospitals have closed in the past 10 years due to financial pressures, said Jan Emerson, spokeswoman for the California Hospital Association. Inadequate funding from government programs along with reduced insurance payments, high labor costs and other factors have forced some hospitals to close units.

Pitts, of the CDC, said U.S. hospitals have been reducing bed capacity, which causes backups in admissions and exacerbates overcrowding. "The major solution over the past 10 years has been to allow these patients to sit in the hallways in the ER," he said.

"The main problem with ER overcrowding is I can't get the admitting patients out. I can't get them to the ICU, to the operating room or to the wards," Mallon said.

He said people who lack access to other care options contribute more to overcrowding than patients who rush to the emergency room in nonemergency situations.
Overcrowding in the emergency room

A study by a unit of the Centers for Disease Control and Prevention found that emergency room visits increased 32 percent from 1996 to 2006, outpacing population growth of 11 percent. Other findings:

-- The rate of overall emergency room use increased 18 percent.

-- About 13 percent of visits to emergency departments resulted in a hospital admission.

-- More than half of all 2006 hospital admissions came through emergency departments, up 38 percent since 1996.

-- Infants had the highest ER visit rate; people over 75 were next.

Online: To read the full CDC report, go to cdc.gov/nchs.

Source: National Center for Health Statistics

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