Insured Patients Overcrowding Emergency Rooms

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Emergency rooms overcrowded with uninsured patients is a staple of our debate over the woes of our health care system. Representative headlines include "Uninsured patients flood emergency rooms" from Reuters on MSNBC, "Uninsured patient load is straining emergency rooms" from Cox News, and "Emergency rooms feel fiscal pain; Uninsured patients cost hospitals, docs millions, study says" in the San Francisco Chronicle.

Hospital emergency rooms may indeed be overcrowded, but they are mainly filled with people who have some form of health insurance. The New York Times reports a new study which finds:

People who frequent emergency rooms are widely assumed to be there because they lack insurance, the implication being that their complaints are too minor to take up the E.R.'s valuable time. A new study argues that this is largely a myth. In Annals of Emergency Medicine, researchers say they have found that most patients who make frequent emergency room visits are insured and have a regular source of health care….The study found that 84 percent of the frequent users had insurance and that 81 percent had regular health providers.

Of course, hospitals have to cover their costs for treating the 16 percent of emergency room patients who don't have health insurance by boosting the bills for insured patients. If every patient could pay for emergency room care, then hospitals that are losing money on their ERs now would not be forced to close them down. This is why mandatory private health insurance (with vouchers for poor people) is a good alternative to our slow slide toward socialized medicine.

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  1. Circular Logic of Nationalized US Health Care:
    a. Nationalized Health Care is good
    b. Higher Taxes is bad
    c. Higher Taxes can NEVER be good
    d. Nationalized Health Care = Higher Taxes
    e. Therefore, Nationalized Healh Care is bad
    f. Forget why we thought National Health Care is bad
    g. Return to step a

  2. My mother’s an ER nurse. Let me tell you one reason for ER overcrowding:

    Say that it’s daytime. Say that the hospital has an urgent care center located right next to the ER. Say the urgent care center is open and less crowded. (All these conditions are true of my mother’s hospital. And, for those who don’t know, treating a minor condition in an urgent care center is cheaper than treating it in an ER, since the ER has more overhead for equipment, specialty staff, etc.)

    And let’s say that a patient comes in with a problem that the triage nurse can plainly tell is perfectly suitable for the urgent care center.

    What would common sense say? Well, common sense would say that a polite referral to the urgent care center should be given: “Sir, I think it would be better if you went across the street to urgent care. The wait is shorter and they are experienced in treating this problem.” (Assume, for the sake of argument, that the weather is pleasant and the patient doesn’t have any sort of condition that would make it tough to walk across the street.)

    Common sense would be wrong. A suggestion to use urgent care can be interpreted as an effort to refuse service, which is illegal.

    Now, another situation. Say somebody walks into the ER at 2 am. She’s decided that this would be a good time and place for a pregnancy test, never mind that there are lots of better and less expensive ways to do this. Or this person has decided that it’s a good time and place to get this wart examined that she’s had for a couple years (assume that the wart hasn’t changed shape or done anything else that would indicate skin cancer, and the triage nurse has been apprised of that fact).

    Can the triage nurse suggest waiting until morning, when doctors’ offices and urgent care centers and free clinics and other sorts of less expensive and perfectly adequate treatment options are available? No. Mind you, I’m not even talking about refusing care. I’m talking about making a suggestion, followed with “Of course, if you’d really prefer to do this now we can, but you’ll have to wait a few hours while we treat two heart attacks, an elderly woman who broke her hip, and a car accident victim.”

    Hospital administrators have told the ER that such a statement could put them in legal jeopardy.

    Now, I don’t know if this is the fault of risk-adverse administrators, stupid legislators, stupid regulators, eager plaintiffs, or whoever. No doubt Dave W. will show up and explain to me which category is at fault. OK, fine, you’re right. The category that you designated is in fact at fault. Great. The problem remains that triage nurses are, at least in some hospitals, prevented from even suggesting reasonable and affordable alternatives to the ER.

