Emergency departments (EDs) nationwide are busy places. In some locales they are overcrowded. In places like Los Angeles and other dense, urban areas with high poverty, they are over-capacity to such an extent that they can grind to a halt for all but the highest priority cases.
In years past, it was not unheard of for a major Los Angeles ED to have waiting times of up to 72 hours. Yes, three days. This is easily a long enough wait, as one triage nurse put it to me, for patients to actually get better and go home. A long wait is not a proper form of triage, but for some EDs there is clearly little choice.
A common understanding (and possible point of pressure relief) is that some, if not many, patients who are seen in the ED could be re-directed away from the ED and managed in primary care. On the surface, this makes sense. Patients use the ED for things as simple as pregnancy tests, which to many observers is absurd.
But changing that is not so simple.
Some rather unhelpful perceptions of ED users further complicates the process. For example, if someone is paying for their own care, getting a pregnancy test at the ED seems simply like an expensive choice. But if you are uninsured or Medicaid-insured (where taxpayers are often picking up the tab), getting a pregnancy test at an ED is, in my experience, more often perceived as abuse. Remember, the federal Emergency Medical Treatment and Labor Act (EMTALA) requires hospitals to see and stabilize all patients regardless of insurance or ability to pay.
A student of mine, who works part-time in a local ED, rightly asked whether the new American Health Care Act (the Republican-led bill to repeal and replace ObamaCare) might help solve this problem. Colleagues in his ED had told him that rampant abuse of EDs by Medicaid patients would be less of a problem if fewer people had Medicaid. They are right. But mostly in a way that solves the needs of the ED, not the needs of patients.
Health insurance, including Medicaid, opens the door to medical care, including EDs. So fewer insured means fewer users of ED care. With the Congressional Budget Office estimating the Republican bill will cause more than 14 million people to lose Medicaid coverage, some EDs could see indeed fewer patients in their waiting rooms. But those patients (and the 9 million privately insured patients who will also lose coverage) will not just stop getting absurd pregnancy tests in the ED. Many of them will stop getting care altogether.
The story, however, is not really about EDs or insurance.
The overcrowding in EDs is probably more about primary care. If we are going to argue (or hope) that primary care can divert some ED visits, the primary care system must be capable of receiving them. And that is not entirely clear.
The workforce challenges in primary care are nothing new. A recent UCSF report on California shows that only 36% of MDs now provide primary care, and only two small regions of the state meet the minimum ratio of primary care physicians to population (60 per 100,000 population) that the Council on Graduate Medical Education recommends. Two larger areas of the state, in fact, have ratios below those required by law for managed care plans. The same report finds that nurse practitioners and physician assistants do not yet solve these deficits.
Are we still overestimating how many ED visits can be offset by primary care?
A new piece published in Medical Care, “Incorporating Alternative Care Site Characteristics into Estimates of Substitutable ED Visits” offers some valuable perspective here. In short, the authors say it is not enough to simply assume that primary care can handle ED diversions, but that we should consider the hours that primary care is open and the services that primary care offers.
Take the example of the pregnancy test. Nearly all primary care offices can do these. But say a woman learns that she might be pregnant on a weekend. She may be able to get a pregnancy test faster by going to the ED than waiting until her primary care provider’s office re-opens the following week. She may even have to wait for an appointment later in the week. In such a case, is this still an absurd ED visit? Perhaps not.
Another example is someone with an injury that requires an X-ray. Even if this happens during normal primary care business hours, many primary care offices do not own an X-ray machine. In such a case, a referral may be required to another site that may also need a separate appointment. In such a case, is going to the ED for a simple X-ray still considered unnecessary? Probably not.
There are many complex examples we could consider. And the authors urge us to do so by offering a range of hours that primary care offices are in practice and a range of service capabilities. Using these scenarios, the authors suggest that we might be able to cut ED visits by anywhere from 5 to 27%, which is probably lower than the stories about absurd and abusive ED visits suggest.
In brief, the problem with ED overcrowding is probably less a story of emergency departments, than it is about the relatively stressed primary care system. Strengthening the primary care system is a necessary first step to buffering against overuse of the ED.
If you want to dig more into these issues, I’ve written before about the value of primary care, and some innovations in ways to deliver that care. And a colleague on the Medical Care Blog recently wrote an excellent piece about team-based care in primary care. Be sure to check those out (additional blogs on primary care can be found here).
Gregory Stevens