ER overcrowding


Category : Medical Rants

Unfortunately the IOM report (like many recent ones) lacks a common sense view. Speaking of ER delays and overcrowding

Most ER problems arise because we underfund generalist care. With laws that require ERs to see patients, regardless of complaint and payment ability, the ER becomes the court of last resort. Unless you are very sick, the ER is a lousy place for routine medical care.

The arrogance of the report is highlighted in their belief that hospitals can squeeze in more patients than they have beds.

More comments can be found IOM: No more ER diversion and Wish I’d said that.

I know members of the IOM committee. I do believe they want the best for patients. I do believe that are totally off base in their recommendations.

The solutions are all economic. We need better access for health care outside of ERs. We can only get that if we fund primary care better and subspecialties less well. We need to recognize the importance and difficulty of delivering excellent primary care.

The lack of adequate reimbursement for primary care (relative to subspecialties) leads to serious externalities on our system. But then, do we really have a system?

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Comments (13)

I think thee’s a lot of arrogance in absolving the hospital of any responsibiity to ease ED overcrowding. Overcrowding isn’t a result of ED inefficiencies, it’s a lack of hospital ownership of the patients admitted to the hospital through their own ED.

I’ve had some thoughts at my blog.

i agree, it is an economic issue…

However, i am interested in studying how the concept of Artificial Scarcity plays a role…

i am not an economist, but it seems that rather than increasing primary care salaries (see boutique medicine w/ 500 patients at min. $2000= 7figs. . .)

if the supply of doctors were allowed to increase (ie free market introduced), given US population of 300 million and current doctor level at 2.5 doctors/1000 population… how many doctors would be required to increase competition to the point that dealing with doctors is like dealing with a good waiter/mechanic/service professional/… Where if the service is poor/price too high- well there is always plenty of competition in the marketplace. Is there a supply level that could drive down doc salaries to the level to $100K?
Further, how would this effect doctor insurance premiums, if by reducing patient load/doc, exposure risk was reduced accordingly?

(i would love to read a Freakonomics type article that crunches these type of numbers accordingly)

Further, safety is an issue- but standards can be introduced w/o stifling competition? Also, what about the associated poor access to healthcare- which in itself is an enormous safety issue?

important thoughts to think about:
Does small number of supply hurt quality of care/ access of care?
What would be safety implication of open stds. ie say a national exam vs formal schooling, and junior status or other rethinking of residency…

Finally, if you or someone you know is genuine need:

on a personal note, a family member currently travels oversease now for regular care inaccessible to us despite several in family docs. We only took this step after a bad experience with a doc which he may have wrote off as a misunderstanding but left us with years of medical debt from which we are only now emerging… do not get in this position- go overseas:
interesting facts:
overseas hospitals are more transparent, have better recovery rates, and are audited by the same Geneva organization that certifiies US hospitals.

given this, for myself and the family the ER and US healthcare is strictly off-limits except in case of medical trauma- in which case i simply want to be stabilised to the point of going overseas.
(W Virginia is currently considering passing legislation that would allow employers to offer insurance that covers overseas care)

Anyhow, this is my two cents on “ER overcrowding”, yeah it is an econ issue (but not a billing one), and if you need care dont deal with the humiliation and disrespect of becoming a charity case, go overseas- maintain your dignity.

this is my current “solution/advice” and thoughts on a topic that is effects us all deeply

i am interested in learning more about these issues… does anyone have recommended reading, ie freakonomics of health, maybe actuarial reading, or better look at how medschool/residency training numbers are determined?


Ms. Leslie Norwalk, recently promoted to Acting Director of CMS, commented at an investor conference that the main reason for ER overcrowding is that hospitals often cannot transport patients that need to be admitted to a room on a timely basis. So, according to her, the issue is basically one of throughput and not overcrowding. Separately, HCA says that half of its inpatient admissions come through the ER, and 20% of all of their ER visits result in an admission.

At the same time, I see no reason why hospitals cannot have primary care clinics either next door, across the street, down the hall or on a different floor to which non-emergency cases can be sent after a quick screening.

