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The Emergency Room Conundrum: We Can Do Better

May 14, 2015
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Last week, I was sick.

I’m not writing this because I want sympathy (although, if you have some Warheads candy that you want to send my way…I won’t be opposed). No, I am writing this because it made me realize the enormity of one of our foremost challenges in reforming the healthcare system: reducing usage of the emergency room.

As I lay in bed in pain at 2 a.m. in the morning, my wife asked me, “Should I take you to the ER?” I knew that it was wholly unnecessary, that the pain of my stomach bug was only temporary and not even close to being serious enough to warrant a trip there. I knew that even with health insurance, a trip to the ER was costly.

Yet, part of me wanted to go. I knew it would immediately make me feel better. For a brief fleeting moment, the short-term benefits outweighed the agonizing, smarter long-term decision to wait and see a doctor in the morning. Ultimately, my head won over my heart. I waited it out.

For many people, this kind of decision is a lot more complex. My wife and I have health insurance, we are in a pretty good network with good doctors, and can afford to wait. Despite the best intentions of the Affordable Care Act (ACA), many are still without health insurance and those with it aren’t in the best of networks. Being in a bad network means that going to the doctor the next day isn’t a reality.

Moreover, there are other factors that get people to say, “Yup, let’s go to the ER.” Take away insurance and there is still a primary care provider shortage going on in this country. Some people don’t have a primary care provider. The guy I saw the day after I considered going to the ER wasn’t mine, even though he was nice enough to schedule me. There’s also the fact that some people don’t have access to care because they are too far away (i.e. they live in a rural area or don’t have access to transit). Finally—but most importantly—sometimes they actually need emergency care.

The American College of Emergency Physicians (ACEP) recently released a survey that revealed emergency care has increased since the ACA was enacted. That’s right, even though the ACA was meant to decrease ED visits, it has done the opposite. The ACEP survey found that 75 percent of emergency physicians surveyed said they are seeing more visits. More than half (56 percent) of the respondents said the number of Medicaid patients is increasing.  

If we are being honest, the ACEP probably has a bias. I’m sure they feel slighted by all these attempts to drive them out of the picture. But the truth is…ED visits are increasing. A study led by researchers at the esteemed University of California at San Francisco found that the rate of ED visits for non-injuries had risen from 2005 to 2011. Oddly, the researchers found that the rate of ED visits for actual injuries dropped. Another study, from Modern Healthcare, found that hospitals with the busiest EDs in 2013 were reporting higher volumes in 2014.

In a nice column in The New York Times, Ezekiel Emanuel, M.D., a policy guru, famed author, chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania and a former adviser at the Office of Management and Budget (OMB) during the implementation of the ACA, wrote about the different ways a nonprofit cooperative in Seattle reduced ED visits among patients in a challenging population. Dr. Emanuel said the overall difference between what the cooperative did and others have not was patient engagement. They not only incentivized patients to stop going to the ED, they educated them on where else they could find care.

The nonprofit cooperative used social media, in-person conversations, and telephone calls to educate and assist patients. From what Emanuel wrote, it sounds like it was a real concerted effort and not just a one-off campaign.

It doesn’t have to be a carbon copy of that strategy though. There is really no limit to what constitutes as engagement. An HIE that sends out clinical alerts when a patient goes to the ED to a primary care provider, who then has a team member reach out to the patient is a popular example we’ve seen. Text message intervention is another. Telehealth should be an option for rural patients. If a provider or payer is feeling real adventurous, they can tackle the problem at a population level. Studies have shown that internet searches and Twitter can predict ED visits in a region.

The point is, as Emanuel said, you can’t expand insurance coverage, offer a few bucks, and expect a wholesale change. It has to be that and more. People have to know better. It’s up to providers, payers, and other stakeholders to engage and change their behavior.

So when they wake up in the middle of the night in pain, they have to assess their situation and make a reasonable decision, and not just think with their heart.

Unless, of course, their heart is the problem.




When you are feeling ill in the middle of the night, a very effective option is to have a live video consult with a doctor from home, using your smartphone, tablet or computer. A discussion with a doctor can often get you started on the right treatment (the doctor can send an electronic prescription directly to your 24-hour pharmacy), or can give you guidance about how quickly you need to see the doctor in person. The range of advice spans from "go right now to the ER", to reassurance that you can wait till tomorrow, or sometimes, the doctor can refer you directly for evaluation by a specialist.