The study is the first to quantify the problem, according to Dr. Stephen R. Pitts, the lead author and an associate professor of emergency medicine at Emory University. Examining records of acute care visits from 2001 to 2004, the researchers concluded that 28 percent took place in emergency rooms, including almost all of the visits made on weekends and after office hours.
More than half of acute care visits made by patients without health insurance were to emergency rooms, which are required by federal law to screen any patient who arrives there and treat those deemed in serious jeopardy. Not only does that pose a heavy workload and financial burden on hospitals, but it means that basic care is being provided in a needlessly expensive setting, often after long waits and with little access to follow-up treatment.
“More and more patients regard the emergency room as an acceptable or even proper place to go when they get sick,” Dr. Pitts said, “and the reality is that the E.R. is frequently the only option. Too often, patients can’t get the care they need, when they need it, from their family doctor.”
The new federal law is expected to bolster primary care by increasing reimbursement for practitioners, luring students into the field with incentives, expanding community health centers and encouraging new models known as accountable care organizations and patient-centered medical homes.
The authors warn that it might not be enough. “If history is any guide, things might not go as planned,” they wrote. “If primary care lags behind rising demand, patients will seek care elsewhere.”
A separate study in the same issue of Health Affairs illuminates another source of waste in the health care system — medical liability and defensive medicine.
The paper by three Harvard professors and a colleague at the University of Melbourne in Australia estimates that the medical-liability system added $55.6 billion to the cost of American medicine in 2008, equal to 2.4 percent of total health spending.
More than 8 of every 10 of those dollars — $45.6 billion — was attributed to defensive medicine by physicians who order unnecessary tests and procedures to protect themselves from malpractice claims.
While the dollar amount is “not trivial,” the authors noted that the fraction of total health spending “is less than some imaginative estimates put forward in the health reform debate.”
The authors, led by Michelle M. Mello of Harvard’s School of Public Health, estimated the cost of various components of the medical liability system, including payments to malpractice plaintiffs, defensive medicine, administrative costs like legal fees and lost time by clinicians. Rigorous estimates have been scarce in the past, they wrote, while adding that their own calculations “should be interpreted cautiously.”
The new health law did not make substantial changes to the medical liability system, despite Republican calls for restrictions on malpractice claims.
“Reforms that offer the prospect of reducing these costs have modest potential to exert downward pressure on overall health spending,” the study concluded. “Reforms to the health care delivery system, such as alterations to the fee-for-service reimbursement system and the incentives it provides for overuse, probably provide greater opportunities for savings.”