Primary Care Shortages Lead to Increase in ER Use, Study Finds

The dramatic increase in emergency department use during the past several years has been driven, in large part, by the chronic shortage of primary care physicians, according to a study in the Oct. 22 issue of the Journal of the American Medical Association, or JAMA.

"Uninsured Adults Presenting to U.S. Emergency Departments," which was conducted by researchers at the University of Michigan, Ann Arbor, found several reasons for emergency room overcrowding, including a decreasing number of emergency departments and inpatient hospital beds. But it also concluded that overcrowding is directly tied to the declining number of primary care physicians, said Manya Newton, M.D., M.P.H., an emergency department physician and one of the primary authors of the study.

"Emergency department crowding is extremely multifaceted," said Newton, a clinical lecturer in the emergency medicine and internal medicine departments at the University of Michigan. "One of the interesting things is emergency department overcrowding exists in countries throughout the world, many of which have national health insurance. Everyone is insured, yet there is still crowding."

During the past 10 years, ER use has more than doubled in the United States, increasing among the insured and uninsured, said Newton. In fact, the number of ER visits by insured patients has increased in that time from 35 visits per 100 people per year to 39 visits per 100 people annually, according to Newton.

"That doesn't sound like a huge increase, but when you are looking across millions of people in America, that is enough to drive crowding," she said. "One of the reasons that is happening is a lack of access to primary care."

Insured individuals technically have access to primary care physicians, but as these physicians become more overloaded and fewer in number, people are forced to seek care from emergency departments, said Newton.

"There is a decreasing number of primary care physicians, and that is hurting everyone -- the insured and the uninsured," said Newton.

The study, which was funded by the Robert Wood Johnson Clinical Scholars program, looked at commonly held beliefs and assumptions about ER use, relying on Medline data since 1950 for analysis, as well as documents from the Government Accountability Office and the CDC.

"We looked at all of the supporting studies for each assumption," said Newton.
In many cases, well-respected authors and journals made sweeping statements about the uninsured and emergency department use, saying things like, "Everyone knows the uninsured are X, or it is well understood the uninsured are Y," said Newton.

"There would be no citation, and it would be published," she added. "When I was looking into it, I began to realize that I wasn't sure these statements were true, which is how I ended up writing this paper."

Newton said she began to realize that it was difficult to separate facts from commonly stated beliefs and assumptions. "It probably was confusing to many other people, and there was nothing in the literature to clarify it," she said. "If we were making policy or medical decisions based on assumptions that were not true, we had two risks -- one, we waste time and resources, and two, we could actually harm people."

One of the first assumptions addressed in the JAMA article is that the uninsured are the major culprits behind ER use and overcrowding, an assumption dispelled by the study. "There are increasing numbers of everybody -- insured and uninsured -- coming to emergency departments," Newton said.

Another common assumption is that the uninsured are showing up in ERs with minor ailments or injuries. In reality, the uninsured tend to postpone care longer than their insured counterparts; as a result, they are sicker by the time they access emergency care, Newton said.

"It is very easy to look for a scapegoat, especially when you are sitting in the emergency department with a broken arm, and you're asking, 'Who are all these people coming in here?'" she said.

As an ER physician, Newton is well aware that emergency departments have high fixed costs. But like many others, she said she assumed that the cost of seeing a patient at 3 a.m. in the ER is not itself a major cost driver -- another false assumption. Unlike primary care physicians, emergency department physicians have to "start from scratch" with each patient and must assume that patients are "dying until they prove otherwise," said Newton. As a consequence, ER physicians are forced to order a battery of tests to rule out possible afflictions.

Primary care physicians, by contrast, have ongoing relationships with their patients, allowing them to more easily and effectively diagnose and treat patients, saving time and money in the process, Newton said.

Newton said she hopes the study will focus attention on the real causes of emergency department crowding and, in turn, will underscore the actual access-to-care barriers facing the uninsured.