why and how can people abuse the ER?

brainkandy87 · Feb 12, 2012

Meh, I'm a liberal and a universal health care proponent. I don't mind people "abusing" the ER at all. I think humanity has evolved to the point where health care is no longer a privilege, but a basic human right. I think if we followed the trend of nearly every other industrialized nation and had a universal health care system, we wouldn't have as many people coming to the ER for silly reasons. Everyone could have a primary care provider. They wouldn't need to use the ER as their clinic.

Editorial Team / Moderator · Feb 12, 2012

Everyone could have a primary care provider. They wouldn't need to use the ER as their clinic.

In military health, every does have a primary care provider. They still come to the ER because a) they haven't bothered to call their primary care manager (PCM) (and this is where I educate!), or b) they can't get an appointment (this is the more prevalent reason). There simply isn't enough PCM time to go around.

During day shift, family practice/internal medicine and peds will let us know how many appointment slots they have open that day, and if we have patients suitable for referral, our doc will review the chart after triage and we'll send the patient to their PCM for an appointment. While this is a drop in the bucket in our high-volume ER (we do this with maybe 6 patients a day out of our 110+ average daily census), but every little bit helps to ease the strain on our already overstretched resources. To give you an idea of how overstretched ... last Monday we saw a total of 130 patients in a 24 hour period, and only 6 left without being seen. We have 11 beds in the core ER (staffed 24x7, of course) and 4 beds in our fast track (staffed 15 hours daily). Crazy numbers for that amount of beds, I know.

Altra, BSN, RN · Feb 12, 2012

I completely agree with Lunah ... PCPs for everyone would not even come close to eliminating ER abuse. We see plenty of insured folks with long-standing relationships with their PCPs. They include the mothers of young children with earaches who call their pediatrician, but are unable/unwilling to take the appointment times offered "because they weren't convenient", those in need of a "free" pregnancy test or OTC pain relief for an owie, those who wish to drop off Grandma for a 6-hour head to toe workup for "altered mental status" or "frequent falls" or "poor oral intake" ... and the weekly spurt of Friday-Saturday night STD checks between 7 - 10pm. (I could offer my and my coworkers theory on that last one, but I'm pretty sure it would be considered insensitive).

So brainkandy87, I'm a fellow single-payer health care proponent (but not a liberal one ) ... but the ER will be the ER, so long as EMTALA prevails.

psu_213, BSN, RN · Feb 12, 2012

We recently encountered at situation where a 20-something called her doctor saying that her grandmother, in LTC, was "very sick" and needed to be sent to the ER (mind you, the facility said the granddaughter had not visited in months). Rather than the MD reassuring the granddaughter and visiting/examining the pt, the MD called the faciliity and told her to sent the pt to the ER. As it turns out, the granddaughter thought that the facility was providing substandard care to the grandmother, and wanted the ER to admit her to the hospital while they shopped for home helath services to care for the grandmother at home. So, the MD totally dropped the ball on his responsibilities, but, also, all of us paid for the ambulace trip and the ED visit. Part of ED abuse is PCPs who pawn off the work of examining the pt by telling them to come in the ER...some of the doc's at our hospital do it all time.

brainkandy87 · Feb 13, 2012

I completely agree with Lunah ... PCPs for everyone would not even come close to eliminating ER abuse. We see plenty of insured folks with long-standing relationships with their PCPs. They include the mothers of young children with earaches who call their pediatrician, but are unable/unwilling to take the appointment times offered "because they weren't convenient", those in need of a "free" pregnancy test or OTC pain relief for an owie, those who wish to drop off Grandma for a 6-hour head to toe workup for "altered mental status" or "frequent falls" or "poor oral intake" ... and the weekly spurt of Friday-Saturday night STD checks between 7 - 10pm. (I could offer my and my coworkers theory on that last one, but I'm pretty sure it would be considered insensitive).
So brainkandy87, I'm a fellow single-payer health care proponent (but not a liberal one ) ... but the ER will be the ER, so long as EMTALA prevails.

I just worked twelve hours and am far too tired to get into a health care debate, but I will restate what I originally said: we wouldn't have as many people coming to the ER for silly reasons. I am in no way saying it would eliminate it. People are stupid and people will always use the ER for stupid reasons. However, there would be far fewer people using the ER as their primary care provider. Why do uninsured people come to the ER? Because they know they won't have to pay for treatment.

