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March 31, 2006


Hellmut Lotz

From the perspective of an immigrant, one feature that is bizarre about the US health system are the physicians with multiple offices. Some of those offices are closed two or three days a week. If your primary care physician is not reliably available then it makes sense to rely on the emergency room instead.

The reason why US doctors need more offices than physicians in other developed countries is probably the fragmented insurance market. If every physician could bill every potential patient then most health care providers could probably settle for one office.

Moreover, whenever you get hurt you could just walk into the office of the next doctor and know that your insurance would cover you.

In light of a fragmented market organized by exclusive contracts, only emergency rooms are universally and reliably available.

I don't really know if any of this is accurate. But that would be some of the factors that might play a role.


This squares exactly with my experience and our payor mix. I don't think that anybody (that I know of) suggested that the uninsured crisis was the cause of the ED overcrowding crisis. It may be one of many factors, and in some ways an indirect cause, but my understanding was that the primary cause is more due to the closures and consolidation of hospitals resulting in a shortage of inpatient beds and a failure to expand existing EDs. If everybody has insurance, *I* might make more money, but I doubt our ED would suddenly become a ghost town.

At any rate, the frequent flyers, like other disproportionate users of healthcare, account for maybe 10% of the population and 80% of the ED visits. Not really -- but it seems like it. But it's true that for most people, one ED visit a year is uncommon. But we have our clients who come in every other month, two or three times a month, and of course the folks who come weekly or more often. Some are mentally ill (most?), almost all have some chronic health condition, most are disabled and/or unemployed, some are drug addicts/alcoholics. For those with strictly medical aiments, many are on Medicaid and cannot find a clinic that takes medicaid, so the ED is their only avenue of healthcare. And then you have the elderly & nursing home population -- I won't even go there.

I would disagree with only one minor point you made -- the overusers of ED services tend to be Medicaid primarily and Medicare next. There's a small segment of uninsured folks who are frequent flyers: in my experience, most of the uninsured folks are working poor who do not want to come to the ER because they know they can't pay the bill. They have an enormous disincentive to come to us. Medicaid folks have no such disincentive and many tend to treat the ED as a convenience clinic. "Citizens," meaning employed and commercially insured people, are far less likely to come to ther ER, and when they do, the likelihood of serious affliction is far more likely.

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