Nonurgent Use of Hospital Emergency Departments

Overview

Hospital emergency departments occupy a unique position in the American health care system. They are open around the clock, required by federal law to screen and stabilize anyone who walks through the door, and serve as the front line for everything from heart attacks to sprained ankles. For years, a widely held view among policymakers has been that too many people use emergency departments for problems that could be handled in a doctor's office, and that diverting these "nonurgent" visits to primary care settings would ease crowding, lower costs, and improve care.

In testimony before the U.S. Senate Subcommittee on Primary Health and Aging in May 2011, Peter J. Cunningham, Ph.D., a senior fellow at the Center for Studying Health System Change (HSC), presented research challenging several of these common assumptions. His findings suggested that the problem of nonurgent ED use was more complicated, and the potential cost savings more modest, than many believed.

Growth in Emergency Department Use

Americans made approximately 124 million visits to hospital emergency departments in 2008, according to the National Hospital Ambulatory Medical Care Survey (NHAMCS). That represented a 28 percent increase from 1995. But the numbers need context. Emergency department visits, while growing, still accounted for just 10 percent of all ambulatory care encounters. Physician office visits totaled 956 million that same year — representing 80 percent of ambulatory care — and had themselves grown 37 percent since 1995, an even faster rate of increase.

On a per-person basis, Americans averaged 41 ED visits per 100 people in 2008 versus 320 physician office visits per 100 people. About 23 percent of Americans visited an emergency department in a given year, compared to 84 percent who saw a physician in an office setting. The increase in ED use, in other words, was part of a broader surge in demand for ambulatory care across the system.

The Insured, Not the Uninsured, Are Driving the Increase

One of the most persistent assumptions about ED crowding is that uninsured patients are the primary cause. The data told a different story. Between 1995 and 2008, the share of ED visits classified as self-pay or no charge — categories that largely capture the uninsured — actually declined from 17 percent to 15 percent. Meanwhile, the share of visits by privately insured patients rose from 37 percent to 42 percent. Privately insured individuals accounted for roughly 60 percent of the total growth in ED volume during this period. The uninsured accounted for just 9 percent.

The perception that uninsured people flood emergency departments may stem from their greater dependence on EDs when they do seek care. More than one-quarter of all ambulatory visits by uninsured patients were in emergency departments, compared to 7 percent for the privately insured. But in terms of raw numbers and growth, insured patients were the main drivers of increased ED traffic.

How "Nonurgent" Are Emergency Department Visits?

Estimates of the share of ED visits that qualify as "nonurgent" vary enormously, ranging from less than 10 percent to about half, depending on the methodology used. The most credible national data, based on triage assessments by ED staff, painted a more restrained picture. In 2008, only 8 percent of ED visits — about 9.9 million — were classified as nonurgent, meaning the patient could have waited two hours or more to be seen. Another 21 percent were semi-urgent, 39 percent were urgent, and 16 percent were immediate or emergent. The share classified as nonurgent had actually declined slightly since 2000.

The difficulty in classifying urgency was illustrated by a common example: a patient arriving with chest pains fearing a heart attack, only to be diagnosed with severe indigestion. From the patient's perspective, the visit was clearly urgent. Based on the final diagnosis alone, it might be classified otherwise. The majority of ED visits fell into a gray zone — not true emergencies, but not clearly inappropriate either.

Why People Choose the Emergency Department

Lack of a primary care physician was not the main reason people turned to the ED for nonurgent problems. Among those visiting the ED for nonurgent conditions, two-thirds reported having a regular source of care at a doctor's office. Only 3 percent said the ED was their usual source of care. People who used the ED for minor ailments actually tended to have more physician office visits over the course of a year, suggesting the issue was not lack of access to primary care but rather specific circumstances that made the ED more practical at that moment.

Convenience was a major factor. Two-thirds of all ED visits occurred outside normal business hours — evenings, nights, and weekends — when most primary care offices are closed. For patients who could not take time off work or who developed symptoms at night, the ED was often the only option. Growing capacity constraints in physician offices, including longer waits for appointments, also contributed. As office-based practices became busier, some excess demand for ambulatory care spilled into emergency departments.

Hospitals Have Financial Reasons to Expand ED Capacity

Contrary to the common view that emergency departments are financial drains, many hospitals were actively expanding their ED capacity. More than one-quarter of emergency departments had expanded in the two years before 2008, and a similar share planned further expansion. Researchers at the University of Southern California estimated that closing an ED would cost a hospital one-third or more of its inpatient admissions — far exceeding any savings from shutting it down.

Emergency departments function as a gateway to inpatient admissions and procedures, particularly for privately insured and Medicare patients. This gave hospitals little incentive to discourage ED use by insured patients, even for nonurgent problems. Hospitals were more likely to focus diversion efforts on uninsured patients, whose visits generated uncompensated care costs.

Cost Savings: Smaller Than Assumed

Total spending on ED visits reached $47.3 billion in 2008, or about 4 percent of total health expenditures. While a GAO report estimated the average cost of a nonemergency ED visit at $792 versus roughly $100 at a community health center, other research suggested the savings from shifting nonurgent visits to office settings might be smaller than commonly thought. One study found nonurgent ED visits cost only about three times what they would have cost in a physician's office — not the seven-to-one ratio some estimates implied.

The most significant savings potential lay in the Medicaid program. Medicaid enrollees had the highest per-person rates of ED use and accounted for more than one-quarter of nonurgent visits. Because Medicaid patients already made up a large share of community health center patients and tended to live in areas where CHCs were located, programs steering nonurgent Medicaid ED visits to health centers had the best prospects for meaningful cost reduction.

Quality May Be the Bigger Gain

Cunningham argued that the quality-of-care improvements from shifting nonurgent ED visits to primary care settings could be more significant than the cost savings. ED use for minor problems was associated with fragmented care, poor communication between emergency physicians and patients' primary care doctors, duplicated testing, and inadequate follow-up. Surveys showed that more than three-quarters of patients with scheduled office appointments rated the thoroughness of their exam positively, compared to only about half of ED patients.

Redirecting nonurgent visits to primary care was also seen as a necessary step toward building patient-centered medical homes — a model that coordinates care across providers, reduces redundant services, and ensures patients have an ongoing relationship with a primary care physician.

About HSC

The Center for Studying Health System Change was an independent, nonpartisan health policy research organization affiliated with Mathematica Policy Research. HSC also served as the research arm of the National Institute for Health Care Reform, a 501(c)(3) organization established by the International Union, UAW; Chrysler Group LLC; Ford Motor Company; and General Motors.

Sources and Further Reading

CDC/NCHS — Ambulatory Health Care Data — National survey data on emergency department and physician office visits.

U.S. Government Accountability Office — Congressional oversight reports on health care delivery and costs.

AHRQ — Medical Expenditure Panel Survey — National data on health care use, expenditures, and insurance coverage.

Kaiser Family Foundation — Medicaid — Data and analysis on Medicaid programs, enrollment, and spending.

Commonwealth Fund — Research on emergency care, primary care, and health system performance.