Tip No. 1 For Taking Charge Of Mass. Health Care Costs: Avoid The ER. Doctors Push Back.

(Open Grid Scheduler / Grid Engine/Flickr)
(Open Grid Scheduler / Grid Engine/Flickr)

If you're wondering why health care costs so much, a state agency offers what it says is one little piece of the answer: emergency room visits.

Forty-two percent of emergency room visits in Massachusetts in 2015 were for problems that could have been treated by a primary care doctor, according to the state's Health Policy Commission. This state agency, which is charged with driving down costs, says a 5 percent cut in avoidable emergency room trips would save $12 million a year; 10 percent fewer such visits would save $24 million. That extra spending is passed on to all of us in the form of higher health insurance premiums.

But emergency room doctors say this method of calculating savings is inaccurate and misguided and have urged the HPC to drop it. They point to the Centers for Disease Control (CDC) which says just five percent of ED visits in 2013 were non-urgent (page 9, table 7).

Why the big difference? The HPC gets to 42-percent by analyzing bills. It's an after the fact assessment of the crippling stomach ache that might have been appendicitis, but wasn't. The CDC's number is prospective. It's based on "a visit in which the medical record indicates that patient should be seen within 120 minutes to 24 hours."

The HPC stands by its model and numbers. Director of Research David Auerbach says it answers the question, "if we have a health care system doing what it is supposed to do, treating patients with the right care in the right time, in the right place, what percent of ED visits could have take place in another setting?"

The HPC says more Massachusetts residents should consider calling a hotline, seeing their primary care physician or trying an urgent care center before going to an emergency room.

"If it’s not a true emergency, you’re going to wait for hours in the emergency room, it’s not the best practice for coordinated care, and you run the risk of having a lot of tests that might not have been necessary if you saw your regular provider," said Sarah Sadownik, deputy director of the research at the HPC.

The Massachusetts College of Emergency Physicians (MACEP) says that's the wrong message. They say patients should not be asked to determine if they need a primary care doctor or the capability of a full emergency room to treat chest pains or a severe headache.

"You just never know when one of those sore throats might turn out to be something really catastrophic such as a rapidly swelling peritonsillar abscess," said Dr. Melisa Lai Becker, president of the MACEP. "Every emergency room physician has so many scary stories."

The HPC says it is breaking down some of the ways Massachusetts could save money without doing harm. We'll be looking into many of these tips as they are released. But ED doctors say this one, steering patients away from emergency rooms, could do some real harm if it undermines the funding that keeps emergency rooms open for all residents, 24 hours a day, seven days a week.

"I'm worried that the way that we're looking at cost reduction and blaming emergency department visits is going to threaten the viability of the emergency care safety net," said Dr. Peter Smulowitz, a past president of the MACEP.


Smulowitz says there would be very little savings if the health care system builds out primary care and urgent care centers while keeping emergency rooms open, but reorganizing EDs around types of patient visits might reduce spending.

Debate about how the state can cut costs on emergency room visits is heating up.  Major employer groups consider this "low hanging fruit as we try to get hold of costs in the health care system," said Chris Geehern, executive vice president at Associated Industries of Massachusetts.

"Frankly if you sit in an emergency room in Massachusetts on a Friday night, you'll see people who have the flu or something wrong with their finger, things that need attention but not the full apparatus of an urban teaching hospital emergency department," Geehern said.

The HPC is posting lots of details about ED visits across Massachusetts, including the top five reasons people go: sinus problems (sinusitis), stomach pain (that's my work zip code), rashes and skin conditions, acid reflux and bronchitis. Here's a breakdown by zip code:

Many people go to an ED during office hours.

(Courtesy Massachusetts Health Policy Commission)
(Courtesy Massachusetts Health Policy Commission)

We used to assume that most of the people who visit an emergency room were uninsured. But that doesn't seem to have been the case before the state expanded health coverage and is likely even less true now. Here's the most recent comparison available.


If you want more details about avoidable ED visits, try this. And if you're up for a deep dive into the reasons Massachusetts has some of the highest health care costs in the country, — and maybe the world — here's the HPC's most recent cost trends report.

Editor's Note: We heard from some emergency room doctors about our reporting on the HPC analysis and wanted to revisit this post.  It has been updated with further reporting.

This article was originally published on May 25, 2017.


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Martha Bebinger Reporter
Martha Bebinger covers health care and other general assignments for WBUR.



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