Cover Story

Emergency Care Examined

A yearlong inquiry by Managed Care

Peter Wehrwein

The emergency department is the impressive diagnostic front porch of the American health care system.

It is a high-tech wonder and the product of generations of hefty investment in trauma care. It is among the finest expressions of what American medicine can do, a high-wire act of human judgment, expertise, and technology, of pressure-packed performance when lives are hanging in the balance. It is one of the neural nodes of the health care system that must make careful, considered decisions about diagnosis and treatment with little time to spare (“time is brain” and other mottos apply). “Unfortunately, most people have a significant misperception about what emergency care is and why people access it,” says Vidor Friedman, MD, president of the American College of Emergency Physicians. “The ED functions as a rapid diagnosis treatment center for undifferentiated illness.”

Scores (maybe more) of movies and television shows have dramatized the heroics, filling our heads with images of good-looking doctors and nurses in a rush to open the airway, keep the patient breathing, restore the heartbeat (“Clear!” yells the doctor wielding the defibrillator paddles). Some patients make it, some don’t. Those entertainments shouldn’t diminish appreciation—actually, awe—of the real thing.

But the emergency department is also the backdoor of the American health care system—a kind of open wound that is symptomatic of deficiencies of how American health care is organized, delivered, and paid for.

It is the place where people go for care as a last resort because they lack other options. It is where epidemics that are a failure of an attenuated public health system rear their heads. It is where the “difficult” cases go and circle back to, time and time again: the “frequent fliers” with comorbidities, people with behavioral health and substance abuse problems. And today, the emergency department is the source of acute cases of financial toxicity—five- and even six-figure “surprise bills” that hit patients because of high deductibles, narrow networks, the outsourcing of certain hospital services, and numerous other factors.

From certain vantage points, the decades-long effort to improve the management of American health care looks like one long-running (and losing?) battle to keep people out of the emergency department.

Let’s do a better job of coordinating care, shall we? Why? Partly to keep people out of the emergency department.

Domiciling primary and other sorts of care together in cozy patient-centered medical homes will, said its proponents, help keep people out of the emergency department.

ACOs will give providers an incentive to move health care upstream to prevent conditions from getting worse and becoming costlier to treat, and that includes ... keeping people out of the emergency department.

Indeed, one of the selling points for the ACA was that expanding health insurance through the exchanges and Medicaid would reduce the number of Americans depending on the country’s emergency departments for their health care. What happened is a good deal more complicated. Some data show that emergency department use did go down among young people who were added to their parents’ health insurance policies because of the ACA. Yet three quarters of the American College of Emergency Physician’s 37,000 members say they have seen an increase in patients since the implementation of the ACA.

An experiment in Medicaid expansion in Oregon randomized people to coverage and showed a 40% increase in emergency department use among those newly covered by Medicaid. Perhaps that use will taper off with time. But at least for recently covered Medicaid beneficiaries, the emergency department seems to complement rather than replace the office visit, say some researchers, partly because people who are under the care of doctors will be told by those doctors to go to the emergency department if they have acute symptoms. Maybe more importantly, Medicaid coverage also offers some protection from the avalanche of bills that hit the uninsured who go to the emergency department.

Friedman’s observation fits with that interpretation: “Primary care is really about prevention and maintenance,” he says. “Emergency care is really about acute, undifferentiated illness. People get sick, they don’t know what is going on and they go the ED. If you call your primary care physician, 80% of the time he or she will tell you to go to the ED.”

Our yearlong look

During the rest of this year and with several stories, Managed Care is going to take a long, hard look at emergency care in the context of how American health care is managed, organized, and paid for. Our coverage kicks off this issue with Contributing Editor Jan Greene’s story about air ambulance services, their rising prices, and surprise billing.

In future issues, we’re going to delve into the complicated interplay of insurance coverage and emergency department use. Some research upends the belief that the uninsured are heavy users of the emergency department. Instead, the findings suggest that insured and uninsured use the emergency department at similar rates.

Urgent care centers have become common and retail clinics are as ubiquitous as Starbucks. Do they really siphon off some patients who otherwise might go to the emergency department? Keep in mind that their services are limited when it comes to things like diagnostic testing and admitting patients to the hospital. They also won’t see uninsured patients, and in some cases, patients covered by Medicaid. We’ll be taking a look.

Hospitals are always looking for ways to cut costs and reduce financial risk. Some are adding advanced nurse practitioners and physician assistants to their EDs while others are contracting their ED services to outside companies. Some are doing both. What role should “physician extenders” play in the emergency department? As contracting arrangements become more common, it leads to other issues like surprise billing.

Burnout is a huge issue in emergency medicine, according to Friedman. “We are trying to help our doctors be more resilient. Nurses don’t last very long. When I started in emergency medicine 30 years ago most of my nurses had 15 to 20 years of experience. Now I am lucky to have somebody who has five years.”

Insurers have played around with benefit design and increasing copayments for emergency department visits. Does that kind of financial disincentive really work—or does it just shift cost to the enrollee?

We’ll be asking a lot of questions this year, looking for answers—and posing new questions. We hope you’ll join us in our inquiry.

Please send any tips or suggestions for our continuing coverage of emergency care to the editor, Peter Wehrwein, at


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