    Whether these unnecessary ER visits are paid for out of pocket, by insurance, by taxpayers, or by other patients after somebody defaults on payments, the bottom line is that these are a big money sink, and they’re unnecessary.

  3. Common sense would be wrong. A suggestion to use urgent care can be interpreted as an effort to refuse service, which is illegal.

    A referral to the urgent care center is not going to be actionable, unless something bad is going to happen to the patient as a result of it. So why are the people who employ your mother acting like such nincompoops:

    1) They are behaving rationally; experience has shown that people do in fact die on the way to urgent care; they cannot train the triage people sufficiently to trust them with that alternative.

    OR

    2) They are not behaving rationally. They have other reasons, probably economic, for wanting work to go thru the ER. I prefer this hypothesis. the reason I prefer this hypothesis is that the US spends more on healthcare and gets a shorter lifespan in return. Somebody is wasting money. My favorite trick is when somebody wastes a lot of money and then blames John Edwards for their problems.

    The idea that uninsured people are suing hospitals and winning based on minor harms caused by urgent care center referrals is ludricrous to me as a conscious adult.

  4. BTW, I’m willing to believe that some of this is the fault of administrators who want to direct as many patients as possible into the department with the highest overhead and highest price tag. But I also suspect that, in a more sane legislative/regulatory/judicial environment (take your pick of villains), they’d be more likely to shrink the department that costs more money to run and try to get as many patients as possible into a setting where it’s cheaper to treat them. Charging a lower fee for a cheaper service might still yield a higher margin than charging a higher fee for a more expensive service.

  5. they’d be more likely to shrink the department that costs more money to run and try to get as many patients as possible into a setting where it’s cheaper to treat them. Charging a lower fee for a cheaper service might still yield a higher margin than charging a higher fee for a more expensive service.

    Good analysis, but it assumes competition. If they put me in charge to introduce competition into the healthcare industry I would do it. And things would work just like you say here. They won’t . . .

  6. A referral to the urgent care center is not going to be actionable, unless something bad is going to happen to the patient as a result of it.

    Except you can’t make the referral, regardless of whether “something bad is going to happen to the patient” until you have done a full workup on the patient. Period. Its a federal law.

    The idea that uninsured people are suing hospitals and winning based on minor harms caused by urgent care center referrals is ludricrous to me as a conscious adult.

    The idea that making a referral to an urgent care center places a hospital at risk under the Emergency Medical Treatment and Active Labor Act is a fact. The idea that a violation of said Act will result in being barred from Medicare, and thus lose its main source of revenue, is also a fact. The idea that a complaint can be filed by anyone and will trigger headlines and a federal investigation regardless of how well founded it is, is also a fact.

    You may find these facts ludicrous (I know I do), but they are facts nonetheless.

  7. Unnecessary is in the eyes of the beholder. If the criteria for necessary is admission to the hospital, then the vast majority of ER visits are unnecessary. Of course, a good number of admissions to the hospital turn out to be unnecessary, such as when chest pain turns out to be reflux or chest wall pain.

    People use and abuse ER’s for reasons that are good to them, if not good to insurance companies or health care workers. It is a lot easier to avoid paying for health care if one gets the care from an ER than say a doctor’s office. While waiting one’s turn at the ER might take several hours, or even the good part of a day, getting an appointment to see a doctor in some markets might take two weeks or longer.

    Hospitals are looking at closing ER’s, because that is the easiest way to avoid caring for people who have no intention of paying the bill. A hospital without an ER gets patients through referral from a doctor’s office. The doctor’s office provides a screen against no-pay patients.

  8. trigger headlines and a federal investigation

    Some nobody triggered an investigation by stubbing his toe on the way accross the street. I wouldn’t be surprised if there were federal investigations under the law you cite to. However, I am just saying that I doubt these were triggered by triage behavior according to the desirable hypopethical T. has sketched for us (eg, nearby urgent care facility with quik service).

  9. I guess it’s different in other states, but if you walk into an ER in NY without insurance they will sign you up for Medicaid, so taxpayers will pay for the cost of the visit.

