The ER Myth vs. Reality

John Commins, for HealthLeaders Media, October 22, 2008

There is a nagging myth out there that it is the approximately 47 million uninsured people in this nation who are clogging hospital emergency rooms for routine care better suited to a doctor's office or a walk-in clinic.

A new study in the current issue of the Journal of the American Medical Association reaffirms what many already know—this is not the case.

The JAMA study, Uninsured Adults Presenting to US Emergency Departments: Assumptions vs. Data, looks at 127 previous studies of emergency medical and surgical care for uninsured adults and found that 53 of those studies carried assumptions about uninsured ED patients that weren't borne out by facts.

"The uninsured have become a scapegoat," says Manya F. Newton, MD, an emergency physician at the University of Michigan and an author of the study. "There is a belief among some people that the uninsured are choosing to be uninsured because they are lazy, and that if they worked harder they could get insurance and all our problems would be solved."

The JAMA study acknowledges that the uninsured population is growing. The numbers of uninsured in hospital EDs are growing, too. And yes, many uninsured use the ED because they lack access to primary care. All true.

However, the JAMA study identifies unsupported assumptions in a number of studies about the uninsured; namely, that they were the main cause of ER overcrowding; and that they have less-serious conditions than insured patients and use the ED as a matter of convenience.

"These studies weren't subtle at all," Newton says. "We see in quotes 'uninsured patients realize that no matter what complaint they have, even if it's not an emergency, they can get care in ED for free.' Or 'it is widely understood that the uninsured show up for non-urgent problems.' These statements are made with no citations," she says.

The CDC in August found that the uninsured make up 17.4% of ED visits. Patients with government sponsored health plans, and privately insured patients, make up about 42% and 40% of the ED volume, respectively. The CDC also reports that ED visits increased 32% nationally from 1996 to 2006, from 93 million to 119 million visits. At the same time, the number of EDs decreased from 4,019 to 3,833, exacerbating crowding.

It's easy to understand why the general public—especially someone who's just waiting three hours for emergency care—might have an exaggerated sense of the problems that the uninsured are creating in the nation's EDs. Newton says it's difficult to explain why the myth continues to thrive among well-educated healthcare professionals who really should know better.

"It's easy to confuse anecdotes with data," Newton says. "If you are on the front lines of a busy emergency department, it's easy to remember the person who shows up for the sniffles who makes you mad rather than the 300 people who showed up appropriately."

"It becomes part of the common culture," Newton says. "I was guilty of some of these assumptions myself. And I hear them repeated again and again from my colleagues. Then it becomes something that everybody knows and nobody questions."

John Commins is the human resources and community and rural hospitals editor with HealthLeaders Media. He can be reached at
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