Is Emergency-Room Overuse a Myth?

A seven-year federal study by UC-San Francisco found that only a small fraction of ER visits, or 3.3%, are “avoidable.”

The conventional wisdom in the healthcare industry for decades was that emergency room use is often unnecessary and a waste of expensive resources. This view was firmly supported by a 1996 study reported in the New England Journal of Medicine that stated that it is widely believed that 50% of the 90 million emergency room (ER) visits each year were unnecessary. In addition, the study reported that 50% of ER charges went unpaid. Many healthcare experts, including me, felt that uncompensated care resulted in major cost shifting to health insurers and employer paid health plans. As a result, the unnecessary use of emergency rooms by the uninsured and the working poor had been a major emphasis in healthcare reform efforts for decades and was a major driver for enactment of the Affordable Care Act, and the individual mandate just recently overturned by the GOP tax plan. See also: Opioids: Invading the Workplace Today, one of the major national health insurers has a policy to charge higher out-of-pocket costs, or actually deny payment, to insured claimants who use the emergency room unnecessarily. The president of the health insurer stated that the ER should only be used for the purpose for which ER departments were created, “for life-threatening conditions and not common medical ailments.” This policy is vigorously opposed by healthcare consumer rights organizations and many emergency room physicians. Now, a seven-year federal study reported by the University of California at San Francisco stated that, today, only a small fraction of ER visits, or 3.3%, are “avoidable.” Laura Burke, an emergency room MD and researcher at Beth Israel Deaconess Hospital in Boston, stated that, “sore throats and runny noses are not bogging down the system.” She firmly believes only a few visits are truly preventable and the reason that patients come to the ER are “usually for reasons that make sense. Maybe they work two jobs and at 2 a.m. was the only time they could come for care.” Many emergency room physicians agree that ER visits are not the best option for minor infections and sprained ankles but worry that the crackdown by health insurers will result in patients avoiding the ER when they, in fact, have a serious health problem. If the health insurers’ goal is to save money, retrospective claim denials could have the opposite effect. Chest pains that someone thinks are indigestion due to the pepperoni pizza they had for supper may be the onset of a heart attack. ER visits in the U.S. are escalating and expected to reach 150 million visits per year. Researchers believe the aging population and the opioid crisis are driving up recent utilization. Last year, there were 64,000 fatal opioid overdoses in the U.S., a 22% increase from 2016. A local EMT stated to my friend that half of all their calls now involve heroin/fentanyl/opioid overdoses. This is a national nightmare with no end in sight. On top of this national opioid crisis, the Centers for Disease Control and Prevention (CDC) has just issued a flu emergency that has spread to 49 states. This is the first time in 13 years that the flu has hit all 48 continental states and is particularly dangerous to children and the elderly. According to NBC News, there have already been 20 pediatric deaths due to this strain of the flu, versus three pediatric deaths this time last year. This year’s flu season started early, took off quickly and is now peaking as a full–fledged epidemic. CDC officials estimate the epidemic could turn bad to worse and run another 13 weeks. The national flu emergency is now complicated by a shortage of Tamiflu, which can dramatically reduce the symptoms if administered within 48 hours of the onset of symptoms. In addition, there is now a widespread shortage of IV bags in ERs, because a major manufacturer based in Puerto Rico was devastated by recent hurricanes. Some ERs are now using Gatorade instead of IVs to help treat dehydration due to flu symptoms. Otherwise healthy people with mild cases of the flu should be treated by their primary care provider within two days of the onset of symptoms. But high-risk patients, including the elderly and children under 14, and anyone having trouble breathing, who can’t keep fluids down or who runs a fever over 100 for more than one day should seek immediate medical attention. Maybe it’s time to revisit health insurance policies by state and federal health officials about retroactive denial of payments due to all the “unnecessary” use of ERs based on a myth and outdated 20-plus-year-old studies that are no longer valid. At the same time, even if only 3.3% of ER visits are “avoidable,” that still results in roughly five million unnecessary ER visits per year in the U.S. Health insurers want patients to consider alternatives to the ER such as drugstore walk-in clinics, urgent care centers, nurse 800-number health line services and telemedicine. I also highly recommend the use of 100% credible free resources such as the CDC and Mayo Clinic websites. See also: The Real Problem With Healthcare in U.S.  The American College of Emergency Physicians (ACEP) recommends people be familiar with symptoms of common illnesses and injuries. Minor medical conditions such as colds, low-grade fevers, cuts and sprains should be treated by primary care providers and walk-in clinics. Serious conditions such as loss of consciousness, signs of stroke, heart attack, major bleeding, trauma, sudden severe pain and coughing or vomiting blood should immediately result in a 911 call. The amazing people who work in ER departments, the physicians, nurses, technicians and support staff are overwhelmed across the country right now. In California, triage tents are being set up outside ER departments. One EMT unit in Dallas is reporting a 600% increase in calls. Let’s hope and pray they will have the resources available to prevent this public health crisis from getting worse and can stop preventable deaths, especially if it as simple as someone fearing that their ER bill won’t be covered by health insurance.

Daniel Miller

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Daniel Miller

Dan Miller is president of Daniel R. Miller, MPH Consulting. He specializes in healthcare-cost containment, absence-management best practices (STD, LTD, FMLA and workers' comp), integrated disability management and workers’ compensation managed care.


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