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More insured than uninsured patients filling hospital EDs

Busy doctors' offices and fewer managed care restrictions may be playing a role.

By Damon Adams, amednews staff. Nov. 24, 2003.

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The uninsured aren't the only ones contributing to emergency department overcrowding. Insured patients are increasingly adding to the burden.

A new study found that insured Americans accounted for most of the 16% increase in hospital emergency department visits during a six-year period ending in 2001. Nearly 108 million people went to emergency departments in 2001, according to the study by the Center for Studying Health System Change, a policy research organization in Washington, D.C.

Visits by the privately insured rose 24.3% to 43.3 million from 1996-1997 to 2000-2001, the study said. During the same period, Medicare patients' visits increased 10% while ED visits by people with Medicaid remained steady. The increase for the uninsured was 10.3%.

"For emergency room doctors, obviously, they're getting busier and getting called on to do more and more things," said Peter Cunningham, PhD, the study's lead author and a senior health researcher for the center.

Researchers were surprised insured patients played such a large role in the increase because it is a widely held belief that the chief source of ED overcrowding is visits by the uninsured.

The study, released last month, said capacity constraints of office-based doctors and loosened managed care restrictions may be contributing to nonurgent ED visits. Doctors may be reacting to increased workloads by referring more patients to emergency departments, according to the study.

Other research by the center shows more patients are finding it difficult to make appointments with their office physicians, and they are experiencing longer waiting times.

"People who can't get in to see their doctor immediately or for a time that's convenient for them, they're going to the ER," Dr. Cunningham said.

Uninsured patients still a problem

Higher patient loads and lower reimbursements led some practices to limit care to the uninsured, prompting those patients to go to EDs, the study said. Physician office visits by the uninsured decreased 36.9% from 1996-1997 to 2000-2001.

"Because of changes in the health care system, we have become the main diagnostic point in the system. Patients' access is limited whether they have insurance or not," said J. Brian Hancock, MD, president of the American College of Emergency Physicians.

But some emergency physicians dispute the new findings.

"We're seeing an overall increase in ED visits, but the percentage of people who have insurance hasn't changed," said Douglas A. Carmichael, MD, an emergency physician in Austin, Texas.

A study released in September by the center said some physicians were referring more patients to EDs because of rising liability insurance rates.

Physicians said higher reimbursements, caps on noneconomic damages in malpractice lawsuits and other system changes could help reduce the burden on hospital emergency departments.

"We need to have a health care system that is physician-led and patient-care focused," Dr. Hancock said.

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