A new report from the National Center for Health Statistics (NCHS), the nation’s chief health statistics agency, suggests the longstanding perception uninsured patients are clogging the nation’s emergency rooms (ERs) is a myth.
There is a widespread perception uninsured patients are a leading source of unnecessary ER visits because they lack a primary care provider, a perception echoed by President Obama and other political leaders as a rationale for their recently passed health care legislation.
The report finds ER use is more closely associated with Medicaid enrollment Patients covered by Medicaid seek care in the ER more frequently than both the uninsured and those covered by private insurance.
Medicaid Doubles ER Use
According to the report, released in May, nearly one-third (32 percent) of Medicaid enrollees used the ER at least once during a 12-month period in 2007. Individuals with private health coverage were only about half as likely (17 percent) to visit an ER, and a similar proportion—one in five—of individuals without health coverage did so.
Medicaid enrollees were three times as likely (15 percent vs. 5 percent) as the privately insured, and twice as likely as the uninsured (15 percent vs. 7 percent), to have visited an ER twice in the previous year.
Rationale Behind Visits
Nearly 120 million ER visits are made in the United States each year—approximately 11 percent of all U.S. ambulatory care visits. Some of that care could be done elsewhere, says Dr. Stephen Nichols, a regional medical officer for Schumacher Group, which contracts for emergency department services at community hospitals.
“In general, 5 percent to 25 percent of patients who visit an ED in a community hospital have non-urgent complaints that could easily have been addressed in an outpatient setting,” he added.
Dunn agrees and thinks the number of non-emergencies is even higher. “Thirty percent to forty percent are emergencies or urgent care and deserve treatment within a reasonable time,” Dunn said. “But it is care that could be seen to in an urgent care clinic or a well-equipped office, though the patients probably are better off in the emergency department.”.
‘Frequent Fliers’ Drive Costs
So-called frequent fliers, a term emergency department (ED) personnel sometimes use to describe patients who are costly and frequent visitors to the ER, are far more apt to be enrolled in Medicaid than any other type of coverage, the study found.
According to the report, one in twenty (5.1 percent) of Medicaid enrollees visits the ER four or more times per year, whereas only 1 percent of people with private health coverage visit an ER that often. Medicaid enrollees are 2.5 times as likely as the uninsured to be frequent users of ERs.
Confirms Earlier Findings
The NCHS report arrived just one month after a report by Eduardo LaCalle and Elaine Rabin, both from Mount Sinai School of Medicine in New York City, published in the Annals of Emergency Medicine, which reached similar conclusions. In the Annals study, only 15 percent of frequent users were uninsured. Nearly two-thirds (60 percent) of frequent visitors to the ER were covered by government insurance—Medicaid or Medicare.
Patients who frequent the ER may constitute only about 5-8 percent of ER patients, but they account for approxinately one-quarter of all ER visits, where care is often free to the patient and they can avoid having to book an appointment in advance. Both reports conclude frequent users of the ER tend to be in poor health.
“Of the patients who use the ED frequently, the largest factors are a lack of a strong social network, a lack of alternatives and/or awareness of them, genuine illness, and combinations thereof,” Nichols said.
Flood of New Patients
The Congressional Budget Office projects 32 million uninsured residents will gain health coverage under Obama’s health care law, with about half of them being covered by Medicaid. These new reports suggest that, contrary to the claims of those who supported the legislation, expanding coverage will result in more patients turning to the ER, a point Nichols acknowledges.
“If reform encourages primary care, more folks will overflow into EDs as the demand already outstrips the supply,” Nichols said.
LaCalle and Rabin share this view.
“Because a frequent user is more likely to be covered by government insurance than to be uninsured, if having public insurance somehow increases ED visits, then insurance may actually increase the number of frequent ED users,” they wrote.
Opposite Result from Intentions
Dr. John Dunn, a specialist in emergency medicine in Brownwood, Texas, reports the figures are slightly different in his region.
“The distribution is roughly 30 percent uninsured,” Dunn said.
He explains this may be because fewer Texas residents qualify for Medicaid than in other states, while the percentage of people without health coverage is higher. Yet Dunn maintains this new data could indicate a major portion of the new health care legislation will achieve the opposite effect of its intent.
“There is nothing to indicate that a high level of insurance would reduce ED visits,” Dunn said. “If you were sick on a Saturday or at night, where would you go?“
Devon M. Herrick, Ph.D. ([email protected]), is a health economist and senior fellow at the National Center for Policy Analysis.
Frequent Users of Emergency Departments: The Myths, the Data, and the Policy Implications: http://www.annemergmed.com/article/S0196-0644(10)00105-8/abstract
NCHS Data Brief: Emergency Room Usage: http://www.cdc.gov/nchs/data/databriefs/db38.pdf