Only 45 percent of the 354 million annual visits for acute care in the United States are made to patients' personal physicians, as Americans increasingly make busy emergency departments, specialists or outpatient care departments their first point of contact for treatment of new health problems or a flare up of a chronic condition like asthma or diabetes.
The findings, which appear in the September edition of Health Affairs, do not bode well for the nation's already busy and frequently undermanned emergency rooms. While fewer than five percent of doctors across the U.S. are emergency physicians, they handle more than 28 percent of all acute care encounters -- and more than half of acute care visits by the under-and uninsured.
According to co-authors including Steven Pitts, MD, associate professor of medicine in the Emory School of Medicine and a staff physician at Emory University Hospital Midtown, and Arthur Kellermann, MD, the Paul O'Neill Alcoa Chair in Policy Analysis at the RAND Corporation and previous associate dean for health policy at Emory University, health reform provisions in the Patient Protection and Affordable Care Act that advance patient-centered medical homes and accountable care organizations are intended to improve access to acute care. However, the challenge for reform, according to study authors, will be to succeed in the complex acute care landscape that already exists.
"Timely access to care is important, especially for those who are acutely ill. First-contact care has been a central tenet of primary care. But over the past few decades, the focus of primary care has shifted as a result of a growing elderly population, the growing burden of chronic disease and the challenge of coordinating care across multiple physicians," says Pitts. "Low rates of reimbursement have accelerated this trend by forcing many primary care physicians to pack their daily schedules with 15-minute office visits -- leaving little time for patients with acute health problems."
The study, which took place between 2001 and 2004, shows that Americans made an average of 1.09 billion outpatient visits per year to physicians, averaging 321 visits per 1,000 people each month. Slightly more than a third of all encounters, or 354 million per year, were for acute care -- treatment of new problems or a flare-up of a chronic health condition.
Twenty-two percent of acute care visits were managed by general/family practitioners, 10 percent by general internists and 13 percent by general pediatricians. Many involved treatment of minor upper respiratory problems, such as cough and sore throat. Office-based specialists handled 20 percent of acute care visits, generally for conditions in their respective areas of expertise (e.g., skin, eye and orthopedic problems). Twenty-eight percent of acute care visits were managed by hospital emergency departments, typically for more complex and potentially dangerous conditions such as stomach and abdominal pain, chest pain and fever.
"One of the biggest barriers to providing acute care in primary care practice is that many primary care doctors have packed schedules. This makes "same day" scheduling, much less treatment of walk-in patients, extremely difficult," says Kellermann.
"Busy schedules also discourage primary care physicians from taking the time they need to treat patients with complex, undifferentiated complaints. It is faster and simpler to refer them to a specialist or the nearest emergency department. Ensuring timely access to primary care is a desirable goal, because it increases a person's odds of finding a "medical home." Unfortunately, for many years now, primary care in the U.S. has been in decline," Kellermann says. "Patients have adapted by seeking care elsewhere when they get sick."
Our data indicate that more than half of acute visits today involve a doctor other than the patient's personal physician. Dr. Pitts adds, "More than a quarter of all acute care visits, including virtually all weekend and "after hours" encounters, occur in hospital emergency departments. Heavy use of emergency departments for problems that a primary care provider could treat, if their patients could get in to see them, is not desirable from a societal perspective," says Pitts. "Too often, emergency care is disconnected from patients' ongoing health care needs."
"Hospital emergency departments are vital, particularly when your life is on the line." Kellermann says. "Americans know that when they can't get care elsewhere, the ER is the one place in our nation's healthcare system where the doctor is always "in." Strengthening primary care is a major goal of healthcare reform. If successful, it will be a win for everybody."
In addition to Pitts and Kellermann, other study authors included Emily R. Carrier, a senior health researcher at the Center for Studying Health System Change in Washington, D.C., and Eugene C. Rich, a senior fellow at Mathematica Policy Research, also in Washington, D.C.
- S. R. Pitts, E. R. Carrier, E. C. Rich, A. L. Kellermann. Where Americans Get Acute Care: Increasingly, It's Not At Their Doctor's Office. Health Affairs, 2010; 29 (9): 1620 DOI: 10.1377/hlthaff.2009.1026
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