The Impact of Non-Urgent Care on Florida Emergency Rooms

One of the biggest problems in healthcare today is the overuse of emergency departments for non-urgent care. Below is a detailed discussion of this important topic with an emphasis on what's happening in Florida emergency rooms.

The Scope of the Problem

About one-third of all Americans go to the emergency room when they need medical care, even when their medical need isn't an emergency. This statistic comes from a survey conducted in 2016 by three well-respected partners: National Public Radio (NPR), the Harvard T.H. Chan School of Public Health, and the Robert Wood Johnson Foundation.

A comprehensive compilation of older data, going back almost three decades to 1990, shows a similar trend. This report was published in 2014 in the American Journal of Managed Care (AJMC). It shows, on average, 37 percent of all emergency department visits were deemed non-urgent either before or after the initial examination. Many scholars have cited the report, entitled “Deciding to Visit the Emergency Department for Non-Urgent Conditions: A Systematic Review of the Literature.” The writer reviewed a total of 63 full-length published studies, as well as almost 2,000 research abstracts.

The state of Florida is in line with the national average of non-urgent visits to emergency rooms. Abe Aboraya, a health news reporter in Orlando, Florida, ran a story on non-urgent care in Florida emergency rooms with an NPR affiliate (WMFE). For this story, Mr. Aboraya interviewed Professor Robert Blendon from Harvard. Blendon reported that almost one-third of all Floridians had used an emergency room for non-urgent health care needs in the past two years. The story ran nationally on NPR's All Things Considered program, and the audio is available in their archives.

What Do Emergency Room Doctors Think About the Problem?

Dr. Eric Forsthoefel, an emergency physician at Tallahassee Memorial Hospital, has witnessed hundreds of non-urgent cases at the Bixler Trauma & Emergency Center. In a recent interview, Dr. Forsthoefel explained why this is such a problem. “Because of a chronic lack of access to primary care medicine many patients turn to the Emergency Department for help. Of course, no matter how emergent the issue we still make it our duty to provide paramount care for every patient. Each patient that comes in the emergency department will be tended to by nurses, techs, a physician, other support staff, and will also require a bed. However, the increasing volume of non-urgent patient visits stretches our resources and makes it a substantial challenge to manage critically emergent medical crises that require immediate attention and constant monitoring. It makes it very challenging for the entire staff.”

Dr. Forsthoefel stated “Emergency departments and staff are working harder and harder to remain efficient while providing the best care possible regardless of acuity. We understand that many people have various barriers of access to healthcare. However, time and resources that are intended to be used in acute and emergent situations are increasingly being diverted to chronic and non-emergent conditions making emergency departments in our communities less efficient and less effective. It’s very difficult to maintain patient flow. The situation is becoming critical.” Many other emergency doctors in Florida and across the United States express similar concerns regarding the impact of non-urgent cases on emergency departments. It's an ongoing problem that is increasing in frequency.

Why Do People Go To the Emergency Room For Non-Urgent Care?

Dr. Forsthoefel's assessment corresponds with published studies regarding patients seeking non-urgent care in emergency departments. One of the most-cited studies was published in the Annals of Emergency Medicine in 1991. 335 randomly selected patients with minor illnesses waiting in the George Washington University Hospital emergency room were asked to take a survey regarding their purpose for coming to the emergency room.

The George Washington University study included a diverse sampling of people from affluent to low-income. It also included patients with and without insurance. Most of the highly educated, high-income earners were there because they thought it would take too long to get an appointment with their primary care provider. Most primary care physicians schedule about 24 hours out, and they wanted to address the problem quicker. Lower-income patients liked the overall convenience of the emergency department or didn’t have an established relationship with a primary care provider.

Other studies indicate that younger patients are more likely to seek medical care from an emergency room for a non-urgent issue. In many of the studies, the ethnicity of patients does not emerge as a significant factor. However, according to a study by the University of Florida’s Bureau of Economic and Business Research (BEBR), African American Floridians are more likely to seek emergency room care for non-urgent medical issues than Caucasian Floridians, even though African Americans are less likely to seek medical care overall.

Six studies since 1990 have indicated that gender may play a part in a patient’s decision to go to the emergency room for a non-emergency. Two studies suggest that men are more likely to seek non-urgent care from an emergency department, while four other studies suggest the opposite. So, the jury is still out on this one. Marital status seems to have no significant influence. Interestingly, patients who’ve recently stayed the night in a hospital are less likely to go to the emergency room for non-urgent care.

Some Deterrents Come With Too High a Cost For Patients

Some experts have suggested that the copays and deductibles be altered to deter patients from going to the emergency room for a non-urgent issue. While this may sound good in theory, there are major problems that could arise from such a drastic financial shift. It would also disproportionately affect people in low-income brackets.

Further, according to research published in JAMA Internal Medicine (Journal of the American Medical Association), adding copayments to emergency room visits for those with Medicaid acts as a very poor deterrent at best. Researchers examined data from 2001 through 2010 for eight states. Florida, Kentucky, Minnesota, Montana, Ohio, Pennsylvania, South Carolina, and Washington all added copays for ER visits. However, the copay addition didn’t result in a significant difference in the number of non-urgent emergency room visits in any of these states.

