ER Problems and Access to Care

The June 19 edition of USA Today featured an article proclaiming that my hometown, Houston, is the perfect example of a "health care crisis."

Nationally, more than 15% are uninsured. In Texas it's nearly 24%, the Census Bureau says, the highest percentage among the states. Here in Harris County, it's 30%, according to state figures, the highest rate among the nation's top 10 metropolitan areas.

As the Houston area struggles to deal with a rising tide of uninsured, it offers a lesson for the nation: Let the problem get out of hand — to a point where nearly 1 in 3 people have no coverage — and you won't just have a less healthy population. You'll have an overwhelmed health care system.

The article then goes on to discuss Harris County's well-documented ER problems, but notes that "[t]he greatest demand for health care isn't in emergency rooms. It's at the clinics and health centers designed to relieve them."

Not that the problems relating to ERs are not important, but sometimes it seems as if that is the problem that dominates attention, when in fact it is merely a symptom of the general access to care problems. 

Or is it?

If ER overcrowding is a function of access to care -- which certainly seems reasonable -- then one would expect ER utilization to be lower in countries who have nationalized health care.  But, recent evidence from Canada suggests, surprisingly, that is not at all the case.  Whatever one's feelings on the merits of national health care, it seems difficult to argue that a country with 45 million uninsured enjoy greater access to care than a country in which everyone is insured.  In any case, recent studies of ER utilization in Canada indicated very similar wait times and overcrowding problems in the ERs that were examined.

So why are ERs so overcrowded? The authors of the Canadian study posit that people -- even the insured -- use ERs as a portal to health care partly because it is convenient in the sense that its doors are open 24/7 (so long as the hospital maintains an ER, which is of course a relevant area of concern).  Yet, there is little evidence that screening out nonemergent conditions would have a substantial impact on ER utilization and wait-times, at least in part because ER patients are always triaged, so sicker patients are almost always going to be seen before patients with nonemergent conditions.  Moreover, there is solid evidence (see p. 7) that people who are insured privately and who have Medicare account for much of the growth trends in ER utilization.

Despite the fascinating preliminary evidence from Canada, I nevertheless maintain that focusing merely on ameliorating ER problems misses the forest for the trees inasmuch as such problems are really effects of the overall nonsystem of health care in the U.S.

Thoughts?

Comments

[deb martin]

i totally agree. gone are the days of people swarming ben taub's ER for an earache, believe it or not, "indigent" and "ignorant" are not wholly interchangeable. enough media hoopla has educated the indigent about the hospital system and most understand unless it's life threatening it's an exercise in futility. harris county grows by the millions, yet never a new clinic opening, and come on,the same two hospitals? what the heck is the city of houston health dept for? i guess their too busy with std clinics and TB to bother with primary care, even though primary care could prevent both. texas medicaid reorganized the program at the first of the year.plans dwindled from 6 to 3, most notably texas children's opted out, sending their patients down to ben taub to add to the overload. i spent three hours going through the amerigroup book making calls. right up front in the book, at least 30% of the docs have the symbol for "not accepting" by their name. almost all of those without the symbol are also not accepting, telling me their "panel" just closed. i selected a local doc's office for my son because they were listed in the book as accepting. they tried every which way to run me off, but i finally waited around until i saw the doc himself leaving and asked him in the elevator to take my son as a patient. he accepted, but his nurse is terminally rude over it. when my son injured his ankle playing basketball at school, i called the primary and he did an xray. concerned, he ordered an MRI, but amerigroup said only an ortho could order one. funny thing, NO other doc in the practice at hilcroft medical group takes medicaid, including dr. frazier in the next pod, who happens to be the sports dr. so i guess we'll end up in the st. lukes minor care eventually if his pain gets any worse or he reinjures the ankle, both likely scenarios. forget ben taub, i spent 22 hours there with a broken arm, then waited two years for surgery, but that's me and not my child who has medicaid star plus. health care should be universal, and should start with wellness, nutrition and prevention. but we get into ethical delemma's like how birth control could help prevent people from cranking out kids until they can provide for them. until my older son was diagnosed with cancer a couple of years ago, i worked and my kids had insurance. but go to any foodstamp office and see the throngs of children being BORN into public assistance. how about citizens who cannot afford health care bartering their time for care with community service? i volunteer on several projects, but how about an organized project where people who need assistance swap their time for med services? according to the labor board, volunteer time is currently worth around $18 per hour. finally, face it, people with more money expect better care, expensive drugs and private services. fine, they deserve it, but at private places like our new designer hospitals. perhaps our fine docs at st lukes, methodist etc could pro bono a bit in the community, to take pressure off of ben taub?

[GruntDoc]

I've had some thoughts on my blog:
http://gruntdoc.com/2007/06/primary-care-access-the-ed-and-1972.html

And, for deb martin, my experience working in similar hospitals, the other (non tax supported) hospitals are writing off millions in uncompensated care, so they're doing what they can while still staying open.