While I agree that primary care docs are undercompensated, at least some of the ER overcrowding problem could be alleviated by better management.

It seems to me that the reason for ER overcrowding actually partly lies at the feet of Congress. EMTALA has forced ERs to see any and all comers, and the decline of primary care has exacerbated the problem. The ER at my hospital has a fast track area, equivalent to the primary care clinic mentioned by BC, and this has not alleviated the overcrowding problem in the acute area. Ther’s a stringent throughput policy about how quickly patients are to be transferred to the floor once the doc is notified about the admission, and this still hasn’t helped our overcrowding. Part of the problem may stem from the admitting docs requesting further testing while down in the ER – you never know, the low back pain may be a rupturing aneurysm that doesn’t belong on a medical service. Our ER is really well managed, and we still have problems.

Any discussion of ER overcrowding that does not focus primarily on the fact that the care is free for a good segment of its customers should be ignored as hopelessly detached from reality. In my Er, 30% are “Self-Pay,” and many of the rest are Medicaid. When the price is $0, the demand is essentially unlimited, no matter what you’re selling, except for hazardous waste. So, in they come, the vast majority with nothing wrong that requires ER level care. A quick glance at the presenting complaints reveals plenty of complaints such as “fussy,” “flu symptoms,” “twisted ankle,” “sore throat,” ad nauseam. If they were seen in an urgent care clinic or pediatricians office, they would get a minimal workup and reassurance. The standard of care in an ER is higher, and the price is right, so they get time consuming, expensive, and (for the most part) ultimately worthless evaluations using the full resources of the hospital. Meanwhile, the few with truly urgent problems wait in line, and the few with insurance or money get shafted financially to pay for the cost of running the ER.

ismd is absolute correct- this is a Congress-created problem. There is a mandate that every person get screened for urgent problems regardless of abaility to pay. Technically, it would be possible to tell the parents of the kid with the runny nose that they have to pay if they want anything more than reassurance from the receptionist, but in the real world, once they’re in, they get the full Monty.

The best thing that could happen to American medicine would be for Congress to get its worthless hands off of it and let the doctors and nurses run it. That’s the way it was for the first 188 years of this republic, and nobody died in the streets for lack of medical care. Don’t hold your breath.

In the case of hospital ER’s that serve large numbers of people that are either uninsured or on Medicaid but have no relationship with a PCP, I wonder if it would make sense to keep track of who these people are, where they live, how often do they utilize the ER, and what percentage of the ER’s visits they account for. If most of them are coming from one or two or three zip codes, it might make sense to put subsidized 24 hour primary care clinics in those locations and publicize their existence including by communicating directly with the frequent ER users.

On the other hand, if it would be cheaper to just expand the capacity of the overcrowded ER’s, then that approach should be considered. There are some interesting accounting questions in trying to measure the profitability of the ER. In the case of HCA, I said earlier that half of its inpatient admissions come through the ER. That suggests that if they had no ER, they would lose half of their inpatient business. Or, if a patient is sent down the hall for an MRI, the radiology department captures the revenue even though the ER drove the “sale.” If, at the end of the day, hospitals are being largely compensated for services rendered to the uninsured via either Medicare disproportionate share payments or state uncompensated care pools, I’m not sure what they are complaining about from a revenue standpoint. If the ER department is already being efficiently managed and throughput is satisfactory for those that need to be admitted, maybe expanding the ER is what’s required.


Your experience is a statistical anomoly. You need to meet a few different US doctors. When someone in you family needs urgent care (think MI or Stroke), the quality you receive will be markedly reduced by the trip across the Atlantic.

As someone who admits medicine patients from the ER, the overcrowding problem has nothing to do with how long it takes to get someone up to the floor after the decision has been made to admit. Let me illustrate this with an example. Imagine you have a limited amount of hospital beds and the time it takes to transfer someone up to the floor is instantaneous. If there is a continuous flow of patients, eventually the floors will fill up.

