Hopefully you don't slice your finger cutting a bagel and rush to your local emergency department only to find it is closed! An alarming new study published in the Journal of the American Medical Association (JAMA) found that almost one-third of emergency departments have closed in the last two decades.
This is particularly troubling when you consider that ER visits are on the rise. In fact another JAMA study from 2010, found that ER visits have increased at twice the rate of the US population. To date, about 120 million people a year are treated in emergency departments around the country. Emergency medical care is not only our healthcare safety net, it is our public health safety net. Your local emergency department is an integral part of our homeland and national security; functioning as a key component and critical response to both natural and man-made disasters, as well as terrorist threats.
Yet is seems as though emergency medicine is treated as the poor stepchild of healthcare. Vilified in the press as expensive care with long waits that everyone hates, because it is overcrowded with people who don't have real emergencies. It is often the example politicians and pundits use to point to our failing health care system. However, I believe that none of this is true; in reality it is actually the glue that is holding together our health care system. As an ER doctor, I am tired of defending it. Let's discuss the top three myths or misconceptions about emergency medicine.
Myth 1: Emergency care is the most expensive type of health care.
Let's start with the cost of emergency care. It is unique care in that emergency departments are open 24 hours a day, 365 days a year with multiple resources at their disposal. Emergency physicians, laboratories, x-ray facilities, operating rooms and a range of medical specialists are all on standby waiting to take care of whatever comes through the door. No one is ever turned away. A study from 1996 in the New England Journal of Medicine (NEJM) looked at the cost of a visit to the ER. When you factor out fixed costs of having all these resources available, the actual cost of treatment of ER patients is comparable to treatment in a primary care office. In fact it is even more economical than trying to staff and open private offices or urgent care centers with all the comparable resources and hours.
As far as actual health care dollars attributed to emergency medical care are concerned, it's little more than a drop in the bucket. In 2008 the Department of Health and Human Services (DHHS) estimated health care spending was at 2.4 trillion dollars, while during the same year the Agency for Health Care Research and Quality (AHRQ) calculated the total expenditure on emergency care was only 47.3 billion dollars -- 2 percent of overall spending. This means that out of every dollar spent on health care in the U.S., two cents is spent on emergency care. Two cents is not a bad bang for your health care buck -- especially when you think about all of the loved ones that this care saves.
Despite, on average, four hour wait times across the country, believe it or not ER patient satisfaction is relatively high, in the 80 percent range, according to last year's Press Ganey survey.
All of the resources available in an ER make it sort of a one-stop shop. Patients realize that when you come into an emergency room with a problem, most of the time you receive a diagnosis and some treatment during that visit. For example, if you visit your doctor with a serious headache it may take several visits and several days in between to get the CT scan, then the results and get in to see a specialist for something such as a migraine. Compare that to going to the ER for a very bad new headache: You come in and see the emergency doctor and you get a CT scan with results, as well as a referral to a specialist if needed -- all in that one visit. People understand why it may take four hours.
Myth 2: ERs are overcrowded because most emergency visits are unnecessary.
There is a misconception that ERs are just filled with people who don't have real emergencies. Last year the Centers for Disease Control and Prevention (CDC) reported that 92 percent of emergency visits are for medical conditions that need treatment within two hours. This report also found that patients with non-urgent medical conditions seen in the ER had dropped to less than 8 percent. No real accepted medical definition exists for the term "non-urgent," as one man’s urgency is another man's emergency. However, the CDC defined non-urgent cases as those requiring timely medical care within two to 24 hours, pointing out that the term non-urgent does not mean unnecessary! Anyone who has tried to get into his or her private physician's office without a prior appointment to be seen certainly appreciates the void emergency departments fill. And as an emergency physician, I cannot begin to tell you how many times patients come to the ER because their private doctor told them he couldn't see them on short notice and to just "go to the ER."
Myth 3: The emergency department is overflowing with uninsured patients.
The ER never turns anyone away. Emergency physicians see it as a moral obligation and there is also a federal mandate called the Emergency Medical Treatment And Labor Act (EMTALA) that ensures we treat everyone first, regardless of his or her ability to pay. According to an American Medical Association (AMA) poll conducted in 2003, emergency physicians provide at least four times more charity care than any other medical specialist.
However, a 2009 JAMA study found that it was a misconception that ERs are full of uninsured patients. In fact, the uninsured try to avoid the emergency departments as long as possible, because they don't usually want to incur health care bills. The CDC report referenced above, broke down the payer mix for emergency departments. They found only about 15 percent of patients in ERs were uninsured, 25 percent had Medicaid, Medicare accounted for about 17 percent and almost 40 percent had private insurance. The rest were unknown.
The heaviest users of emergency departments are the elderly and the chronically ill. I've found that these patients use the ER as a supplement to their primary care as opposed to a substitute. With the baby boomers aging, we are sure to see increases in emergency department use. The fact that most patients coming to the ER actually have some type of health insurance should make us realize that access to health insurance doesn't always ensure access to medical care.
As we move forward with health care reform, this is an important fact to remember. The state of Massachusetts knows this all too well. After enacting their universal coverage policy they saw a 2 percent increase in the number of emergency visits across the state in just one year. This was due to an increasing demand for care -- as more people got health insurance coverage -- that was unable to be met by the supply of primary care doctors. And now the American Association of Medical Colleges (AAMC) is predicting an even worse physician shortage. Americans will face a shortage of almost 90,000 doctors in the next 10 years. And as usual, it will be your local ER that picks up the slack.
As the 2012 presidential campaign ramps up and talk of health care reform or repealing Obamacare heats up again, remember we are all just a heartbeat away from an emergency. So, when and if you need critical emergency care, its good to know that there are dedicated professionals standing by to save your life. It is without a doubt the best two cents you will ever spend!