Emergency rooms are responsible for nearly half of all hospital admissions in the U.S., and that number continues to rise. In areas with a large uninsured population, like South L.A., an examination by an E.R. doctor can be the only health care they receive.
A recent report from the RAND Corporation found that between 2003 and 2009, emergency department admissions grew about 17 percent.
Dr. Sean Henderson, the chair of the Department of Emergency Medicine at the Keck School of Medicine of USC, explained that he's legally required to treat anyone who requests treatment, regardless of the severity of someone's condition.
"If you come in and ask for my care, that's the mandate," he said. "I don't have a choice there, and I don't want a choice. That's what I'm here for. The rule is if you think it's an emergency, I think it's an emergency, and we'll take care of it together."
Dr. Felix Aguilar, the president and CEO of UMMA Community Clinic in South Los Angeles, says that's true, explaining that a lot of area patients are forced to go to the E.R. for conditions that earlier intervention by a primary care doctor could have prevented. But, he added, so many in South L.A. are uninsured that this kind of E.R. usage is inevitable.
"If they don't have regular coverage and a regular medical home, they're more likely to end up in situations like that," said Aguilar. "They're more likely to end up in the E.R. for acute care visits."
Henderson added that folks who are undocumented, have no insurance or don't have enough coverage are the ones who often end up in the E.R.
"They'll come to us for preventive care, but they'll wait until their disease has progressed to a point to where it's more complicated than it was when they got it three months ago," he said.
Redirecting primary care patients
RAND found that the growth in E.R. admissions accounted for "nearly all" of the growth in overall hospital admissions over the years, easily offsetting a 10-percent decrease in admissions via outpatient settings, like clinics or doctors' offices.
Researchers wrote that this suggests that primary care doctors and other "office-based physicians" are directing patients to emergency departments to have the doctors there decide whether or not to hospitalize someone.
Dr. Henderson, who's also the chief of emergency services at L.A. County + USC Medical Center, agreed with that analysis.
"They're sending [patients] to the E.R. first to have us serve as a gatekeeper," he said. "We sort through the patients they send us and then we're the decision-maker for deciding whether or not the patient has to go to the hospital."
Henderson noted that the E.R. is better able to carry out "more complex diagnostics and workups" than the office of a primary care provider. The doctors there also aren't under the same kind of time-crunch that primary care doctors are. And, while Dr. Aguilar notes that there's "quite a bit of cost associated with going to the emergency room" – which varies case by case – Dr. Henderson says going to the E.R. is "always cheaper" than getting admitted to the hospital.
"I'm already there," said Henderson. "I'm a paid-for cost. Whether or not I have a patient, the emergency department is already staffed and set up. If you don't come in, that's fine, but I'm still getting paid."
Henderson explained that E.R. doctors can give patients more advanced care than they'd receive at their primary care doctor's office.
"I wouldn't necessarily admit you [to the hospital]," he said. "I'd be able to give you an IV; I'd put you in observation for 12 to 18 hours and make sure you get better."
While that sort of care isn't cheap, he said, at the end of the day, it's much less expensive than a hospital bed.
Is this sustainable?
The RAND study found that E.R.s "may be playing a constructive role" in reducing hospital admissions and, thus, overall medical costs. But Henderson said the current model still isn't sustainable. Then again, he added, neither is the Affordable Care Act.
"A lot of my patients won't receive the benefits of President Obama's plan because they're not documented," he said, which means many of them will keep going to the E.R.
That's part of the reason why it's not an option to simply stop the current model, said Dr. Aguilar.
"We have to try and coordinate care better if we're really going to tackle this problem," he said. "It's not an option to say 'Don't send them to the E.R.' or 'Don't go to the E.R.'"
Coordinating care means emergency and primary care doctors need to be able to get notes from each other; they need to be able to see what treatments and tests the other carried out and what diagnoses were made. Aguilar noted that could be another cost-saver: Better coordinated care would mean fewer duplicate tests, which are pricey.
"Many times in our clinic, we see patients that show up saying they went to the E.R.," he said. But when asked what treatment they received, their response is usually: "I don't know."
In the meantime, said Henderson, emergency doctors can still try to keep costs down by preventing hospital admissions and "trying to be judicious with testing." They can also "participate in the preventive care of patients" when they're in the E.R.: screen them for obesity, for example, or gauge their smoking habits.
But, Henderson said, until there's a widespread commitment to seeing a doctor regularly for preventive care, people will still use the E.R. in situations where they could just as well be seen in a regular doctor's office.
The reason? "It's just easier in the E.R.," said Henderson. He notes many people work and don't have the flexibility of scheduling their work day around a doctor's appointment. He contends that would be the case, even if everybody had access to affordable health insurance.
But for now, according to RAND, that doesn't appear to be the case.
Researchers found that most emergency patients don't use the E.R. for the sake of convenience, but rather because they don't see any other options or because they were sent there. What that means, they say, is that it's best to concentrate efforts on expanding timely access to primary care.