Additionally, there is a finite time you have to allow the ER physicians to provide the high quality care everyone demands from them. If you have one bad day in the ER, you owe someon $212 million dollars and your insurance company will sue you not to pay it. ( I love my home state)

The problem is the flow of patients coming into the doors of the ER. Anyone who says anything different has never worked in an ER. I don’t care if your name ends with ARNP, MD, MBA. You either need to stem the flow by making it harder to get into the ER, or offer people alternatives that are just as convenient and free.


Thnx for the reply!

In regards to my medical debt, I dont think it is a statistical anomaly. Recently there was a Harvard study, that said majority of cases of personal bankruptcy stem from medical expense. So i think im in good company.

Further, regarding frivolous use of health resources, I recall reading a Kansas State study with cited many in that state not seeking out health care because of inability to pay… But I dont work in an ER setting, so if u see alot of those cases than yes, as u say “it must be more difficult to get into the ER or offer people alternatives that convenient and free”

Well, I dont agree with proposals of providing it for free, doctors should be able to sell there services- that why I love this country… land of opportunity, free capital. But along with that comees the idea of competition. I honestly dont believe that medicine is so difficult that an average person with a 100 IQ cannot perform the duties of average medical situations.

Therefore, (i believe and have heard others more qualified than I make the case that) the number of doctors that get produced needs to be opened up… Unfortunately, I dont see that happening anytime soon, ie my overseas suggestion.

The initial post was about increasing the salary/compensation of primary care doc duties/procedures, as means of reducing ER overcrowding. I countered that i didnt agree, and felt that the problem was number of doctors produced. Then I pointed out sources where doctors can be found. Finally, someday i would love to meet more US docs(as was suggested), but right now they are overvalued in my opinion (due to artificial market scarcity) and I dont like the idea of having to be a charity case.

Again, thanks for the reply b, I hope I haven’t offended you in any way, and we fundamentally agree on most points. Ill concede that ive never worked the ER. But i wasnt discussing logisitcal/ operational issues.

Do you believe there is a doctor shortage? Do u think the market is at equilibrium regarding supply/demand? How would issues of safety get addressed if the system ever was opened up? What would happen to doctor salaries if another 10K got certified each year? What about insurance premiums? These r important issues that should be addressed/modeled/ better understood.


I have no idea whether we have a doctor shortage. But as I understand economics, so long as reimbursement is not up for competition the rest is moot. Basically, how will increasing the number of docs decrease costs if reimbursement is the same via medicare for the procedure. The doctors whether ER or not will not be competing on price. Increasing the number of docs will just increase utilization(see the heart docs prove the point of all services ER and others. If you want price competition by increasing the number of doctors, erasing fee schedules from medicare is going to have to occur concurrently. Good luck.


thanks for the response

I dont know too much econ either (few semesters as undergrad), but regarding utilization sounds like your talking about Say’s law: supply drives demand

im referring more to equilibrium pt in supply-demand curve

More generally speaking however, increaseing supply of doctors is not a moot point with respect to decreasing costs- even with fixed pricing structure (ie competition would force service concessions- guaranteed appt time, email consult, free gauze/bandages, no office pay… markets get creative given fierce competition). I recall something my econ prof said- for someone willing to do something for $10, there is someone willing to work for $9, $8- until equilibrium or dynamics change the landscape, and the cycle repeats.

Yes, its crazy that the fixed pricing system exists… but if doctors are literally fighting for business, for the chance to even bill medicare… then concession will follow.

It sounds like ur saying that if doctors arent allowed to bid up, that noone would care to do the job…?

Unfortunately, talk of implenting competitive practive, usually ends with a pessimistic Good Luck.

Myself and a growing number of middle-class Americans (see HB4359), we will seek out transparent, competitive service overseas- as a viable market option.

For my family, we have regained our dignity through this measure. Further, I would be very interested to utilize the care of a WalMart nurse when that comes to my state (currently in Florida only).

Finally, someone mentioned that hospitals as private entities never let anyone “die on the streests”. Well, thats not quite true.

