Center for Studying Health System Change

Insured Americans Drive Surge in Hospital Emergency Department Visits

Study Counters Perception that Uninsured People are Major Cause of Crowded EDs

News Releases
October 23, 2003

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ASHINGTON, D.C.—Contrary to beliefs that uninsured Americans are a major cause of increased emergency department crowding, insured Americans accounted for most of the 16 percent rise in hospital emergency room visits between 1996-97 and 2000-01, according to a national study released today by the Center for Studying Health System Change (HSC).

"Across the country, emergency departments are crowded and seeing a lot more patients, and most of the increase, surprisingly, is from insured people, not the uninsured," said Paul B. Ginsburg, Ph.D., president of HSC, a nonpartisan policy research organization funded exclusively by The Robert Wood Johnson Foundation.

U.S. hospital emergency department (ED) visits increased to almost 108 million annually in 2000 and 2001, an increase of about 16 percent from 1996-97. Emergency department visits between 1996-97 and 2000-01 increased 24 percent for privately insured people, 10 percent for Medicare beneficiaries, 10 percent for self-pay or no-charge—typically uninsured—patients but were unchanged for Medicaid beneficiaries, according to the study based on data from the Centers for Disease Control and Prevention’s (CDC) National Hospital Ambulatory Medical Care Survey.

Together, privately insured and Medicare beneficiaries accounted for almost two-thirds of the overall increase in ED visits. In contrast, self-pay or no-charge patients accounted for about 11 percent of the increase in ED visits. People with other sources of coverage—worker’s compensation, for example—or unknown coverage accounted for the remaining increase.

For privately insured people, the 24 percent increase in ED visits paralleled an across-the-board increase in ambulatory care use, including a 29 percent increase in physician office visits between 1996-97 and 2000-01, the study found. In contrast, for uninsured people, the 10 percent increase in ED visits was accompanied by a 37 percent decrease in physician office visits, resulting in uninsured people relying on emergency departments for an even greater part of their medical care. One-fourth of all doctor visits by the uninsured now take place in emergency departments, compared with 17 percent in 1996-97.

"Uninsured people clearly are not a major factor in increased crowding at most hospital emergency departments, but uninsured people’s growing reliance on emergency care indicates decreased access to other sources of care, including physician’s offices. Getting medical care outside of the emergency department is definitely becoming more difficult for uninsured people," said HSC Senior Health Researcher Peter Cunningham, Ph.D., who co-authored the study with HSC Research Assistant Jessica May.

The study’s findings are detailed in a new HSC Issue Brief—Insured Americans Drive Surge in Emergency Department Use. In addition to the CDC survey, the study also reports findings from HSC’s Community Tracking Study Household Survey, a nationally representative survey involving about 60,000 people

Other key findings include:

• In 1999-2000, less than half of all emergency department visits—47 percent—were classified as either emergent—requiring care within 15 minutes of arrival—or urgent—requiring care within an hour. This is true for all insurance groups with the exception of Medicare patients—about 57 percent of their visits were emergent or urgent. About 27 percent of all ED visits were classified as semi-urgent or nonurgent, defined as patients requiring care within one to 24 hours of arrival, while the remaining 26 percent of ED visits were of unknown triage.
• Increased emergency department use has resulted in patients waiting longer. The proportion of emergency department patients who waited more than 30 minutes increased from 36 percent in 1999 to 45 percent in 2001.
• Uninsured and Medicaid patients wait longer at hospital EDs than do privately insured people and Medicare beneficiaries, perhaps reflecting differences across insurance groups in the type and severity of health problems presented at the ED. Also, ED visits by uninsured and Medicaid patients are likely to be more concentrated at certain hospitals, such as urban public hospitals, that are especially crowded because they serve a large number of low-income and medically indigent people who rely on emergency departments as their usual source of care.
• Longer emergency department waiting times are associated with dramatically lower patient perceptions of the quality of their care. Among ED patients who waited more than an hour for treatment, only 28 percent rated the thoroughness of their exam as very good or excellent, and only one-third gave a positive assessment of how well the doctor listened to them. In contrast, 66 percent of patients who waited 15 minutes or less gave a positive assessment of the exam and physician. It is unknown whether these large differences in length of waiting time reflect actual differences in clinical quality.

Capacity constraints experienced by office-based physicians, combined with a loosening of managed care restrictions, may be contributing to increases in ED visits. Other HSC research shows that more patients are having problems making timely appointments with their doctors. And, more physicians report having inadequate time with their patients and more are closing their practices to some new patients.

"Emergency departments are open 24 hours a day, seven days a week—no appointment needed. If patients can’t get in to see their doctor, they may view emergency departments as more convenient sources of primary care than their regular physicians," Cunningham said.

Physicians also may be responding to increased workload by referring patients to EDs with greater frequency, and declines in risk contracting and capitation mean they no longer have financial disincentives to do so. In some cases, increased utilization may be associated with physicians practicing defensive medicine by sending potentially risky patients to EDs instead of providing care in their offices.

Gail Shearer, director of health policy analysis, Consumers Union, www.consumer.org
"This study helps dispel the myth that uninsured people contribute disproportionately to increased use of hospital emergency departments. The fact is that insured and uninsured people use emergency departments at about the same rate. At the same time, it’s clear that uninsured people’s access to other sources of care, especially physicians’ offices, is dwindling, making the uninsured more and more reliant on emergency departments for care. A universal health care system would assure that everyone has ready access to affordable health care at the appropriate venue, easing the reliance on emergency departments for nonemergency care."

Carmela Coyle, senior vice president for policy, American Hospital Association, www.aha.org
"This study reflects what we’re hearing from America’s hospitals: our emergency departments are busier than ever. More and more people are turning to the emergency department for care regardless of insurance status. With an aging population and easing managed care restrictions, there’s a greater use of hospital services. On top of that, emergency departments are the only places open 24 hours a day, seven days a week."

J. Brian Hancock, M.D., president, American College of Emergency Physicians, www.acep.org
"While the research may suggest some of the increasing volume is due to insured patients, the uninsured are still a significant factor contributing to the financial instability of the emergency health care system. The demand for emergency medical care is growing among all Americans, and the emergency medical system is struggling to keep up with that demand with dwindling funding and resources."

The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely insights on the nation’s changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is funded exclusively by The Robert Wood Johnson Foundation and is affiliated with Mathematica Policy Research, Inc.