Avoiding Emergency Rooms
On a recent Sunday afternoon, a 75-year-old Philadelphia man with a fever of over 102 degrees was unable to reach his doctor. So his daughter took him to an emergency room, where the two sat for hours until he was examined by a physician who found no reason for the fever and decided to admit him overnight.
The man was given oxygen, a chest X-ray, a blood test and, finally, a urine test, which revealed a urinary tract infection. The problem was solved with a prescription for an antibiotic, but at a cost of thousands of dollars to Medicare.
Like so many other health issues seen in American emergency rooms, the man’s infection was a common problem easily diagnosed and treated at a fraction of the cost by a primary care physician — if patients could reach their doctors when needed.
Experts report that more than half the problems patients bring to emergency rooms either do not or would not require hospital-based care if an alternative source were readily available.
As the Philadelphia patient, who is a friend of mine, found, care in an emergency department for a routine medical problem can result in unnecessary hospitalization, tests and procedures that may even complicate a patient’s medical problem.
I don’t blame doctors in private practice for wanting to work reasonable hours and have evenings, weekends and holidays to spend with family and friends. But the medical profession has thus far failed to adequately fill in the gap left by doctors who no longer make house calls or answer the phone 24/7.
The Leonard Davis Institute of Health Economics reported in 2005 that one quarter of primary care practices had no weekday hours after 5 p. m.; more than half lacked weekend hours, and nearly one quarter were unable to see patients for an urgent problem. The problem has grown even worse today.
Many doctors now work 9 to 5 or its equivalent, but patients can — and often do — become acutely ill or injured between 6 p. m. and 8 a. m. They turn to emergency rooms for help, where, rightly or wrongly, they expect access to all manner of tests and medical specialists.
Emergency rooms are open 24/7, and every hospital that accepts Medicare and Medicaid is obliged by law to treat everyone who comes in, regardless of citizenship, legal status or ability to pay.
Contrary to what many think, the rising use of emergency rooms for routine medical issues is not caused by poor people without insurance or a personal physician. The biggest increase has involved insured middle-class patients and those with personal physicians who could not reach or see their own doctors when they needed care.
The overuse of emergency rooms is a growing and increasingly costly problem that results in overcrowding, long waits, overly stressed health professionals and compromised care for people with true emergencies.
In a research brief issued in 2010, the New England Healthcare Institute reported that overuse of emergency rooms “is responsible for up to $38 billion in wasteful spending in the United States every year.” The institute estimated that avoidable visits to emergency rooms “range as high as 56 percent of all visits.”
In a study of emergency department use by patients with medical insurance, the California HealthCare Foundation found that 46 percent of the problems could have been handled by a primary care physician, but two-thirds of the patients said they’d been unable to get care outside the emergency room.
Of course, patients can’t always know what is and what is not a true emergency. Is that pounding headache a migraine or portent of a stroke? Is that pain in the arm a pulled muscle or a symptom of a heart attack? Is the bad stomach pain a case of indigestion or appendicitis?
Researching a symptom on the Internet sometimes exacerbates a patient’s fears with lists of serious, even deadly, diseases that the symptom might represent. Those with chronic medical problems may lack a clear understanding of their disorders and may not know how to cope with changes in their conditions.
When patients in distress call their doctors, they often cannot get appointments for that day or the next. What used to be the proverbial advice to “take two aspirin and call me in the morning” has become a recorded message to go to an emergency room if they think the problem can’t wait.
Many cities and towns now have urgent care or “walk-in” clinics, sometimes attached to hospitals, where patients can be seen without appointments or long waits.
Very early one morning, a friend took her 3-year-old son to urgent care when he awoke with a fever and sore throat on the day they were to fly to Puerto Rico. A throat swab indicated that it was unlikely to be strep throat, and the child was given acetaminophen to reduce his fever and relieve his discomfort.
Many more such clinics are needed, staffed perhaps by newly licensed doctors, physician assistants and nurse practitioners. Or, as Dr. Marvin Moser, a professor of medicine at Yale, suggested in an interview, “Parts of hospitals that are closing could be kept open as walk-in clinics, where costs are considerably less, there are no four-hour waits and no automatic tendency to admit patients to the hospital.”
Group practices can — and often do — rotate having a doctor on call during off-hours, weekends and holidays. Virtually every doctor has a cellphone, and those in solo practices should be asked to give patients the number or include it in the recorded message when the office is closed.
If you have a chronic medical problem, such as a heart condition or asthma, your doctor should devise a care plan that will reduce the chances of a crisis that requires emergency care. Comprehensive patient education, especially for those with chronic conditions, can help to alleviate concerns when a symptom occurs. If your doctor does not provide such information verbally or in print, ask for it or educate yourself by researching your ailment on the Web. Better yet, get a new doctor who tells you what to expect and when to seek medical help.
Adding to problems with emergency room care are high and widely ranging out-of-pocket costs to patients for seemingly identical conditions.
Dr. Moser said his 11-year-old granddaughter, who had a bad stomachache, received questionable tests at outrageous charges at an emergency room in California where the child’s doctor had told the family to take her. The bill included $356 for a routine blood count, $1,212 for a blood analysis and $1,135 for a sonogram — not to mention $1,288 just for walking in the door.
In a new study, Dr. Renee Y. Hsia of the University of California, San Francisco, and co-authors found that among the 10 most common outpatient conditions seen in emergency rooms nationally, charges ranged from $4 to $24,110 for sprains and strains; $15 to $17,797 for headaches; $128 to $39,408 for kidney stones; and $50 to $73,002 for urinary tract infections.