Privately Insured People’s Use of Emergency Departments: Perception of Urgency is Reality for Patients

Originally published by the Center for Studying Health System Change (HSC). HSC was a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation.

Perceived Urgency, Not Convenience, Fuels Emergency Department Use

Reducing avoidable visits to hospital emergency departments by steering patients toward lower-cost care settings remains a top priority for health care purchasers and payers across the country. To accomplish this goal, it is important to understand why privately insured individuals choose emergency departments over other options when confronted with an urgent medical situation.

Findings from the 2012 Autoworker Health Care Survey (AHCS), funded by the National Institute for Health Care Reform and conducted by the Center for Studying Health System Change (HSC), challenge a common assumption. Rather than convenience driving insured people to emergency departments, the data show that patients who are most likely to use EDs genuinely believe they need immediate medical attention. The survey covered 8,836 active and retired nonelderly autoworkers and their spouses.

Roughly 23 percent of respondents experienced an urgent medical problem in the three months prior to the survey. Among those with an urgent condition, nearly half (44%) ended up receiving treatment in an emergency department. Of those who had an urgent problem, close to half reached out first to their regular source of care, usually a primary care physician, and those individuals were less likely to visit an ED.

Convenience was cited as a factor by only about 7 percent of respondents, and fewer than 2.5 percent identified it as the sole reason for choosing the ED. The most common explanation, cited by nearly half (49%) of ED users, was the belief that their medical issue constituted a genuine emergency requiring immediate attention. About 30 percent said this was their only reason for going.

People who reported that their primary doctor could provide rapid access to advice and same-day visits were significantly less likely to end up in emergency departments. Instead, these patients relied on their primary care clinician for urgent medical needs. However, the majority of autoworkers indicated they did not have this level of timely access to their primary physician, despite holding relatively comprehensive health coverage.

Patients Believe They Face Genuine Emergencies

Contrary to the popular notion that many patients intentionally use emergency departments for routine or primary care, autoworkers most frequently reported going to the ED out of real concern for their health. The perception of how severe their condition was and how quickly they needed medical attention were the strongest predictors of whether a patient chose the ED, even after controlling for health status and personal characteristics.

Patients who felt they needed to see a clinician within a day were significantly more likely to visit an ED compared with those who thought their problem could wait two or three days (30% vs. 20%). This sense of urgency also shaped the care pathway: among people who first contacted their primary physician, those who believed they needed to be seen the same day or the next were more than twice as likely to be referred to the emergency department as those who could wait longer. Additionally, patients with a greater sense of urgency were half as likely to contact their doctor at all, thereby reducing the opportunity for their physician to direct them to an alternative care setting.

About one in four respondents reported that their doctor's office was closed when they needed help, and roughly a quarter said their physician told them to go to the ED.

Accessible Primary Care Reduces ED Visits

A large share of people with urgent medical needs did attempt to contact their primary physician first. When initially deciding to seek care for an urgent problem, whether a new condition or a flare-up of an existing one, nearly half of all patients contacted their doctor for help or advice. Another 20 percent called 911 or went directly to the ED, while 17 percent first contacted or visited an urgent care center. Individuals enrolled in health maintenance organizations (HMOs) were more likely to contact their doctor (52% vs. 43%) and less likely to call 911 or go straight to the ED (17% vs. 22%).

Patients who first reached out to their doctor were much less likely to end up in an emergency department. Among the 75 percent of patients with urgent needs who contacted a doctor's office or clinic, nearly 60 percent were treated by a doctor or nurse in an office setting, and another 12 percent had their issue managed over the phone. Almost a quarter were referred elsewhere, with more than half of those referrals directing the patient to the ED.

Overall, more than four in ten people with an urgent medical problem ultimately received treatment in an emergency department. But those who initially contacted their personal physician were considerably less likely to end up in the ED. Specifically, 23 percent of people who contacted their own doctor ended up in the ED, compared with 32 percent of those who contacted an urgent care center and 32 percent who reached out to a walk-in clinic.

Primary Care Access Gaps Drive Self-Referral to Emergency Departments

Nearly a third of autoworkers said they typically could not get an appointment with their personal physician as quickly as needed, and nearly half reported difficulty getting timely answers to medical questions when calling their doctor's office. The significant proportion of patients referred to EDs by their own physicians may reflect the seriousness of their complaints, but it could also signal that doctors were unable to see patients promptly or provide the full range of services required.

Patients' own assessment of their access to primary care played a major role in determining where they sought urgent care. Those who gave their physicians' offices high marks for getting care as soon as needed, scheduling routine appointments in a timely fashion, and getting answers to medical questions both during and after regular office hours were less likely to use emergency departments. This held true even after accounting for other factors.

This finding is especially notable because patients who have tested these dimensions of their clinician's practice likely did so because of illness, meaning they would be expected to have more acute medical needs that might not be manageable outside an ED.

Health Status and ED Utilization

People who sought care for an urgent problem were more likely to describe their physical or mental health as fair or poor and to suffer from more chronic conditions compared with the broader autoworker population. Nearly 60 percent of those with an urgent medical problem said their issue was connected to a chronic health condition, most frequently musculoskeletal problems or high blood pressure. These individuals were also higher users of medical services overall, including more ED visits, hospitalizations, and visits to both primary care and specialty physicians.

