Scott MacStravic, Ph.D.
I can recall when the hospital emergency department (ED) or room (ER) was considered a major advantage, with high trauma center designation the best advantage to have. Large numbers of patients enter the hospital through the ER, and as long as the local public hospital took care of the “knife and gun club” patients who had no insurance or ability to pay, the ER was an essential portal for hospitals to have.
Thanks to the decline in the number of short-term general hospitals, the number of their ERs has declined as well, while new specialty hospitals and free-standing ambulatory care facilities have not made up for the decline. According to a recent article, the number of hospital ERs has fallen by 12% since 1990, while demand for ER care has skyrocketed. [P. Kletke “The Disappearing Hospital Emergency Department” Hospital & Health Networks Aug 1, 2006 (www.hhnmag.com)]
Countering this trend is the fact that trauma centers have more than doubled during that period, from 678 to 1604, a 137% increase, as the proportion of hospitals with such centers increased from 13 to 35%. And the combination of more people choosing ER for care (per capita visit rate up 10%) and the growing population (up 18%) has produced an increase in ER use of 30%, and since the number of ERs has decreased, an increase in the use of existing ERs of 50% over the past fifteen years.
ERs have always been used for three levels of need: 1) truly emergent care where patients need care immediately or risk severe damage, even death, and need the facilities of the hospital to deal with the problem; 2) urgent care where patients need care promptly, but do not require the unique facilities of the ER, and could obtain needed care in an urgent care center, or even a physicians’ office if one were available; 3) non emergent/urgent care where patients lack a regular physician or usual source of care, and may be unsure whether they would be welcomed elsewhere, or does not wish to wait until one is available.The apparatus needed for truly emergency care is very expensive, and with few patients really needing it, could be prohibitively expensive if the ER were only used by emergency patients. Even urgent care pay significantly more in an ER than they would for similar care in an urgent care center. And ER charges for non-emergent/urgent care tend to be outrageous compared to what a physician visit or trip to a convenience care clinic would cost.
There has been a strong concern over “misuse” of ERs by non-emergent/urgent patients for decades, but little effective action taken to reduce such numbers. The recent burgeoning of convenience clinics located in supermarkets, superstores and drug stores has created a whole new infrastructure for reducing ER visits by offering a better, more conveniently located and affordable alternative. Urgent care centers have not caught on as well as might have been expected, but convenience care may well make a big dent in ER use.
More important, convenience care clinics may force physicians to open their offices at more convenient times for families where both parents work, further increasing the options available to them, and saving them the costs and long waits predictable in ERs. Harris County, Texas has imposed a deposit requirement of $150 in its public ERs, or $80 for its urgent care centers, if patients have non-urgent signs and symptoms.
The deposit requirement, coupled with waits that sometimes extend to 12 hours for ER care, is expected to discourage at least some patients from seeking non-urgent care in the ER, and steer more to the growing urgent care capacity it is creating, to routine visits at community health centers, or even to the growing number of convenience clinics opening in the area. Harris County expects the ER volume to decline by 20% thanks to its “RightCare” strategy, and greatly reduce the roughly half the time its ERs spend on divert status.
While “punishing” people for using ERs is one way to reduce misuse, it is likely that a marketing strategy would work better. Harris County community health centers often involve eight-week waits to get an appointment, for example, though they try to see patients who need to be seen for minor illnesses within a week or two. Clearly, patients in general will want to be seen far more promptly than that, and would be better off going to a source of care that could become their medical home. The challenge is to make access to urgent or simply convenient care far more available and affordable than ERs are, enough so to attract people away from ERs, rather than expecting ERs to drive them away through unaffordable pricing and ridiculously long waits.
Remember Me
