Two new studies indicate potential problems with the movement to divert nonemergency patients from hospital emergency departments.
The reports were published in the March 7 issue of the New England Journal of Medicine.
In the first study, HMO patients who were required to make copayments of $25 to $35 for each visit to the emergency department used emergency services 15% less often than patients who didn't make copayments.
However, some of those patients who decided not to visit the emergency room because of the copayment had diagnoses that were classified as "often an emergency." Some of those diagnoses included head trauma, sickle cell crisis, complications of pregnancy and pelvic inflammatory disease.
The study reviewed data on 300,000 enrollees in Kaiser Permanente's Northern California division in 1992 and 1993.
An accompanying editorial by Robert Steinbrook, M.D., the New England Journal's editor, called the findings of the Kaiser study "troubling." Steinbrook concluded, "By any standard, a substantial proportion of patients with these diagnoses should be evaluated in the emergency department."
The second study found that the actual cost for a nonemergency visit to a hospital emergency room during 1993 was $62, compared with the average cost of $40 to $45 for an initial visit to a physician's office.
Researcher Robert M. Williams said his study indicates that the costs to treat nonemergency patients may not be as high as previous research has found.
"Hospitals can clearly compete with physician offices for the treatment of nonemergency cases," said Williams, who is a past president of the American College of Emergency Physicians and adjunct lecturer at the University of Michigan School of Public Health.
Williams said emergency departments are a cost-effective option to treat patients with nonemergency conditions, especially during weekends and other times when physician offices are closed.
To control costs, most HMOs require preauthorization before paying hospitals to treat members who have nonemergency conditions. Some hospitals have responded by developing triage guidelines for nonemergency patients in order to reduce managed-care payment denials (Jan. 29, p. 37).
"There is no need to send these patients away, as many managed-care payers have been doing," Williams said.
Some experts contend emergency rooms are an inefficient setting for nonemergency patients. A 1993 General Accounting Office study indicated that 43% of all emergency room visits are nonemergency and could be treated in less expensive primary settings.
"The (GAO) estimated $7 billion can be saved in emergency care," Williams said. "If you take a look at the true costs of providing the care and the additional costs of treating the indigent, the savings are not as great as people think."
Williams' study also found that because of high fixed costs and charity-care requirements, the average charge for a nonurgent visit was $124, compared with average charges of $54 in a physician's office. However, the marginal cost-the cost for one additional patient during busy hours when the emergency department is fully staffed-was only $24, Williams said.
Williams said hospitals could compete for managed-care contracts to treat nonemergency patients if they altered their charge structure.
"Hospitals are competing for managed-care contracts with loaded costs," Williams said. "Emergency department physicians don't think they get enough credit for the revenue they generate, and then they are saddled with additional costs."
Williams examined costs of 24,000 emergency department visits at six hospitals in Michigan during 1993.