Uninsured patients not driving ED overcrowding, study says

An emergency physician's review of decades of academic articles found unfounded assumptions on how often and why the uninsured visit emergency departments.

By Doug Trapp — Posted Nov. 17, 2008

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The uninsured aren't to blame for overcrowding emergency departments seeking care for coughs and colds, a new study says.

Evidence suggests that uninsured patients visit EDs because of primary care access problems, according to a recent survey of scholarship on the issue. But the uninsured are generally not showing up in EDs for nonurgent care and they are not the primary reason EDs are becoming more crowded.

Manya F. Newton, MD, MPH, an emergency physician and University of Michigan professor, was reviewing academic articles for a project in early 2007 when she kept coming across stated assumptions about the uninsured that weren't backed up with data. One such widely held belief was that visits by the uninsured were a major reason why EDs were becoming overcrowded.

"I began to question whether everyone did know this," Dr. Newton said. "As an emergency physician I was certainly encountering these sentiments in my own [ED]."

She and four other authors examined 127 articles published between 1950 and 2008 that referenced uninsured people's use of emergency departments. Their analysis compared assumptions in the articles with the best available evidence. The study appeared in the Oct. 22/29 Journal of the American Medical Association.

The authors concluded that researchers' unsupported assumptions about uninsured people overusing EDs started to appear in academic articles in the early 1990s at the same time the administration started tighter enforcement of the Emergency Medical Treatment and Active Labor Act. That law, adopted in 1986, requires hospitals to treat people who need emergency care regardless of ability to pay.

Dr. Newton and her co-authors are not the first to debunk assumptions about ED use by the uninsured. In the last few years, she said, several academic researchers have published articles on the subject. But her study was the first comprehensive review of unsupported assumptions in peer-reviewed literature.

EDs are increasingly crowded because they're seeing more aging patients with multiple illnesses, because the number of hospital beds has been declining for years due to financial pressures and facility closures, and because some patients want more immediate care and test results than they receive when visiting a physician's office, said Bret Nicks, MD. He's assistant medical director at Wake Forest University Baptist Medical Center's emergency department in Winston-Salem, N.C.

The analysis, however, did find evidence to support a few common assumptions about ED use. These include statements that the uninsured visit EDs because of primary care access problems, that they're less likely to be hospitalized than other patients with similar conditions and that the uninsured delay seeking care longer than other patients. "The uninsured tend not to show up for minor complaints," Dr. Newton said.

The uninsured visit EDs for a variety of ailments but for one common reason: They're worried, said David Ross, DO, an emergency physician at the Penrose-St. Francis Health Care System in Colorado Springs, Colo. "There's something wrong with them ... that worries them and they don't have another place to go."

Medicaid enrollees are the most frequent ED users. They visit about twice as often as uninsured people and Medicare beneficiaries, who in turn visit about twice as often as the privately insured, according to Centers for Disease Control and Prevention statistics.

Medicaid patients, especially those with young children, do sometimes visit the EDs because of coughs, colds and fevers, Dr. Nicks said. "A lot of times there are things that could simply wait to be seem by their primary care physician," he said, but these patients might have trouble getting a timely appointment with a physician or any appointment at all.

Lawmakers should be careful about embracing false assumptions, Dr. Newton said. Laws to address problems that don't exist or laws that ignore real problems could be the result. For example, steering ED patients with minor ailments to primary care physicians won't work if the area has a doctor shortage, he said.

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Most ED users are insured

Emergency department visits reached a record high in 2006, up nearly 4 million from 2005. But uninsured patients were not the primary drivers of the increase. Patients with no health coverage visited the ED about half as many times per capita as did Medicaid patients.

ED visits
Coverage type 2005 2006
Private insurance 46.0 million (39.9%) 47.3 million (39.7%)
Medicaid or SCHIP 28.7 million(24.9%) 30.4 million (25.5%)
Medicare 19.2 million (16.6%) 20.7 million (17.3%)
No insurance, self-pay and charity care 19.3 million (16.7%) 20.8 million (17.4%)
Workers' compensation 2.0 million (1.7%) 2.1 million (1.8%)
Other or unknown 10.2 million (8.8%) 9.9 million (8.3%)
Total 115.3 million 119.2 million
Visits per 100 patients, 2006
Medicaid or SCHIP 82
Medicare 48
Uninsured 48
Privately insured 21

Note: More than one source of payment may be reported per visit.

Source: National Hospital Ambulatory Medical Care Survey, Centers for Disease Control and Prevention's Division of Health Care Statistics, June 29, 2007, Aug. 6, 2008

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The evidence is in

A comprehensive examination of academic journal articles found that not all common assumptions about the impact of the uninsured on emergency departments are supported by data:

Not clearly supported by data

  • Uninsured patients use the ED for nonurgent or inappropriate care.
  • Uninsured patients are a leading cause of ED overcrowding.
  • Uninsured patients visit EDs at disproportionately higher rates than other patients.

Partially supported by data

  • Increasing numbers of uninsured patients are being treated in EDs.

Supported by data

  • Uninsured patients turn to EDs because they lack access to primary care.
  • Costs are higher for uninsured people seeking care in EDs than the costs would be for care sought elsewhere.
  • Uninsured patients delay seeking care, show up for care at EDs when they are sicker than other patients, and often receive less care than other patients.

Source: "Uninsured Adults Presenting to U.S. Emergency Departments: Assumptions vs. Data," Journal of the American Medical Association, Oct. 22/29 (link)

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