    Hospitals get to affix revenue codes to ER treatment to boost the bill sent to the insurance company/state no matter what the treatment costs. So if the lady who wants a pregnancy tests at 2am gets a $50 test, the facility can attach a surcharge of 500 or more dollars to that treatment.

    ERs around here often triage people into two groups, those with actual emergencies and those with hangnails etc. They still take care of them all, but of course the hangnails might have to wait longer than the mutiple gunshot patient.

    If you compare insurance companies which are not hospital affiliated with those that are you see very different patterns of ER usage among their insured. Hospitals with health plans don’t mind having busy ERs since they can write off the costs for their own members while having an open door policy for EVERYONE in the neighborhood.

  10. However, I am just saying that I doubt these were triggered by triage behavior according to the desirable hypopethical T. has sketched for us (eg, nearby urgent care facility with quik service).

    Referring someone to an urgent care center without doing a full workup and certifying that patient as stable for discharge is a violation of EMTALA.

    If the patient is a no-pay patient (and many are), and the urgent care center is run for profit (and many are), then the urgent care center has every reason to file a patient dumping complaint with the feds (and many have been).

    Sorry, Linkee,I’m not aware of an on-line repository of such complaints and investigations.

  11. This is going to sound stupid to somebody, I’m sure, but if this is an issue why even have a separate urgent care facility? Why not just integrate it into the ER as a module and triage patients to it as warranted? Allow anyone who wants to, to bypass the triage and self-select as an ‘urgent’ case.

    Then there’s no ‘across the street’, just one emergency department with graded levels of care in different modules.

  12. You know, there is a simple way to cut costs, improve service and it won’t cost tax-payers a dime…

    Stop staffing medical boards with AMA members, and end the practice of allowing the AMA to limit via the power of the state the number of medical school graduates.

    It is this artificial shortage in medical care created by government officials on behalf of the AMA that is making things more expensive.

  13. It’s not in a hospital’s interest to have an urgent care center, only in an insurance companies interest.

  14. Maybe because urgent care centers are not subject to the EMTALA law that RCD cites to?

    In other words, urgent care centers may have better ability to both turn away people (insured I assume) and to inject delay into the treatment.

    These situations aren’t static. the urgent care center accross from T.’s mothers ER my not turn a lot of people away now and may operate time efficiently now. However, if the facility ever did become as popular as T. and I would like, the urgent care facility would be a lot freer to let people die in the waiting room than the “real” ER.

    That is my best guess as to why they are separate. Just a long way of saying “market segmentation.”

  15. That sounds like a perfect use of insurance. Why pay premiums unless you’re able to get an excellent doctor when there really is a situation where you health can be adversely affected permanently?

  16. the urgent care facility would be a lot freer to let people die in the waiting room than the “real” ER.

    A person who’s at risk of dying in the waiting room wouldn’t be triaged to urgent care. Even if you have no confidence in the decency or skill of the hospital staff and management, a person at risk of dying probably needs some seriously expensive treatment. Why send that profitable patient away?

    The whole idea of running an urgent care site and an ER is to take financial advantage of gains from specialization. Keep in mind that even though I complain about the ER not being able to triage people away, the ER isn’t the only place that refers people to urgent care. The ER is the only place that can’t urge people to go there, but they aren’t the only source of info on where to go. Hence urgent care centers do in fact make money despite the rules constraining triage nurses.

    The issue is not the profitability of urgent care centers. They’re doing fine. The issue is what to do with people who wind up in the ER when they could do just as well elsewhere.

  17. A person who’s at risk of dying in the waiting room wouldn’t be triaged to urgent care.

    Yeah, I forgot to say what I originally meant to say. The person who uses the ER is not neccessarily paying for better or faster care. Rather, they are paying for a more favorable triage. And by “more favorable triage” I mean a triage where the providers are absolutely terrified of making the type of mistake where you get less care than you need and are also terrified that the triage will be too slow.

