Correspondence
Costs of Visits to Emergency Departments
N Engl J Med 1996; 335:209-211July 18, 1996
- Article
To the Editor:
Although Williams's study of the costs of visits to emergency departments (March 7 issue)1 appears to be generally well designed, I believe its whole premise is penny-wise and pound-foolish. When performed in many millions of patients, even relatively low-cost procedures result in large overall expenditures. Limiting any care that may be less than completely necessary, however inexpensive, is a worthy goal in this era of expanding costs and shrinking resources.
The lack of access in certain areas to any care other than that provided by the emergency department is an argument for improving access, not for providing nonurgent care in emergency departments, whatever the cost. Discouraging the use of hospital emergency departments for nonurgent care and making alternatives available might promote the use of regular physicians' services, which in turn might prevent not only nonurgent visits to the emergency department but also some urgent visits. A payment system that is fair to all might go a long way toward making this approach a reality. It would be worth the time and effort to identify incentives that will bring doctors to the inner cities and to persuade patients to obtain care in settings other than the emergency department.
1 ReferencesCarolyn L. Baier, M.D.
9406 Bulls Run Pky., Bethesda, MD 208171
Williams RM . The costs of visits to emergency departments. N Engl J Med 1996;334:642-646
Full Text | Web of Science | Medline
To the Editor:
Marginal costs alone underestimate the true cost of emergency care, as compared with the potential savings associated with the use of primary care. Misinterpretation of Williams's findings may lead to the false claim that expanded access to community-oriented primary care is unnecessary since emergency visits appear to be so inexpensive. A complete and accurate cost analysis has to include the costs of failure to prevent, when possible, the development of disease, acute exacerbations of disease, and sequelae, as well as the costs of unscheduled outpatient visits, hospitalizations, all encounters, and days lost from work or school.
For example, patients with asthma often report a history of frequent visits to the emergency department. Establishing an ongoing relationship with a primary care provider allows for evaluation of the patient, education, and long-term management. In this example, primary care includes teaching the patient to avoid or control the triggers of asthma attacks; preventive care, including influenza and pneumococcal immunizations; long-term management with antiinflammatory agents; peak-flow monitoring at home; self-adjusted stepped treatment; and management by telephone. Such an approach reduces the total cost of care.1-4
4 ReferencesSteven B. Auerbach, M.D., M.P.H.
U.S. Public Health Service, New York, NY 10278Karen A. Becker, M.D., M.P.H.
West Farms Family Practice, Montefiore Ambulatory Care Network, Bronx, NY 104601
O'Brien KP . Managed care and the treatment of asthma. J Asthma 1995;32:325-334
CrossRef | Web of Science | Medline2
Taitel MS ,Kotses H ,Bernstein IL ,Bernstein DI ,Creer TL . A self-management program for adult asthma. II. Cost-benefit analysis. J Allergy Clin Immunol 1995;95:672-676
CrossRef | Web of Science | Medline3
Trautner C ,Richter B ,Berger M . Cost-effectiveness of a structured treatment and teaching programme on asthma. Eur Respir J 1993;6:1485-1491
Web of Science | Medline4
Sullivan SD ,Weiss KB . Assessing cost-effectiveness in asthma care: building an economic model to study the impact of alternative intervention strategies. Allergy 1993;48:Suppl:146-152
CrossRef | Web of Science | Medline
To the Editor:
Williams reports a marginal cost of $24.40 for nonurgent visits and concludes that visits to hospital emergency departments are much less costly than previously believed. By counting only marginal costs and assuming they contribute nothing to fixed costs (operationally defined by the author as those that do not vary from month to month), one could similarly conclude the emergency departments are efficient providers of services to any subgroup — say, for example, left-handed patients. Williams would have us believe that a 15 percent reduction in the total volume of emergency department visits, achieved by decreasing the number of nonurgent visits, as described by Selby et al. in the same issue,1 would have no effect on fixed costs, such as the space assigned to emergency departments, routine staffing levels, or the number of emergency departments needed in a community.
