Challenging a common notion that uninsured patients are clogging hospital emergency rooms, a new study has found that the vast majority of adults who turn up there frequently have health insurance and regular doctors.
The finding suggests that expanding health coverage will not by itself significantly help emergency rooms cope with demands that include patients seeking care for routine problems such as colds or sinus infections, experts said.
The uninsured account for just 15% of emergency-room visits, according to the study to be published today by the American College of Emergency Physicians. The nonprofit organization advocates for the interests of emergency-room doctors and supports medical research.
Emergency rooms are crowded because they fill up with patients who cannot get in to see their own doctor or are waiting for regular hospital beds, experts said.
"We've cut hospital budgets so much, the only way they can be efficient is by operating as close to capacity as possible, like airlines," said Sandra Schneider, head of the emergency medicine department at the University of Rochester in New York.
The study confirms earlier findings that have begun to change scholarly thinking about the cause of emergency room crowding.
Healthcare providers assumed until recently that uninsured patients were the primary cause of crowding, said Diane Jacobsen, a director at the Institute for Healthcare Improvement in Cambridge, Mass., who did not participate in the study. Most doctors are free to turn away patients who cannot pay, but emergency-room doctors must see everyone.
Over the years, however, research has indicated that the problem is broader and more complex. "We often focus on the ER as the problem, when the ER is a symptom of the problem," Jacobsen said.
The study was conducted by researchers with the Robert Wood Johnson Foundation and UC San Francisco. They studied survey responses given by 32,669 households across the country in 2001. The researchers estimated that about 45 million American adults made a total of 80 million visits to emergency rooms between July 2000 and June 2001.
Frequent emergency-room users -- those who visited emergency departments four or more times a year -- represented less than a tenth of all emergency users yet accounted for 28% of all visits, the study found.
About 84% of frequent emergency-room users had health insurance and 81% had a source of primary healthcare either through a doctor or a clinic, the study found. About half had government-subsidized health plans like Medicaid or Medicare, while a third had private plans.
The shortage of hospital beds is only part of the problem causing emergency-room crowding, said Debby Rogers, vice president of quality and emergency services at the California Hospital Assn. A shortage of nurses and on-call physicians also contributes to delays that lead to backups in emergency rooms, she said. "There are a million reasons why ERs are crowded," Rogers said.
As the healthcare system comes under more stress, emergency departments are taking in more of the brunt. Emergency visits increased 26% between 1993 and 2003, according to the Centers for Disease Control and Prevention.
"It is the only door that is open 24 hours," said Brian Johnston, the medical director of the emergency department at White Memorial Medical Center in Boyle Heights. Johnston said as many as 14 of his 18 beds might be occupied by patients waiting to be admitted to White Memorial, an Adventist Health System hospital with 350 beds.
Some hospitals have begun implementing programs to manage patient traffic and to ease emergency-room crowding. At Redlands Community Hospital, an independently owned and operated 172-bed facility east of San Bernardino, surgeons schedule operations to avoid monopolizing intensive-care beds. And in the emergency room, patients with low-priority cases, such as the flu or a dislocated finger, are seen by a physician assistant instead of a doctor.
Schneider said that increasing efficiency would address the problem but not solve it by itself. More funding is needed for emergency departments and hospitals, she argued.
"Right now we are saying, cut, cut, cut, but people are going to have to decide how efficient they want their healthcare to be," she said. "Do they want it to run like the airlines? Where they bump people off when the flight is full?"