    Nothing wrong with market segmentation in the triage market. If the market were competive then urgent care facilities would compete and advertise based on their triage times and survival rates.

  18. Why pay premiums unless you’re able to get an excellent doctor when there really is a situation where you health can be adversely affected permanently?

    Because the insurance companies aren’t honest about actuarial data. With his sinus problems and eye problems, T.’s health insurance rates should be through the roof compared with my virtually healthcare free existence. And old people, fuggedabout it . . . probabilistically they should be paying 10 or 20 times what I used to pay.

    Of course, insurance companies don’t do that because then T. and the AARP would quickly come to support socialized medicine. In this way, my unspent (on me) premiums subsidize the continuedd existence of current private system.

  19. Urgent care centers are not the place to go if, in the opinion of a resonable person, you are having a life thereatening emergency. I don’t think you’ll ever see ambulances bringin people to urgent care centers.

    Urgent care centers are often set up by doctor’s groups and HMOs as an alternative to the ER at times when your doctor’s office is closed.

    I’d be very surprised if a hospital suggested to someone in their ER to go to an urgent care center, unless the hospital ran an HMO and the person was a member. It would be like the hostess in a fancy restaurant sending someone to a cheaper but excellent diner just because there’s a wait for a table at the fancy place.

  20. But you’re seeing this the wrong way. If T’s problem was a chronic one, then insurance companies do charge more for coverage. However, anyone can have an accident, even you, which could rack up 50K in expenses. That type of usage is covered by actuarial tables and averaged out among the risk pool of members.

    Older folks do have their usage looked at separately than younger members, you’re right in saying it wouldn’t be fair to combine young and old together.

    Actually, if you really are healthcare free you are what is known as a medical orphan, and perhaps have something undiagnosed that’s wrong with you which is slowly getting worse (and more expensive). HMOs are trying to get people like you to come in for preventative checkups, which might cost more in the short term, but will be cheaper in the long term if a problem is caught before it really affects your lifestyle.

  21. Older folks do have their usage looked at separately than younger members, you’re right in saying it wouldn’t be fair to combine young and old together.

    I think the only fair way is to combine young and old together. If there was a competitive healthcare market, there sure as shooting would be a company catering to the under 50 set.

    btw, in my two years in Canada I have had both a checkup and a medical emergency where I had to be taken to the emergency room by ambulance. Turned out to be a heat-induced cramp.

  22. I’d be very surprised if a hospital suggested to someone in their ER to go to an urgent care center, unless the hospital ran an HMO and the person was a member. It would be like the hostess in a fancy restaurant sending someone to a cheaper but excellent diner just because there’s a wait for a table at the fancy place.

    They do it all the time, when you go up to the hostess and ask “How long is the wait?”, that is exactly what they are doing. If you’re hungry and don’t really need that filet mignon, and the wait is 2 hours, you’re going to hit the local BK

  23. But the hostess doesn’t suggest going to another place to eat, the customer decideds that on their own.

  24. With his sinus problems and eye problems, T.’s health insurance rates should be through the roof compared with my virtually healthcare free existence.

    Dave, I have used specialty services only to identify and remedy specific problems, and once the problems were fixed I stopped needing expensive services. That’s the whole point of insurance: Something happens, you fix it, you use the insurance to pay the cost of fixing it, and after that the problem doesn’t cost any more money.

    Would you consider it better if I was racked with fever 4 days per month and completely blind in one eye because I didn’t want to abuse insurance? Would that be a better outcome in your view?

  25. No, T. the better outcome is that your insurance goes up because it was your eyes and to discourage other ppl (not you) from various forms of malingering. They do that with auto insurance, no reason they can’t do it with health insurance (other than that you would become a socialized medicine champion, that is).

    If they had to support this policy with acturaial statistics to show that someone with high health costs one year was a lot likelier to have high health costs on an ongoing basis, then they can do that.