GM2RN · Feb 15, 2012

I just worked twelve hours and am far too tired to get into a health care debate, but I will restate what I originally said: we wouldn't have as many people coming to the ER for silly reasons. I am in no way saying it would eliminate it. People are stupid and people will always use the ER for stupid reasons. However, there would be far fewer people using the ER as their primary care provider. Why do uninsured people come to the ER? Because they know they won't have to pay for treatment.

I think your assessment of how many people would change their habits is underestimated and would go unnoticed by most facilities. People will not change their desire for the instant gratification of having a diagnosis "now" rather than wait to see their PCP, even if they have insurance.

TheSquire, DNP, APRN, NP · Feb 15, 2012

I think your assessment of how many people would change their habits is underestimated and would go unnoticed by most facilities. People will not change their desire for the instant gratification of having a diagnosis "now" rather than wait to see their PCP, even if they have insurance.

Having done a review of the literature on this topic once upon a time, I can say that it's not just in the water in the US, it's everywhere - nonemergent/nonurgent use of the ED is an international issue.

My prior statement stands - inappropriate usage of the ED is a universal phenomenon not limited to the US. brainkandy87's logic doesn't hold up to facts.

GM2RN · Feb 15, 2012

My prior statement stands - inappropriate usage of the ED is a universal phenomenon not limited to the US. brainkandy87's logic doesn't hold up to facts.

I was rushed to make my previous post and meant to say overestimated not underestimated. Maybe that confused you? If not, I don't get why you quoted my post since I am essentially agreeing with you.

Anna Flaxis, BSN, RN · Feb 17, 2012

I think a PCP for everyone *would* make a big dent, provided that said PCPs would/could make appointments on short notice. When you're having abdominal pain and can't get in to see your PCP for three weeks, it just makes sense to go to the ED. Part of the problem is lack of health insurance to help cover the costs of primary care, and another part of the problem is a shortage of primary care providers. Why is that? Because medical school is so expensive, and primary care is less lucrative, so not as many people with the aptitude for medicine enter medical school, and of those that do, a large number specialize. I think what we need, in addition to universal health care, is an affordable medical education program. I would go to med school in a heartbeat if it were affordable, instead of being so outlandishly expensive that it would bankrupt me.

VICEDRN, BSN, RN · Feb 17, 2012

Will add if no one else has...

pts with medicaid/medicare cards make no co-pay and have no consequences for seeing the ER doctor instead of the primary care MD that the government has optimistically assigned them to. I can not tell you how many times I have heard a variation of: "this is quicker and i have no co-pay either way." or "the er doctor gives me more pain pills than the primary care doc when I am sick." or "this is open 24-7 and i don't like the appointment times in the primary care md's office." etc, etc.

i have met pregnant patients that didn't know a pregnancy could be diagnosed anywhere BUT the ER because where they live everyone has medicare/medicaid and everyone can go to the ER!

VICEDRN, BSN, RN · Feb 17, 2012

Would like to point out that brainkandy is right: in the U.K., there is no EMTALA and you have no "right" to be seen in the ER. In fact, people are routinely turned away when wait times develop. When a universal system exists, we do not need to protect someone's right to basic care, it becomes a given.

psu_213, BSN, RN · Feb 18, 2012

Yesterday I had yet another pt from the 'go the ER rather than the PCP' culture. She said "this pain has been going on for years and worse over the last few months. I really hate coming to emergency, but I had to come since I really need something for this pain." (As a side note, it was chronic sciatica pain.) The was nothing we were going to do other than give her an Rx for pain meds. Something needs to happen to stop this waste of time, money, and resources.

My ideas: 1. More PCPs. More incentives (namely, financial incetives) for doctors to become PCPs.

2. Require people to have a PCP.

3. Increased copays to go to the ER (if not admitted). Co pay is higher for ER visits if a pt does not call their PCP first before coming to the ER. Lower copay if they call their PCP first and the PCP tells them to go the ER.

4. Incentives for PCPs to see pts rather than just send them to the ER because it's easier. Tort reform will also help here. Maybe even a 'penalty' (lower reimbursement?) for PCPs that sent their pts in rather than treating the pt themselves. This one maybe difficulty to patrol/enforce/justify, but if silly ER visits are going to decrease, PCPs have to be on board too.

If we are going to have universal healthcare, then we need cannont just indiscriminately throw money at the problem. There needs to be real health care reform. The goal is to improve the overall health of individuals, and only increased, regular contact with a doctor who knows the pt is going to improve the pt's health....no increased access to the ER.