Study: Insured Visits Help Clog ERs

October 23, 2003 ( - Observers of the US health system may have to rethink the long-held view that serious strains on hospital emergency rooms come from the uninsured, since a new study suggests it's actually from those with health coverage.

According to a national study released today by the Center for Studying Health System Change (HSC), a Washington, DC-based health think tank, insured Americans accounted for most of the 16% rise in hospital emergency room visits between 1996-1997 and 2000-2001.

“Across the country, emergency departments are crowded and seeing a lot more patients, and most of the increase, surprisingly, is from insured people, not the uninsured,” said Paul Ginsburg, HSC president, in a statement.

The study said US hospital emergency department visits increased to almost 108 million annually in 2000 and 2001, over 1996-97. Emergency department visits between 1996-97 and 2000-01 increased 24% for the privately insured, 10% for Medicare beneficiaries and 10% for self-pay or no-charge-typically uninsured-patients but were unchanged for Medicaid beneficiaries, according to the study based on data from the Centers for Disease Control and Prevention’s (CDC) National Hospital Ambulatory Medical Care Survey.

Together, privately insured and Medicare beneficiaries accounted for almost two-thirds of the overall increase in emergency visits. In contrast, self-pay or no-charge patients accounted for about 11% of the increase in emergency visits. People with other sources of coverage – worker’s compensation, for example – or unknown coverage, accounted for the remaining increase.

A General Care Increase

For the privately insured, there was an across-the-board increase in ambulatory care use, including a 29% increase in physician office visits, which paralleled the 24% increase in emergency visits between 1996-1997 and 2000-2001, the study found. In contrast, for uninsured, the 37% drop in doctor visits was accompanied by a 10% increase in emergency visits, raising concerns that the uninsured were relying more on emergency departments for an even greater part of their medical care. One-fourth of all doctor visits by the uninsured now take place in emergency departments, compared with 17% in 1996-1997.

“Uninsured people clearly are not a major factor in increased crowding at most hospital emergency departments, but uninsured people’s growing reliance on emergency care indicates decreased access to other sources of care, including physician’s offices. Getting medical care outside of the emergency department is definitely becoming more difficult for uninsured people,” said HSC Senior Health Researcher Peter Cunningham, who co-authored the study with HSC Research Assistant Jessica May.

Other key findings include:

Increased emergency department use has resulted in patients waiting longer. The proportion of emergency department patients who waited more than 30 minutes increased from 36% in 1999 to 45% in 2001.

Uninsured and Medicaid patients wait longer at hospital emergency rooms than do privately insured and Medicare beneficiaries, perhaps reflecting differences across insurance groups in the type and severity of health problems presented at the ER. Also, emergency visits by uninsured and Medicaid patients are likely to be more concentrated at certain hospitals, such as urban public hospitals that are especially crowded, because they serve a large number of low-income and medically indigent people who rely on emergency departments as their usual source of care.

Longer emergency room waiting times are associated with dramatically lower patient perceptions of the quality of their care. Among emergency patients who waited more than an hour for treatment, only 28% rated the thoroughness of their exam as very good or excellent, and only one-third gave a positive assessment of how well the doctor listened to them. In contrast, 66% of patients who waited 15 minutes or less gave a positive assessment of the exam and physician. It is unknown whether these large differences in length of waiting time reflect actual differences in clinical quality.

In 1999-2000, less than half of all emergency department visits – 47% – were classified as either emergency – requiring care within 15 minutes of arrival – or urgent – requiring care within an hour. This is true for all insurance groups with the exception of Medicare patients; about 57% of their visits were emergent or urgent. About 27% of all emergency visits were classified as semi-urgent or nonurgent, defined as patients requiring care within one to 24 hours of arrival, while the remaining 26% of emergency visits were of unknown triage.

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