    The point is, they don’t want to do this. So instead they spread the costs in a more socialized way to perpetuate an inefficient system. Would have loved to contract out of all of that when I lived in the US. Guess what? U can’t (as a practical matter).

  26. (other than that you would become a socialized medicine champion, that is)

    O RLY?

  27. T.:

    Keep in mind that they don’t know u as well as I do. Maybe a more accurate way would be to say that raising your rates the way they would be raised after an auto accident would tend to make a person in your shoes a champion of socialized medicine. You mileage may vary.

  28. thoreau seems to be taking some hits here.

    Auto insurance isn’t a very good analogy because it’s rather narrow compared to health insurance which is quite broad. If throeau’s eye problems actuarially-speaking made him more likely to need, say, a gall bladder operation later, then the argument would hold more water. On the other hand, it’s possible the insurance business could fragment further as far as what they insure: you see this with dental insurance being separate from other health insurance. If eye-ear-nose-throat insurance were available separately from lung insurance, heart insurance, etc. then perhaps his eye insurance premiums would increase.

  29. The thing is, what we call health insurance isn’t entirely insurance in the sense of paying a premium to protect from risk. It functions like that in part, but it also functions as employer-subsidized health care, since there are tax advantages to getting it through the employer rather than buying it yourself. If more people got health insurance on their own then premiums would presumably be based more closely on history. But since most (no, not all, I know) of the insured are getting the insurance via a third party, it’s really about a third party paying for it.

    Of course, you still get the protection from risk that is part of most other types of insurance, but the premium isn’t based on the individual’s risk. It’s based on the risk averaged over the population. Also, you do get the bargaining advantages of size.

    I’m not here to defend the healthcare system in the US, I’m just here to observe that it isn’t exactly like other forms of insurance, for good or for ill. It serves a multitude of functions, and one can question whether (1) it serves those functions well, (2) whether it makes sense to combine those functions in the first place, and (3) whether this merger of functions has more to do with policy rather than market forces. (I think the answer to the last question is obvious.)

    Anyway, with all that said, I still don’t see how it’s a waste of resources to see a doctor when you’re racked by fever and muscle aches 2-5 days per month (on average) and in danger of losing sight in one eye.

  30. “In this way, my unspent (on me) premiums subsidize the continuedd existence of current private system.”

    This is the feature of insurance that allows for it to exist at all. It is the basic underlying idea behind insurance. If you don’t want to make a bet that your input will be equal to or smaller than what you get out of it, put your money in savings and then don’t complain when you don’t have the resources to pay for your emergency.

    Looking at insurance as you suggest in your posts makes the insurance company just some sort of strange middle man that doesn’t provide a useful service at all. This is probably why you couldn’t convince anyone to play by the rules you suggest. They make no sense. It’s like you want to join an exclusive medical care country club or something with membership based on health status. Not a bad idea, maybe, but certainly not the same animal as health insurance.

  31. Anyway, with all that said, I still don’t see how it’s a waste of resources to see a doctor when you’re racked by fever and muscle aches 2-5 days per month (on average) and in danger of losing sight in one eye.

    It is not a waste of your resources. It is only a waste of mine. Actually it is not even a complete waste of mine becayuse you are about to use those eyes to read the important stuf I have to say next.

    Of course, you still get the protection from risk that is part of most other types of insurance, but the premium isn’t based on the individual’s risk. It’s based on the risk averaged over the population.

    I am saying that a health insurance company competing with other health insurance companies would not be able to sustain this. Because I would be the low hanging fruit and the companies would compete for me and my wife and leave you and your sinii wherever they be parked at now.

    As with the cornsyrup, gov’t regulation is to blame. Both in the employment tax area and the antitrust area. As with the cornsyrup, I suspect that certain companies in the private sector petitioned Congress to make things the way they are and not to change the underlying regulations to something you or I would like (eg, something competitive). As with the cornsyrup, I can’t prove that companies are the ones behind the current sick systems. I understand that my thirst for knowledge about where these trade regs and employment tax laws and antitrust exemptions for “insurance” make me a . . .

