Why Are ER Waits So Long?

Editor's Note: The following is an edited transcript of the first podcast in the Veritas Riff series. For more information on the series, and for other installments in the series, go to veritasriff.org .

The Veritas Riff is a group of friends who combine deep faith with world-class expertise in subjects ranging from politics, science, culture, business, medicine, and more. They offer their informal take on the big questions facing us all. The host of the Veritas Riff is Curtis Chang.

We as individuals have varied experiences of medical care, except one: we will almost certainly find ourselves someday (if we have not already) in an emergency room for ourselves or for a loved one. The situation, almost by definition, will be a crisis. For most of us, the emergency room will be one of the most defining features of an unforgettable chapter of our lives.

In order to understand this crucial aspect of health care, I'm speaking with Renee Hsia, a professor of emergency room medicine at the University of California, San Francisco, and a leading expert on how the public experiences emergency rooms. She is also a practicing ER doctor herself at San Francisco General.

Renee, on average, what kind of wait should I expect before I can be seen at the emergency room?

It depends on where you're going—whether or not, for example, it's an urban hospital—and what type of problem you present with. But your wait can range anywhere from being seen right away, which is rare, to up to eight or even twelve hours. At the University of Southern California, in Los Angeles County, people often wait twelve hours to be seen for something of low acuity, such as a sore throat.

Twelve hours sounds excessive. Have waits always been so long?

No. The average length of stay, a decade ago, was closer to an hour or an hour and a half.

Many of us may not realize that there has been such a change. The obvious question is: Why has this happened? We hear a lot about poor people using ER rooms for primary care visits. Is that why the ER waits are so long?

It is indeed true that many people who are uninsured, or poorly insured, cannot have primary care doctors because primary doctors refuse to see them due to low reimbursement rates. So they may go to the emergency room. But that actually comprises probably less than 10 percent of the visits to the ER.

So if poor people using emergency rooms in place of primary care doctors only accounts for a small part of the problem, what accounts for the rest?

The real reason is supply. We have to consider not only increased demand, but how many doctors are out there to serve the growing number of patients. In the mid-1990s there were about 4,500 emergency rooms in the United States. Now there are 3,900. So if the number of patients is growing, along with population growth, and emergency rooms are closing, then we're going to have overcrowding.

Why are emergency rooms closing when we actually need more of them?

One of the main reasons why hospitals close, or why emergency departments close, is because they can't pay for themselves. For instance, Stanford, where I trained for residency, is in an area with many affluent people, most with good insurance. So the emergency room at Stanford is what we would call a revenue center. Most people admitted to the hospital come through the emergency room with insurance, and they keep the hospital afloat.

In a place like San Francisco, there may be many homeless people without insurance. Yet because there's a federal mandate that emergency departments must see patients regardless of their ability to pay, you have to take those patients.

And of course we want to take those patients, but the problem it presents is unique in health care. Call a cardiologist to request an appointment, and one of their first questions will be, "What insurance do you have?" They're able to say no. Emergency medicine is the only specialty where we're required to see all patients. This is what's called an unfunded mandate. Emergency rooms in such areas are not revenue centers but cost centers, and they make it more difficult for hospitals to stay afloat. So those hospitals will close more often, or they'll close their emergency rooms.

The nature of unfunded mandates in medicine brings to mind a recent experience. My wife and I were struggling to get our daughter to keep her room organized. We would mandate that she put her things away, but we hadn't created proper spaces or an organizing system that would allow her to do those things. We just told her she had to take care of it. So she just kept shoving more things into her closet. It just resulted in a massively unorganized closet and a worse mess . It seems medical care, when it comes to poor people, is rather similar. Everyone is trying to shove them away in the corner, and it just makes a mess.

That's a great way to put it, and let me expand on that point. I can give you another example of shoving the care of poor patients away in one area but not preparing an overall space for them.

