Trendspotter: Many ED Visits Reflect Poor Access to Primary Care

By Ken Terry

In Voltaire’s book “Candide,” he lampooned a contemporary philosopher’s assertion that “this is the best of all possible worlds.” Now a pair of emergency department physicians argue in a Slate article that we don’t need to reform our system of emergency care because most ED visits are necessary and, besides, they don’t cost that much. Apparently, these doctors never read “Candide.”

Zachary F. Meisel and Jesse M. Pines state that just 12 percent of ED visits are “not urgent.” However, the National Health Statistics Report they cite says that 16 percent of visits are emergent, 36 percent are urgent, and 22 percent are “semi-urgent,” which leaves a lot of latitude for defining “non-urgent.” Moreover, during the period covered by the study (1996-2006), there was a 32 percent increase in ED visits, while the number of ED visits per 100 people increased 18 percent. So a growing number of people are coming to the ED more often. That suggests that more people are using the ER for primary care.
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The National Health Statistics report points out that 11 percent of all ambulatory-care visits are made to EDs, although those departments have only 3 percent of physicians in the U.S. “EDs provide unscheduled care for a wide variety of persons for reasons that range from sudden cardiac arrest or severe injury to minor acute problems that occur after business hours, or for which the patient is unable to access a primary care provider in a timely fashion. In 2005, approximately one-fifth of the U.S. population had made one or more ED visits within the past 12 months and some subgroups, such as infants, persons 75 years of age and older, Medicaid beneficiaries, and African Americans, had higher utilization rates than others.”

Another key part of Meisel and Pines’ argument is that because ED visits are only a small fraction of total health spending, they’re nothing to worry about. In fact, because EDs are open 24/7, they maintain, "the marginal cost of treating less acute patients in the ER is lower than paying off-hours primary care doctors.” I don’t know how they calculate that, but other research contradicts it
In a large-scale study of the cost of non-urgent visits to Minute Clinics (retail clinics in pharmacies), primary-care offices, urgent-care centers, and emergency departments, researchers found that, for treating five common conditions, the adjusted mean pharmacy and medical costs per episode totalled $383 in the ED, versus $159 in the primary-care doctor’s office. Even if the primary-care physicians were paid a bit more for treating patients in off-hours—a rather odd scenario—the ED visit would cost twice as much.

The biggest flaw in Meisel and Pines’ theory is that they don’t consider how many of the emergent and urgent visits to the ED result from a lack of access to primary care. Sure, the majority of ED visitors are insured, but how many of them have comprehensive insurance, and how many shun doctors’ offices because of high copays and/or deductibles? Much has been made of the fact that roughly 20,000 people a year die because of lack of insurance. But people who have skimpy insurance and low wages may also avoid necessary care until it’s too late or until they’re compelled to seek aid in the emergency room.

Finally, Meisel and Pines make an outrageous statement about primary care that I cannot let pass. They say, “Most ‘frequent flyers’—a pejorative term used to describe patients who stop by ERs a lot—tend to be the very sick, those with severe asthma, heart failure, or diabetes. When these conditions flare up, patients do, and should,come to the ER. ERs are designed to take care of acutely ill patients, while doctors' offices are not [emphasis added].”

Now, it’s possible to interpret this statement as meaning that, in a true emergency, these patients should go to the ED. If so, I would not disagree with it. But if the ED physicians mean that primary-care doctors are not equipped to care for very sick patients, I think most generalist physicians would beg to differ.

The fact is that we need more and better primary care so that patients who have chronic conditions are properly cared for, and those who are at risk of developing chronic diseases do not get sick. While we need other kinds of prevention, as well, including better eating habits and smoking cessation, those are not a substitute for universal access to good primary care.