  32. So, you’re angry that insurance companies don’t charge me higher premiums based on the fact that I have been treated for things that are unlikely to recur. That’s it, at the end of the day? See, in earlier threads you suggested that my decision to see a doctor was the reason why poor people are sick or something.

    Well, when did I ever argue that I should pay the same premium as you? If we’d had that argument, I’d probably agree with you, believe it or not. I might dispute your assumptions about whether or not I’m as big of a risk as you think I am, but I wouldn’t argue against basing insurance premiums on risk.

    Of course, some health plans are offered as employer subsidized health care rather than risk protection (there is a difference). If that’s what’s deliberately offered, then it doesn’t make much sense to complain that it isn’t a risk management plan with premiums based on risk. And if you don’t like it, I’ll offer the standard libertarian retort: Find a different job.

    And you think that you’re so important that the bright side of my ophthalmologist’s efforts is that I can read your posts? OK…

    Finally, the corn syrup debate between us has never been about farm subsidies. I’m as against them as you are. It’s been about your seeming certainty over an unsupported hypothesis, and your contention that if I don’t assign this question the same priority that you assign it then I must be brainwashed.

  33. Let’s try that one again:

    If they didn’t have a cartel, then some competive company would tailor premiums to actual risks and then pitch that to individuals on a family-by-family basis [continue to part about employers picking, not you]

  34. T.:

    I am using your example aggressively to keep you and the others engaged. Really this is more about us versus the over 50 set.

    Side note: I am not sure auto accidents are that likely to recur either. However, when auto insurance companies compete, they assume the hell out of that particular assumption. Ultimately, whether your sinus problem correlates with likely future healthcare costs is a matter of stats that neither of us are privy to. The physiology of this disease or that is probably not tghe dominant factor here. The dominant factor is probably that sickly people are sickly and nonsickly are nonsickly, probabilistically speaking at least young people. With old people, well, they are all sickly. they luv the current system. It was a big transfer payment from me to them. I opted Canada so that at least my sacrifice is appreciated and not denigrated.

  35. And you think that you’re so important that the bright side of my ophthalmologist’s efforts is that I can read your posts? OK…

    I think my posts are the most intelligent thing you will read all year, notwithstanding the spelling and grammar errors. Just because nobody else thinks I am a genius doesn’t mean I’m not.

  36. Wow.

    I think my posts are the most intelligent thing you will read all year, notwithstanding the spelling and grammar errors. Just because nobody else thinks I am a genius doesn’t mean I’m not.

    Dave W’s “farces” email address has never been so appropriate.

  37. A friend of mine worked at a doctor’s office for several months and told me a lot about what he learned about insurance and medical billing. The most shocking thing was this: what the insurance companies are billed and actually pay is peanuts compared to what uninsured patients are billed. The amount insurance companies actually pay is something like 25% (IIRC) of the “rack rate”. They don’t even try to bill the insurance companies that much.

  38. Insurance companies get the economies of scale just like any other business. If there are two hospital systems that the insurance base of members can go to then the insurance company can use the leverage of only referring to one or the other to lower costs, since they could be sending thousands of cases a year to hospitals.

    There is also DRG (Diagnostic Related Group) billing, where the hospital might agree to x amount for all pneumonia cases, and y amount for a normal delivery, not matter what the length of stay of the patient. these amounts are based on stats which refer to history of tens of thousands of admissions, and break the costs up by national region and urban/suburban/rural utilization.

  39. Insurance companies get the economies of scale just like any other business. If there are two hospital systems that the insurance base of members can go to then the insurance company can use the leverage of only referring to one or the other to lower costs, since they could be sending thousands of cases a year to hospitals.

    This is not an example of an economy of scale. Rather, this is an example of a phenomenom called market power. The two concepts are very different, although I can see why a novice would confuse the two.

  40. Just so you don’t think I am making this up, here is the wiki on economies of scale:

    http://en.wikipedia.org/wiki/Economies_of_scale

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