Ers Still Playing Big Role in Care of Health
The Commercial Appeal Memphis, TN
Jennifer Steinhauer The New York Times News Service

October 25, 2000

Of the many goals of the managed-care revolution, few had as much resonance as the push to get people out of the nation's emergency rooms.

With health maintenance organizations, everyone was supposed to have a primary care doctor who would manage the aches and pains. Preventive care would stave off emergencies like acute asthma attacks, and better use of family doctors would help make emergency room business dwindle.

It has not worked that way. Visits to emergency rooms grew about 3 percent a year from 1997 to 1999 and have risen 6 to 8 percent in the last year, said the leading emergency doctors' group. That trend is expected to continue.

The reasons are similar to those behind other health-care problems: the lack of access to primary care doctors among the poorest Americans and a rising number of Americans in the last decade who are without insurance, often because of higher medical costs. In addition, there are those who find the emergency room quicker and more convenient.

The promises of primary care have been dashed largely, health- care policy experts say, because insurance reimbursements for primary care doctors are so low that too few are willing to be in the field or to extend themselves to late hours or weekends when emergency care is required.

In many areas of the country, especially in cities because of large numbers of uninsured people, emergency rooms are being crushed under the increased volume and patient care often is compromised, doctors insisted.

But in regions where hospitals still compete for business, like New York City, and in areas with many insured residents, emergency rooms are learning to accept and even welcome the increased patient load. Hospitals are making emergency rooms feel a bit like a private doctor's office where waits are short, coffee is pouring and the first question a patient hears is about their condition rather than their payment method.

"Five years ago there was all this talk about inappropriate uses of the ER," said Dr. Dan Wiener, the chairman of emergency medicine at St. Luke's-Roosevelt Hospital in Manhattan. "All we were focused on was how to get them out. Now we are looking at how to give these patients better service."

The emergency department is is the entree for large numbers of patients for most hospitals. Further, a hospital routinely earns more from an emergency room visit than one to a clinic.

But doctors and hospital executives said that insurance companies have gradually lowered payments for visits to emergency rooms, often resorting to what is known in HMO argot as "downcoding," or paying for the diagnosis - say, indigestion - rather than the medical tests to reach that conclusion - say, tests for a heart attack.

A patients' bill of rights, which is lingering in Congress, would make this practice illegal; insurance company executives insisted that it was more often the result of poor billing practices by hospitals than anything sinister on their part.
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