Of the many goals of the managed care revolution, few had as much resonance as the push to get people out of the nation's emergency rooms.
With health maintenance organizations, everyone was supposed to have a primary care doctor who would manage the aches and pains. Preventive care would stave off emergencies like acute asthma attacks, and better use of family doctors would help make emergency room business dwindle.
It has not worked that way. Visits to emergency rooms grew about 3 percent a year from 1997 to 1999 and have risen 6 to 8 percent in the last year, said the leading emergency doctors' group, a figure that is expected to continue.
The reasons are similar to those behind other problems in health care: the lack of access to primary care doctors among the poorest Americans and a rising number of Americans in the last decade who are without insurance, often because of higher medical costs. In addition, there are those who find the emergency room quicker and more convenient.
In New York City, three out of every four visits to an emergency room are for non-emergency care, according to a study by the Commonwealth Fund, a private philanthropic organization.
The promises of primary care have been dashed in large part, health care policy experts say, because insurance reimbursements for primary care doctors are so low that too few are willing to be in the field or to extend themselves to late hours or weekends when emergency care is required.
"The situation is grave," said Dr. Michael Gerardi, a spokesman for the emergency doctors' group, American College of Emergency Physicians. "We are a symptom of the disease that is the health care system."
In many areas of the country, especially in cities because of large numbers of uninsured people, emergency rooms are crushing under the increased volume and patient care is often compromised, doctors insisted.
"We are not adapting very well," said Dr. Daniel Higgins, the medical director of emergency service at Saint Francis Medical Center in Lynwood, Calif., where 27 percent of the patients are uninsured and emergency room visits have risen 13 percent in five years.
But in regions where hospitals still compete for business, like New York City, and in areas with large numbers of insured residents, emergency rooms are learning to accept and even welcome the increased patient load. Hospitals are making emergency rooms feel a bit like a private doctor's office where waits are short, coffee is pouring and the first question a patient hears is about their condition rather than their payment method.
"Five years ago there was all this talk about inappropriate uses of the ER," said Dr. Dan Wiener, the chairman of emergency medicine at St. Luke's-Roosevelt Hospital in Manhattan. "All we were focused on was how to get them out. Now we are looking at how to give these patients better service."
The emergency department is economically complicated. It is the entree for large numbers of patients for most hospitals -- about 52 percent on average in New York and as many as 80 percent in some hospitals. Further, a hospital routinely earns more from an emergency room visit than one to a clinic.
But doctors and hospital executives said that insurance companies have gradually lowered payments for visits to emergency rooms, often resorting to what is known in HMO argot as "downcoding," or paying for the diagnosis -- say, indigestion -- rather than the medical tests to reach that conclusion -- say, tests for a heart attack.
A patients' bill of rights, which is lingering in Congress, would make this practice illegal; insurance company executives insisted that it was more often the result of poor billing practices by hospitals than anything sinister on their part.
Uninsured patients have little choice but to get even the …