Emergency costs

A recent survey from the Maine Hospital Association shows a steady increase in the use of emergency rooms in Maine, leading to speculation about causes and costs of this change. But while the latest increase – 8 percent between 1998 and 2000 – probably can be attributed to many issues with each making a small contribution, Maine should be leery of trying to hold down costs by limiting access to care in emergency rooms.

MHA reports an additional 42,000 visits in 2000 over ’98, for a total of nearly 600,000 visits in a state with only 1.2 million people. That rate is considerably higher than the nation’s and might be the result of a lack of primary-care doctors, an aging population and a belief that waiting for nonemergency care is no longer acceptable. It may also be as simple as the removal of “prior authorization,” which required patients to check in with their primary-care provider before heading for the emergency room.

Further study on actual admittance rates based on the number of ER visits and the its growing use for patient observation may yield further clues about the increase, as would a look at the ER as a waiting room for hospitals lacking open beds. Understanding these care patterns is important because of the enormous and rapidly in-creasing amount Maine spends on health care each year – now something exceeding $4 billion annually.

Dr. Robert Williams from the University of Michigan School of Public Health was wondering about similar costs in his state seven or eight years ago, so he examined 24,010 visits to six community hospital emergency rooms over 12 randomly selected weeks in 1993. His results were published in the New England Journal of Medicine in 1996, and while his study was limited in several ways it provides areas for Maine to consider in looking at its own numbers.

Dr. Williams was interested in the marginal cost of emergency-room care – that is, given that emergency rooms have to be set up and staffed anyway, how much more does it cost to treat one additional patient, say, one that might be treated in a primary-care office the next day, and he broke the cost down according to urgent, semi-urgent and non-urgent care. The overall marginal cost, he found, was $88; for non-urgent care, however, it was only $24. This suggests that directing non-urgent care away from the emergency room might not save very much, and may result in further cost-shifting as the relative proportion of uninsured grew once the insured non-urgent cases went elsewhere.

Regular preventative care for all Maine residents so that they can avoid the need to get treatment at the emergency room at all is still far preferable. But the mere fact that the number of emergency-room visits is rising may be more a symptom of a problem than a problem itself.