1 ReferencesNorman Hearst, M.D., M.P.H.
University of California, San Francisco, School of Medicine, San Francisco, CA 941431
Selby JV ,Fireman BH ,Swain BE . Effect of a copayment on use of the emergency department in a health maintenance organization. N Engl J Med 1996;334:635-641
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To the Editor:
I believe readers of the Journal should have been made aware that Williams received financial support from three emergency-physician staffing companies — Emergency Consultants, EMSA Limited Partnership, and Coastal Emergency Services — as he acknowledged in his University of Michigan doctoral dissertation on the costs of emergency department services. In addition, he acknowledged the contribution of Physicians Billing for “invaluable assistance in the collection of data for this project.”1 Williams's sophisticated analysis included many assumptions and complicated manipulations of data, and biases may have influenced the results. I believe the financial grants are pertinent, as is Williams's former position as president of the American College of Emergency Physicians and that organization's use of the study published in the Journal as part of its current lobbying activities.
1 ReferencesCharles Lucey, M.D., J.D., M.P.H.
Unisys Government Systems Group, Baton Rouge, LA 70809Author/Editor Response
Dr. Williams replies:
To the Editor: Hearst is incorrect in assuming that my conclusions about the relatively low costs of nonurgent emergency department care were based solely on the $24 marginal cost of a nonurgent visit. I reported an average cost of $62 for a nonurgent visit, which is roughly similar to the cost of a visit to a private physician's office.
I agree with Auerbach and Becker that care in the emergency department is not an ideal substitute for ongoing care by a primary care physician. As shown in a recent study, however, Americans who rely on the emergency department for virtually all their medical care may not have access to primary care.1 It could be argued that for patients who lack access to a primary care provider, visits to the emergency department during the early stages of a disease may be cost effective if they prevent the progression of the illness and subsequent hospitalization.
Baier raises an important policy issue. Clearly, there are inequities in the financing of emergency services. Hospitals are required by law to evaluate every patient seeking care.2 The costs of uncompensated care are passed along, through higher charges, to patients who have the means to pay for their care, making it more difficult for hospitals to compete in the medical marketplace on the basis of price. Excess charges may amount to $7 billion per year, prompting managed-care plans and state Medicaid programs to implement strategies to discourage the use of the emergency department.3,4
It is unfair for patients to pay twice the actual costs of the services received, and it seems prudent and reasonable to prevent these high costs by discouraging the use of the emergency department — for example, through copayments and deductibles. Yet, from the vantage point of the health care delivery system, the diversion of insured patients away from emergency departments compounds the financing problem by reducing the pool of patients who can pay for their care and may lead to the closure of many emergency departments. Without an adequate and equitable financing mechanism, many Americans could be left without access to emergency services.
In response to Lucey, as I acknowledged in my doctoral dissertation but not in my report in the Journal, three organizations provided grants that supported the research. The funds were donated directly to the University of Michigan and were used for computer equipment, software, and supplies. I received no compensation from these grants. None of the organizations that provided grants participated in the study design or analysis of the data. As I state in my report, the hospital-selection process is described in NAPS document 05283 (available from Microfiche Publications, P.O. Box 3513, Grand Central Station, New York, NY 10163).
Physicians Billing, which I did not identify by name in the article, provided assistance only in the collection of data on physicians' billing and made no financial contribution to the research. The fact that all six hospitals used the same billing company was acknowledged in the article as a limitation of the study.
My term of office as president of the American College of Emergency Physicians ended before the initiation of this research.
4 ReferencesRobert M. Williams, M.D., Dr.P.H.
University of Michigan School of Public Health, Ann Arbor, MI 48109-20291
The Medicaid Access Study Group
Full Text | Web of Science | Medline2
Emergency Medical Treatment and Active Labor Act, P.L. 99-272, 42 U.S.C. sec 1395 DD (1985) (renamed in 1989).
3
Baker LC ,Baker LS . Excess cost of emergency department visits for nonurgent care. Health Aff (Millwood) 1994;13:162-171
CrossRef | Web of Science | Medline4
Winslow R. Emergency-room visits fall as HMOs target overuse. Wall Street Journal. March 7, 1996:B2.