Level of Urgency Isn’t Always Obvious

In 2015, the Anthem insurance company (Blue Cross and Blue Shield) stopped paying for non-urgent care provided in Kentucky emergency rooms. They added Georgia and Missouri to this list in 2017 and will likely do the same in other states shortly, including Florida. In fact, they have already put New Hampshire, Indiana, and Ohio on the list. They refer to it as "inappropriate use of ERs for non-emergencies." Anthem is the largest insurance provider in the United States, covering about one in eight insured Americans.

Other insurance companies are expected to follow suit, and private employers have already started to pull funding for non-urgent care in emergency rooms. With these changes, insurance companies hope to save money and increase profits. While Anthem has tweaked this policy due to outcry from both patients and physicians, they still refuse to cover most "non-urgent" care in emergency rooms, even in some cases where there’s potential for a dangerous medical situation to arise.

The American College of Emergency Physicians has been making vocal statements in opposition to this new trend. They explain that it can be difficult to ascertain whether a medical issue is “urgent” before the patient has been examined and evaluated. Moreover, if a patient is worried about having to pay out of pocket for an ER visit, he or she may not seek emergency medical care when something is urgent. Some emergency room doctors have flat-out stated that patients will die due to this new policy. It seems that most emergency room doctors would prefer to err on the side of caution. This type of deterrence policy also makes accurately calculating the statistics on urgent versus non-urgent care in emergency rooms much more difficult.

So, for example, chest pain could be the result of a spicy buffet dinner, or it could be the early signs of an impending heart attack. The only way to know for sure is to get it checked out immediately by a physician. Here's another example. Deep pain in the calf could just be a cramp from shopping too much that day, or it could be a potentially life-threatening deep vein thrombosis (blood clot) that could break off and get lodged in the lungs if left untreated. While emergency departments should look for safe ways to reduce non-urgent care in emergency rooms, it's also important to be extremely cautious about how they achieve this. Making sure that patients are still able to access emergency medical care is crucial.

Medicaid is a Special Case

According to an article in the Washington Post, low-income individuals insured by Medicaid are three times more likely to use emergency rooms for non-urgent care as those covered by private insurance. Furthermore, they’re about twice as likely to seek non-urgent medical attention in emergency rooms as those individuals who lack insurance. This includes treatment for non-acute medical ailments like chronic asthma flare-ups, the common flu, various types of infections such as a UTI, and routine type 2 diabetes testing.

There are many potential reasons for these numbers, including that a lack of reliable transportation or access to a primary care physician. Medicaid patients as a whole also tend to suffer from more ailments. It's difficult for some patients covered with Medicaid to find a primary care physician willing to take them on as a patient. In these cases, if the Medicaid recipient goes to a primary care provider, he or she may end up having to pay out of pocket, sometimes without the ability to do so. Therefore, in many cases, especially for those who live in non-urban areas, the easiest and cheapest way to deal with a medical concern is by going to the local hospital's emergency room. In some cases, even though Medicaid patients don’t pay copayments to see their primary care physicians, they may have a copay for any specialists to which their doctors refer them. So a Medicaid patient may go to a hospital emergency room to get all the specialized services he or she needs without having to pay anything out of pocket.

Believe it or not, in some states, emergency departments advertise their services, such as short wait times, to lure in Medicaid patients for non-urgent care. Sometimes they even erect large-scale highway billboard advertisements. Such is the case with the HCA chain of hospitals in Florida. The Centers for Disease Control and Prevention (CDC) reported a 31 percent increase in emergency room visits between 1997 and 2008. This type of profit-seeking emergency room advertising may be a large contributing factor. Again, profit-driven entities are not the best advocates for deciding how to reduce non-urgent care seekers in emergency rooms.

Which Solutions Show the Most Promise?

Emergency department doctors like Dr. Forsthoefel seem to have their fingers on the pulse of possible solutions because the data tends to back up their propositions. In 2005, a Harris Interactive survey asked ER doctors to give their opinions about the top reasons people utilize emergency rooms for non-urgent care. They said that waiting times for appointments with primary care physicians was a huge factor for many, as well as the fact that most primary care physicians aren’t open on the weekends. Many emergency room physicians feel that primary care doctors would help ease the burden on emergency rooms by providing evening hours.

Researchers have taken a multidisciplinary approach to study this issue. Experts can use the data they’ve collected to determine the most effective strategy for reducing non-urgent cases in Florida emergency rooms. Although certain misconceptions could lead to a rise in effective solutions, most of the studies have utilized large sample sizes and compiled data from multiple trusted sources. One misconception is that the patients who show up in ERs for non-urgent issues are largely uninsured. However, the truth is that about 80 percent of non-urgent cases in Florida emergency rooms involve patients who are insured. A majority of these patients are, as previously stated, insured by Medicaid. In fact, according to a survey of data from 1950 to 2008 by the American Medical Association, uninsured patients are far more likely to avoid emergency room visits because they don’t want to rack up high medical bills.

Carefully compiled data has made it possible to predict which types of solutions might be most effective in reducing non-urgent care visits to emergency rooms. Making primary care and other alternatives to emergency medical care more convenient has emerged as the best solution to reducing non-urgent care in emergency rooms going forward.