Emergency department volume rises as office visits fall

As the recession hit the U.S. in 2008 and 2009, more Americans, both uninsured and those with private health coverage, sought care in hospital emergency departments.

The most recent available estimates from the Centers for Disease Control and Prevention show a steep increase in visits to emergency departments and a rise in the percentage of emergency patients who were uninsured.

• In 2009, emergency department visits went up to 136 million from less than 124 million in 2008. That was nearly a 10% increase, the steepest single-year upsurge on record.
• Those 136 million visits worked out to 45.1 visits per 100 people, up from 41.4 per 100 in 2008 and 39.4 in 2007.
• Of the 136 million visits in 2009, 19% were uninsured patients and 39% were privately insured patients, compared with 15.4% and 41.9%, respectively, in 2008.
• In a poll by the American College of Emergency Physicians in March 2011, 80% of respondents said patient volume had increased "somewhat" or "significantly" during the previous year.

At the same time emergency volumes spiked, physician office visits have been in decline, as documented by the Kaiser Family Foundation and other sources.

The CDC doesn't offer any opinions as to what is behind the increase, but ACEP attributes the rise in part to lack of access to, and use of, primary care.

David Seaberg, MD, is president of ACEP and dean of the University of Tennessee College of Medicine, Chattanooga. At Erlanger Health System in Chattanooga, where he is an attending emergency physician, he said he often sees patients with chronic conditions who can't afford to fill their prescriptions or see a primary care physician and end up with acute problems.

"That's extremely common," he said.

Rather than acting as a replacement for primary care, ACEP maintains, emergency physicians treat mostly real emergencies, not routine problems that should be seen by a primary care physician. Often, patients are referred to the emergency department by their primary care physician, either out of caution or because the primary care physician can't see them on short notice or after hours, according to ACEP polling.

Dr. Seaberg said other factors pushed patients to emergency care, including a rise in the number of uninsured in the period covered by the CDC survey and ACEP polling, and patient preference for the "immediate answers" that emergency care provides.

After the enactment of the Patient Protection and Affordable Care Act, uninsured rates actually are declining, from 48.6 million people in 2010 to 46.6 million in the first six months of 2011, according to the CDC. The percentage of people who said they had a usual source of care increased from 85.1% in 2010 to 86.9% in the first six months of 2011, it said.

Analysts attributed the changes in those rates mostly to the health reform law's requirements that most group insurance plans allow dependent coverage up to age 26.

Those trends, and further expansion of insurance coverage under health reform, should drive down emergency department use, analysts said.

"The general wisdom is that in better economic times, people are more willing to spend more money on primary care and preventive medicine, so there is less volume in the [ED]," said Dennis Dunn, PhD, a Chicago-based senior scientist for Thomson Reuters, which has presented data showing consumer spending at physician offices is ticking up. "People are taking care of themselves, and ailments don't become acute as much. Emergency room volume tends to be inversely related to the state of the economy."

However, Dr. Seaberg said he expects emergency department visits to grow further in 2014, when the individual insurance mandate of the health reform law kicks in. The wave of newly insured patients will further strain already-busy primary care practices, leaving emergency physicians to see patients who can't find a doctor to see them, he said. Nearly 90% of respondents to the ACEP poll conducted in March 2011 said they expect health system reform to drive up emergency department volumes.

Several surveys show that physician office visit rates are continuing to decline, in part because insured patients are shelling out more for coverage -- and paying higher deductibles -- so many are still putting off care because of cost.

If economic factors and difficulty accessing primary care continues to drive patients to emergency departments, emergency physicians need to think about how they can coordinate better with primary care physicians and help patients with preventive care and wellness, Dr. Seaberg said.

"The emergency room has to be part of the medical neighborhood," he said.