A statement yesterday from U.S. Health and Human Services Secretary Kathleen Sebelius seems innocuous enough: A lot of people seeking care in emergency departments are uninsured.
But the nation's leading group of emergency physicians immediately took issue with her remarks, saying she's perpetuating a myth about hospital care and is missing a much bigger problem.
In her statement, Sebelius said statistics from a database managed by the Agency for Health Research and Quality show that in 2006, one in 5 patients seen in emergency department settings was uninsured, that low-income patients accounted for almost one-third of patient visits, and residents of rural areas comprised one-fifth of emergency room care.
"Our health care system has forced too many uninsured, rural and low-income Americans to depend on the emergency room for the care they need," Sebelius said. "We cannot wait for reform that gives all Americans the high-quality affordable care they need and helps prevent illnesses from turning into emergencies."
Upon hearing of the release, Nick Jouriles, MD, president of the American College of Emergency, says her statement "perpetuates the myth that patients who come to emergency rooms don't need to be there, and if there were more primary care doctors, they wouldn't be. But the facts just don't bear that out."
Even the Centers for Disease Control and Prevention's "own statistics say that only 12% of patients seen in emergency departments don't need emergency care within 24 hours; everyone else needs to be there," says Jouriles, an emergency room physician in Ohio.
Sebelius' statement implies that emergency rooms would not be crowded, and patients wouldn't have to wait as long—and would get better care—if there were more primary care doctors who would see them in their offices. That's a message perpetuated not just by the Obama administration, he said, but the Clinton and Bush administrations carried that incorrect message too.
In this case, Jouriles says, Sebelius and the White House appear to have an agenda: To beef up support for expanding primary care physicians while ignoring the needs of hospital emergency departments.
"We know we need more primary care providers, but that's a long-term project, one that will take 10-15 years to accomplish," Jouriles says.
He adds that emergency room doctors also want patients to have health insurance.
"But even with primary care being all beefed up, patients will still be getting sick and injured, and they will still be coming to the emergency room."
Jouriles, whose association has been at odds with the Obama administration, in part for not inviting its representatives to health reform summits, says that even when there are enough primary care doctors, and even if emergent patients call them first, their doctors will just tell them to go to the emergency room anyway.
"It doesn't make sense to put resources into that phone call. You need to put resources into the emergency department," Jouriles says.
Right now, resource-starved emergency rooms are struggling to comply with EMTALA (Emergency Medical Treatment and Active Labor Act), which requires Medicare-eligible hospitals to treat all emergent patients who come through their doors until they're stable, regardless of their ability to pay the bill.
"There's no funding for that," he says. "Hospitals can't run a business. And from a patient's point of view, if there are less resources, the longer they will wait, and if you're having a heart attack or are in an accident, you're not going to be seen as quickly as possible."
A new court ruling also may pave the way for some insurance companies to avoid paying emergency doctors or hospitals for care given to their enrollees by out-of-network providers, Jouriles says.
Sources of funds, such as disproportionate share money, doesn't come close to covering the gap, which gets wider as more people lose their jobs and as employers increasingly opt out of purchasing health plans for their employees.
Jouriles says there are 1 billion doctor visits in the U.S. every year, and of those, 120 million, or 12%, occur in an emergency room. Yet only 4% of the nation's doctors are emergency specialists. "You can do the math and see that 4% of the physician workforce is providing more uncompensated care than the other 96% put together."
Sebelius is right on one thing, he says. "She's right that we need to do something about uncompensated care, but we need to put the resources where the patients are, the nation's emergency room, and in 4% of the physician workforce."