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
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
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
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,
"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
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 most
routine care in emergency rooms, which by law must treat every
patient who shows up. …