Some people who have insurance, when they hear these conversations, tune out. They think it doesn't affect them. But it really does. If we're caring for patients who cannot pay for themselves, then we have to subsidize their care by charging more from those who have insurance. It's a little more complicated than this, but to simplify, we require those with insurance to pay more in order to keep hospitals afloat while they also care for those without insurance.

If you look at your own premium, wherever you're insured, I can bet that it's been increasing at an astronomic rate. You may not realize it, because your employer takes more of the hit. But I guarantee you it's been increasing.

So this problem does affect all of us. The mess eventually overflows. One of the things I want to emphasize is, when we think about poor people who have no access to emergency departments, the problem affects not only the emergency rooms in the poorer neighborhoods that are closing. It does affect you, because now those people are going to come to the emergency department in your neighborhood. Health care is not a closed system, where poor or uninsured people stay in their own neighborhoods.

Can you say more about how the overflowing mess affects my individual health care?

Imagine that a person from a poorer neighborhood is shot, and you have a broken leg, and both of you are brought to the same emergency room. You'll wait longer because the trauma gets priority over you. It affects you in that you wait longer, and we also know from other research that when you wait longer for certain time-sensitive conditions—if you have a heart attack, for instance, or if your blood or lungs are infected with bacteria—then the amount of time you wait for treatment is extremely important for mortality rates. Those are compelling reasons to address this issue.

What then would it look like to address the issue? What's the answer? Do we need to build more emergency rooms? Or is the solution more complex?

You absolutely have to look at the whole health care system. There are some places where they used to think it was just an emergency room problem, and they tried to increase the number of beds and doctors. But if you have patients stuck in the emergency room, you're not able to move them, so it becomes a hospital-wide systemic problem. Changes need to be made at a hospital level.

On a larger scale, looking at the whole health care system, we need to consider how we finance and deliver care to patients. Right now the scaffolding of health care is set up in a way that really does produce inequity. So while people are scared to look at wholesale health care reform, that's what it's going to take or else the problem will grow worse.

What's your take on the Obama health care reform, then? Does this address the kind of systemic issues you're talking about?

I think Obamacare is a step in the right direction. More needs to be done. But obviously in a democratic society like ours, it's difficult to get a whole new system pushed through Congress in a way that others will accept. So this I think is a step in the right direction, but much more needs to be done.

Imagine you're sitting next to a member of the Tea Party on a plane. Obama's reforms were a primary rallying point for the Tea Party; it was viewed as a symbol of federal government overreach and intrusion into private life. As a physician, how would you explain to such a person what sounds like your support for the Obama administration reforms?

I would share my own experience, what I'm seeing in the ER. One of the reasons I love working in the emergency room is because it gives you a bird's-eye view of the health care system.

To give one example, a patient last month had had a pacemaker replaced five or six years ago, but he lost his insurance so he wasn't getting follow-up. It was a very simple problem. The battery in his pacemaker was dying, and so his heart rate was growing slower and slower. When he came into the ER, his heart rate was at about 35-40 beats per minute, which is almost unsustainable. He had been feeling bad for months. Now, he didn't know exactly what the problem was, but without insurance he was unable to pay out-of-pocket to see a cardiologist.

He discussed this with his neighbor, who was a cardiologist. His neighbor took his pulse and told him to go to the ER immediately.

It's a simple problem. He needs a battery in the machine that has been placed in his heart. Because he didn't have insurance, he could have died. Those kinds of things should never happen. But these are the kinds of things we see in the ER, and it's sad.

Since you see such sad cases in the ER, how do you personally keep going? What sustains you?

I feel called to this job. It's an incredible privilege to be involved in the lives of other people at times of pain and sorrow. It is frustrating to work in an environment where things like that happen, but that is the reality of this world. This is how it is. We do work to make change on a larger systemic scale; that's what we hope and pray for. But on an individual level, I enjoy working with these patients. Even though it's frustrating and heartbreaking sometimes, our role is to do what we can do within the structures that we're given, and to continue to try to make them better.

Thanks for sharing all of this. If I ever have to go to the ER, I'd like to see you or someone like you when I get there!

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