For relieving ER congestion- another route could be specialty hospitals:

Again, another market indicator that competition is needed and will in one form or another emerge- so maybe there is some hope of a coming market solution

Would someone do a docs job for 90K? If there r folks out there who would perform for that amount, what is maintaining current 250K+ salaries?

These r the ?s the market asks herself everyday… and despite the current bleakness, she’ll find an answer- regardless of fixed pricing or artificial scarcity schemes.

(so be careful what u wish for, someday u might face erased fee schedules from medicare 😉

Supply and demand economics work in the physician arena, although as a prior commenter pointed that
fixed fee schedules and government regulation have a delayed effect on the market.

Mechanics/plumbers/electricians/teachers/lawyers tend to work in differing ways. For those unionized trades people their work rate fees tend to be higher and more standardized than their non union counterparts. The teachers often have more buffers from free market pressures..

For those physicians in private practice, income is almost always determined by Medicare fee for service rates and so those physicians who work in traditionally high cost environments can only make the economic rewards if they see more people in a fixed time interval. What has this to do with physician supply and ER overcrowding? Lots. If you look at the manpower data among physicians leaving medical school there has been a net drop of about 15,000 physicians training in primary care over the past decade.
15,000 physicians = 300 les/state which is a HUGE loss. Where do these patients go when they are sick…to the ER

So why do physicians avoid primary care? Poor reimbursement coupled with high educational debt and
Lifestyle factors..

The loss of 15,000 physicians to non primary care fields accounts for only part of the shortage.

1. Early retirements, job changes due to dissatisfaction account for another loss.
2. Also, women now compromise 50% of med student classes. Many women are balancing work with maternal responsibilities and work half time or ¾ time schedules for many years.
3. Finally, the era of physicians being married to their jobs and working routine 80 hour work weeks is fading away, thus further reducing the effective supply of available manpower.
4. Another factor is complexity.
A. We are treating people at far older ages with much more complex regimens which often requires multiple physician’s proving care to one patient. The era of the Family physician treating the acute heart attack and delivering babies is long gone. Due to the ever aging population its not uncommon to see ICU beds and ER’s full of people who are over the age 80. While thirty years ago, to even be alive at age 80 was a milestone in of itself. Its VERY common to have a 90 year old patient with perhaps 15-50 hospital admissions and ER visits starting after age 75. To keep frail people alive takes a lot of work and resources. A LOT!!!!
B. legal complexity…this is self evident…much of a modern physician work is geared to lowering risk of being sued
C. Bureaucracy….30 years ago there was less of it…a lot less

and finally seeking overseas medical care is a great idea. Our family utilizes overseas labor almost exclusively….from electronics, clothing, cars, and now even tutoring services for our children. Our city road crews now are heavily employing cheaper immigrant laborers which leads ( I hope) to lower taxes.

Walmart values are hard to beat and we shop their all the time. Certainly there is a down side to Walmart (as we all know that Walmart tends to pay very low and tries to utilize part-time employees and minimizes any contributions they can to health care benefits for their employees.
Hey but we get stuff who cares.

The commentator ranting about increasing the number of docs above misses a basic fundamental point.

Healthcare is not a free market. The patient/customer does NOT know what he needs, therefore he has to rely on the “expert” to tell him. This isnt McDonalds where customers can make independent decisions on what they want and need.

Take a look at New York City. By far, it has the largest per capita number of doctors in teh WORLD. If you go to Manhattan, you will literally find a doctors office in every single building.

So that means healthcare is cheap in Manhattan because all those docs are competing against each other, right?

WRONG. NYC routinely has some of hte HIGHEST healthcare costs per capita in the world, despite the fact that it has the most doctors in the world. There is a huge doctor surplus in NYC, yet the cost of healthcare there is very high relative ot other areas with far fewer doctors.

I’m not so sure about the Manhattan description. Yes, physician’s fees are higher in areas like manhattan but so is everyhing else. A sandwich costs much more in manhattan than upstate New York.

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