Poor health, not lack of insurance, drives ED visits

Researchers say a new study debunks the myth that the poor and uninsured are overcrowding emergency departments across the country.

The study published online Oct. 19 by the Annals of Emergency Medicine found that 85% of emergency patients had health insurance and 83% of ED visits were made by people who had a usual source of care such as a primary care physician. People without insurance were no more likely to visit the emergency department than people with insurance.

The mistaken belief that departments are overfilled with the uninsured can lead to misguided policy decisions, said Ellen J. Weber, MD, lead study author and professor of clinical medicine in the division of emergency medicine at the University of California, San Francisco. The stereotype of uninsured patients cramming EDs has been spread by studies that have involved smaller samples of patients and focused on ambulatory and nonurgent patients, she said.

"Most studies were not done nationwide when they looked at emergency department [crowding]," Dr. Weber said.

The study stated, based on a sample of 49,603 adults interviewed between 2000 and 2001, that an estimated 45.3 million adults reported at least one ED visit, resulting in 79.6 million visits. From 1992 to 2002, emergency department visits grew 23% from 89.8 million to 110 million.

The majority of patients going to the ED said they usually got care through a private physician's office. Only 5% said the ED was their usual source of care. Patients without insurance accounted for 15% of ED visits. Poor physical health and poor mental health were the main driving forces for ED visits, according to the study, which will be published in the Jan. 2005 Annals print edition.

"This study is very important in exploding the myths," said Loren Johnson, MD, chief medical officer for Sutter Emergency Medical Associates in Davis, Calif., and past president of the American College of Emergency Physicians' California chapter.

Primary care physicians feel strapped

Last year, a study found similar results concerning who seeks emergency care. Insured Americans accounted for most of the 16% increase in hospital emergency department visits during a six-year period ending in 2001, according to the study by the Center for Studying Health System Change, a policy research organization in Washington, D.C. Visits by the privately insured rose 24.3% while the increase for the uninsured was 10.3%.

The study said capacity constraints of office-based doctors and loosened managed care restrictions may have contributed to the rise in nonurgent ED visits. Doctors may have been reacting to increased workloads by referring more patients to emergency departments. And rising medical liability premiums have made some doctors more willing to send some patients to emergency departments, physicians said.

"Medical liability is definitely a problem, and defensive medicine is definitely a problem," said Robert E. Suter, DO, ACEP president and an emergency physician in Texas.

AMA policy says that the overall capacity of the emergency health care system needs to be increased through facility and emergency services expansions that will reduce emergency department overcrowding and ambulance diversions.

Medical leaders said tort reform would help reduce defensive medicine, and other system changes could lessen crowding of emergency departments.

"Solving the problem of the uninsured is not going to magically clear the [EDs] out," Dr. Suter said.