New answers on ER and the poor

Health-policy wonks have long known that the poorest patients tend to use local emergency rooms the most. It has been thought that limited knowledge of the health system was he primary reason.

But a new study out of the University of Pennsylvania shows that poor patients prefer local emergency rooms because they find the care cheaper, of better quality, and much easier to reach than primary-care providers.

"They were the ones educating us, very eloquently and in a very educated manner, what the incentives are and how we've structured the health-care system away from low-cost preventive care and toward high-cost emergency-room care," said lead author Shreya Kangovi, director of the Penn Center for Community Health Workers and a Robert Wood Johnson Foundation clinical scholar at the Philadelphia Veterans Affairs Medical Center.

The study, published in the July issue of the journal Health Affairs, relied on interviews with 40 Philadelphia residents who were either uninsured or on Medicaid. Respondents overwhelmingly said that arranging primary care was difficult and costly. And often, their doctors would end up directing them to an ER.

"Since they always say [go to the ER] anyway, I just go straight to the ER and don't even bother calling" the primary-care clinic, one interviewee said.

Another echoed those concerns, citing a lack of primary-care availability as a reason to go to the ER.

"Sometimes you can't get to a primary. . . . You may only be able to leave a message for a secretary, so if you have an immediate medical issue you better get to the nearest ER," the interviewee said.

This is a problem, the authors wrote, because emergency care for conditions that can be managed through routine primary care not only costs the government $30.8 billion annually but also leads to people becoming sicker.

But not all of the selected patients saw the same obstacles. The study broke out two distinct groups: high utilizers who had at least five acute-care episodes in the last six months, and low utilizers.

High utilizers tended to face much more serious obstacles related to food, housing, family dysfunction, and drub abuse, which made staying healthy without ER care more difficult. Low utilizers, on the other hand, cited lack of insurance, not being able to afford time off work, and caring for sick family and friends as the main barriers.

These findings may hold financial implications for hospitals that are moving to improve care under government incentive programs, the authors wrote.

"I believe in pay for performance, and I think that it's great to improve hospital quality," Kangovi said. "But we have to think about the balance across settings to make sure that we're providing ambulatory- and outpatient-care quality as well. I think we've been underinvesting in our preventive care system for decades and, on the contrary, we've been investing quite a bit in our hospital care system."

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