Nowhere Else to Go: Why California’s Emergency Rooms Are Filled with Insured Patients

A new survey finds that nearly half of recent emergency department patients feel their problems could have been handled by a physician’s office visit, had one been available, according to an issue brief published today by the California HealthCare Foundation (CHCF).

The report, Overuse of Emergency Departments Among Insured Californians, reveals that California’s emergency departments (EDs) are increasingly being used by insured patients whose health conditions are not true emergencies. These patients generally believe that they have no alternatives for treatment and diagnosis when faced with a sudden illness or accident, the study found.

As hospital emergency rooms in California continue to close, this study takes a close look at the factors that drive ED use in the state.

“The survey results validate that for many patients there are few viable alternatives to the ED,” said Maribeth Shannon, director of the Hospitals and Nursing Homes Program at CHCF. “If more physicians developed the capacity for same-day appointments or after-hours care, and communicated better with their patients about urgent care options, it could substantially reduce ED visits.”

CHCF commissioned Harris Interactive® to conduct two sets of surveys, one of ED patients and one of primary care physicians and ED physicians. The patient survey found four primary factors that drive increased ED use by insured patients who are not critically ill:

  • Lack of access to medical care outside the ED (e.g., same-day appointments with a primary care physician, or evening and weekend appointments);
  • Lack of advice on how to handle sudden medical problems;
  • Lack of alternatives to the ED (e.g., nurse advice lines or urgent care clinics); and
  • Positive attitudes about the ED as a site of care.

Medi-Cal Patients Face Increased Barriers

Publicly insured Medi-Cal patients were more than twice as likely as those with private insurance to have used ED services in the past year. Medi-Cal patients were less likely to have a regular doctor and more likely to use a clinic or ED for their health care, according to the report. They were more likely to report difficulty in accessing routine and preventive care. (An earlier CHCF study documented that nearly half of all physicians in California’s urban counties refused to take Medi-Cal patients, and even fewer were willing to accept new Medi-Cal patients into their practices.)

Medi-Cal patients also were more likely than those with private insurance to believe that, compared to a doctor’s office, the ED provides a higher quality of care, and more likely to report that the ED is the first place they would turn with a medical problem.

“This implies that Medi-Cal recipients perceive the quality of care available in the ED to be superior to that available to them in the community,” said Shannon.

Use Driven by Patients with Chronic Illnesses

Chronically ill patients also had disproportionately greater ED visits. In fact, the survey found that 44 percent of recent ED users reported having one or more chronic conditions. Chronic disease patients have greater needs for care, but apparently have few alternatives for medical needs that occur at night or during the weekend.

More than one in three chronically ill patients said their doctors encouraged them to contact their office before going to the emergency department. But more than half said they had difficulty reaching their physician outside of business hours. More than half of chronically ill patients reported that their ED visits resulted in the need for prescription medications.

“Greater ED use by the chronically ill raises concerns about the continuity and quality of care these patients receive, and it underscores the need for better ongoing management of their conditions, including monitoring of medications,” said Shannon.

Improving Communication and Education

The surveys pointed to the need for better communication between physicians and patients. While 76 percent of primary care physicians reported encouraging patients to contact them before going to the ED, only 35 percent of Californians confirmed that their doctor had done this.

Similarly, most primary care physicians said they were able to accommodate all or almost of their patients requesting a same-day appointment, while more than half of Californians reported being unable to get a same-day appointment the last time they were sick or needed immediate care.

The surveys also indicate that enhanced patient education about proper ED use might help change misconceptions about this specialized care setting. Recent ED users were more likely than other Californians to associate the ED with easy access to diagnostic testing, higher quality of care, access to specialists, convenience, and affordability, in spite of overcrowding and overstretched ED resources that may have a negative impact on quality of care.

Recommended Changes

To ensure more appropriate – and reduced – use of EDs, the issue brief recommends strategies focusing on access and alternatives to EDs. It suggests improving communications between doctors and patients, as well as revamping ED processes to care for patients more efficiently, and making improvements in chronic disease care.

Survey Methodology

The consumer survey was conducted within the United States by Harris Interactive on behalf of the California HealthCare Foundation among 1,402 adults (aged 18 and over) living in California. Interviews were conducted by telephone between February 23 and March 19, 2006. The physician surveys were conducted by mail with 107 emergency medicine and 400 primary care physicians between March 3 and June 29, 2006. The issue brief, as well as a more detailed discussion of the survey methodology are available through the link below.

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About the California Health Care Foundation

The California Health Care Foundation is dedicated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford.