QUALITY: Another Look at the ER Crowding Challenge

More evidence that it's not just the uninsured clogging up our ERs. It's the whole flawed health care system clogging up the ERs.

A study in the Journal of the American Medical Association, described in USA Today, shows that emergency room crowding has multiple causes. Yes the uninsured are part of the problem, and in some cities they are a big part of the problem, but typically the uninsured try to avoid ERs because they are so expensive.

"There's a myth that the emergency department provides free care," JAMA co-author Manya Newton, an ER physician at the University of Michigan, told the newspaper. "Yes, we see anyone who shows up at the door, but when we see you, we will send you a bill. The uninsured don't want to pay thousands of dollars to come in for the sniffles." In fact, the study found that a higher proportion of people with public insurance including Medicare and Medicaid are more likely to use the emergency room. (Medicare patients are of course age 65 and older, or disabled, and naturally the aging population is more likely to get sick than the young and healthier population. But good primary care, chronic disease management and advanced care planning reduce ER use even amongst older and frailer patients.)

As readers of our blog know, other reasons for emergency room crowding are lack of access to primary care doctors (particularly during off hours). "We need to strengthen access to care in the community, regardless of what type of insurance people have," Ann O'Malley of the Center for Health System Change said. "It's misdirected to make the uninsured the bad guys."

Researchers have also identified "patient flow" as an ER chokepoint. That refers to the the process of admitting and releasing other patients in the hospital, making room for folks who need to be admitted from the Emergency Department. If there's no bed, patients wait in the ER, which in turns adds to the ER crowding, wait time and backlog. A shortage of psychiatric beds is also a factor.