Among patients with urgent-care needs who self-referred to the ED, meaning they went without being told to do so by a doctor or nurse, reports of access problems were more common. These self-referred patients were less likely to report being able to get timely routine appointments or obtain help or advice when calling their physician's office after hours. They also were less likely to say that their primary physician spent enough time with them during visits, reviewed their prescriptions with them, or that their other providers had the information they needed from their primary clinician.

Policy Implications

When privately insured individuals believe they have a pressing medical problem and cannot reach their usual physician quickly enough, they frequently head to hospital emergency departments. Despite carrying relatively comprehensive insurance and maintaining relationships with a regular physician, many respondents felt their doctors did not provide timely access to care. This suggests that expanding health coverage and connecting patients to primary care practices may have less impact on ED utilization among insured individuals than expected, unless accompanied by improved access to lower-cost settings capable of providing a moderate intensity of care with urgent response times.

Certain health care delivery innovations, such as patient-centered medical homes, have focused on improving timely access through approaches like same-day appointments, and some evidence suggests these models can reduce emergency department utilization. Other programs, such as Kaiser Permanente's around-the-clock nurse-advice line, staffed with nurses who can access the patient's medical record and communicate directly with the practice to schedule an appointment, may be valuable for patients who struggle to secure timely appointments on their own.

This study, along with other research, indicates that financial incentives alone are unlikely to alter patients' sense of urgency when faced with an unexpected medical problem. Most respondents in this study already had strong financial incentives to avoid unnecessary ED care, because their benefit design included either deductibles or higher copayments for ED visits that did not result in hospital admission, along with lower copayments for primary care and urgent care center visits.

Emergency department care has clear drawbacks for addressing less-emergent needs. It is resource-intensive, contributes to fragmented care, and is inherently unsuited to providing ongoing or preventive care. Some evidence suggests that patients who seek care in emergency departments often report being satisfied with their experience, and in certain cases, even perceive ED care as higher quality than what they receive from their usual clinicians. These perceptions create an additional hurdle for efforts to reduce avoidable ED use.

Beyond financial deterrents, other approaches may prove helpful. Educational interventions targeting high-utilizing patients with chronic conditions that place them at greater risk for urgent medical problems could help guide these individuals toward alternative care settings. Above all, ensuring that patients have access to lower-cost settings that can deliver a moderate intensity of care with rapid response times is likely the most promising path to reducing emergency department use.

Data Source

This Research Brief draws on findings from the 2012 Autoworker Health Care Survey (AHCS), sponsored by the National Institute for Health Care Reform (NIHCR) and conducted by Mathematica Policy Research under the direction of the Center for Studying Health System Change. The survey sample included current and retired nonelderly autoworkers and their spouses with health insurance through General Motors, Chrysler, Ford, or the UAW Retiree Medical Benefits Trust. The sample was stratified by worker type (active vs. retired) and by company/trust, with oversampling of active workers enrolled in consumer-directed health plans.

The survey was administered by telephone (including cell phones) and mail between February and September 2012 and achieved a response rate of 46 percent. The overall margin of error was plus or minus 1.2 percentage points. Analysis in this Research Brief is weighted to be nationally representative of nonelderly autoworkers and their spouses.

Funding Acknowledgement

This Research Brief was funded by the National Institute for Health Care Reform (NIHCR). NIHCR is a 501(c)(3) nonprofit, nonpartisan organization established by the International Union, UAW; Chrysler Group LLC; Ford Motor Company; and General Motors. The Institute contracts with the Center for Studying Health System Change (HSC) to conduct health policy research and analyses aimed at improving the organization, financing, and delivery of health care in the United States.

Sources and Further Reading

Weinick, Robin M., Rachel M. Burns, and Ateev Mehrotra, "Many Emergency Department Visits Could be Managed at Urgent Care Centers and Retail Clinics," Health Affairs, Vol. 29, No. 9 (September 2010).

McCusker, Jane, and Josee Verdon, "Do Geriatric Interventions Reduce Emergency Department Visits? A Systematic Review," Journal of Gerontology Series A: Biological Sciences and Medical Sciences, Vol. 61, Issue 1 (January 2006).

Katz, Elyse B., Emily R. Carrier, Craig A. Umscheid, and Jesse M. Pines, "Comparative Effectiveness of Care Coordination Interventions in the Emergency Department: A Systematic Review," Annals of Emergency Medicine, Vol. 60, No. 1 (July 2012).

Cunningham, Peter J., and May, Jessica, Insured Americans Drive Surge in Emergency Department Visits, Issue Brief No. 70, Center for Studying Health System Change, Washington, D.C. (October 2003).

Peikes, Deborah, et al., Early Evidence on the Patient Centered Medical Home, Agency for Healthcare Research and Quality, Publication 12-0020-EF, Rockville, Md. (February 2012).

O'Malley, Ann S., "After-Hours Access to Primary Care Practices Linked with Lower Emergency Department Use and Less Unmet Medical Need," Health Affairs, Vol. 32, No. 1 (January 2013).

DeLia, Derek, et al., "Patient Preference for Emergency Care: Can and Should It be Changed?" Medical Care Research and Review, Vol. 69, No. 3 (June 2012).

Mortensen, Karoline, "Copayments Did Not Reduce Medicaid Enrollees' Non-Emergent Use of Emergency Departments," Health Affairs, Vol. 29, No. 9 (September 2010).