Incentivized Behavior

To answer the question (“Hey you in the ER! Is this really an emergency?”)—of course not! Historically the utilization of the “ER” runs 35% of the US population, or roughly (and presently) 100M annually. We lives in an exceedingly dangerous and ill society if we believe that one-third of our society has a “true” emergency requiring the services of an “ER” every year. Additionally, in many urban settings, 25% of ER volumes are brought to the ERs by ambulances. Again, we live in a very dangerous and ill society if we believe that one-twelfth of our society is so impaired that an ambulance is required every year.

For many reasons, the ER is the US healthcare system’s equivalent to fast-food. Similarly, the ambulance, often referred to as a cabulance—is just a form of door-to-door public service. Addicting? Essential? Fundamental? A right? A waste? Why? All very fair observations and questions, and I believe all come down to what we have incentivized in our society, directly and indirectly.

For those that utilize the ER and truly perceive every pain, malady and bodily dysphoria (theirs or those they decide for) to be true emergencies it is hard to fault that as inappropriate. I consider that appropriate “overreads” for a kind society and related to all the PSAs that promote self-awareness of healthcare issues. They get an “A” for intent, but only a “C” for excution—but reasonable, when we want a system that should be based on sensitivity trumping specificity.

If you consider all governmental funding sources for healthcare equivalent to a zero-sum game, then I believe it is easy to understand why both the feds and the states are increasing the pressures on the Medicaid programs. It has nothing to do with state surpluses, because the feds and the states share equally in the Medicaid yoke. But (IMHO) has everything to do with where governmentally-derived healthcare spending will need to go—Medicare, boomers, and healthcare information (broadly construed). We are fast coming upon a true constituency-based phenomenon, the largest, single, and united constituency group the US has ever seen begins this year—those residing in both the Medicare and boomer demographics. Contrast that with the diverse constitutency groups composing the Medicaid demographics coupled with the strong negative stereotypes of Welfare, the poor, the immigrant, the illegal, etc. Funding Medicare will always be more politically acceptable over funding Medicaid. Granted the states are not responsible for Medicare funding, but they are responsible for the state and locally employed boomers (and dependents) that will be retiring and utilizing their state/locally funded healthcare.

In California, the Medi-Cal receipents have been placed into managed care Medi-Cal programs that at least in my area (Sacramento) has had four major problems. First, managed care has driven so many providers out of the area there exists long waiting times for any forms of health services. This creates a collateral pressure on the ERs—”managed Medi-Cal” just can’t be seen in a timely manner. Second, because of the inability for them to be seen in a timely manner their health problems are more complicated and more advanced—which snowballs even more ER utilizations.

Third, those not able to get into the managed Medi-Cal programs are pretty much disenfranchised from all providers, because almost all providers are aligned with existing managed plans—there are very few providers that will pickup “straight Medi-Cal.” This constitutes another collaterally pressured group of Medi-Cal receipents into the ERs.

Fourth, a catagory of Medi-Cal called “emergency Medi-Cal,” which was created to provide Medi-Cal coverage for emergency conditions. Whether intentional or not, it is widely perceived that “emergency Medi-Cal” is not for “emergency” as a condition but for “emergency” as a venue. The ER becomes the venue for all Medi-Cal services under this misinterpretation. A very typical dialog with members in this category of Medi-Cal starts with “I have my emergency Medi-Cal and I want….”

What would be the effect of limiting Medi-Cal funding in California—immediate proportional and incremental increases in ER volumes for true emergent needs, for those further disenfranchised from primary care providers, and for those that already believe “the system owes them.” For good and bad reasons, Medicaid programs have incentivized behaviors and expectations over time. Changes in “who is covered” and “what is covered” without credible alternatives and potent counter-incentives will just drive-up ER utilizations.

There is a profound misunderstanding in the US about “Emergency Room,” it is an oxymoron, because utilization of the ER for everything other than a true emergency has been pervasively incentivized.† We have created a near-entitlement in the form of Medicaid and we have created a general expectation that any medical condition may be addressed in an ER.

Aside, when I first started my EM practice I was very incensed at parents on Medi-Cal who would bring their febrile child to the ER to get a prescription for APAP and had a pack of cigarettes sticking out of their shirt-pocket or purse. Over the years, I’ve come to have two reflections on the matter, first, I can’t affect social and healthcare policy in the ER at 3 AM (the hair trying to wag the tail that wags the dog); and second, not writing the prescription only causes the child to suffer.


  1. When I worked in the ED, we referred countless people to the health districts, aka free clinics. Going to the PCP costs money (or at least used to) on any of the 3 PA medicaid insurance plans, but going to the ER is free. Guess what that leads to? Overuse and abuse of the ER. On any given day, it seemed like about 1% of patients actually needed to be in the ER. Many more needed to see a doctor of some sort, but not necessarily in the ER.

    My own views and biases on this became stronger by working in an urban trauma center. Then one night, I ended up there with a massive nosebleed that cost me a litre of blood in an hour. A friend of mine was surveying patients on their reason for going to the ER, if they had contacted their physician first, if they would have contacted their physician had they been able to (via emergency line, etc), and what they would rate their emergency on a scale of 1-10. Me, being the ever biased ED employee that I was, said…”Well I didn’t contact my ENT, and I guess I’d only rate this a 7?” My friend said, “Shut up. It’s a 10.” I ended up in surgery by the afternoon. Heh… I do have to seriously examine my rationale if I need to go to the ER, however, and it’s almost led me NOT to go to the ER when I should have.

    Therefore, I had to raise my eyebrows the other day when one of my baby’s parents told me she was going to the ER for antibiotics. She seemed fine. Why not call her regular physician? In fact, when she returned to the unit, she asked me for the number to family med so she could call them and let them know she’d gone to the ER. Oy vey…

    I did some time out at one of the busiest health districts in the city. It was…interesting… In many cases, the waits were just as long or longer than ER visits. A light turned on. Later, a good friend of mine, who is a social worker in the ED I worked at, asked me about the health districts since we so often direct people to go there instead of coming to the ED for common problems. I suspect the real reason people come to the ER is that they see they can get a wider variety and more in depth (almost left that as in debt..haha) type of care by going to the ER. Still doesn’t cut it as an answer, however!

    And around here – a friend of mine refers to the ambulance as the “horizontal taxicab.” ;)

    Take care!
    Carrie :)

  2. Bad Shift says:

    So, we are victims of our own sucess?

  3. “Victims?” Perhaps at some level, but we got exactly what we incentivized. Field of Dreams: if we build it they will come. If we create a specialty whose livelihood depends upon volume–they will come. If we ratchet down primary care providers and venues (by upping competition and “productivity” via managed care)–they will come. If we, for 40+ years, inculcate themes of dependency, entitlement, immediacy, etc.–they will come. Like so many endeavors, we have been caught by the law of unintended consequences.

  4. For a different perspective on Medi-Cal:

    My son has been on Medi-Cal since he was 3 months old. He’s now 4 1/2. He’s a double-transplant recipient (liver/small bowel), and we’ve never had a problem getting care for him at any ED we’ve gone to or at his pediatrician’s. Then again, we only ever hit the ED when something is Really Wrong, like possible line sepsis or a rejection episode.

    I absolutely hate the invasive questionnaire I have to fill out every year to renew the Medi-Cal–how much money do you have at home? how many uncashed checks? how much do you have in the bank? how many cars do you have? how many people live in your home?–but, there’s no way I could afford to take care of my munchkin without it.

    There’s also no way I can see to get off Medi-Cal now that my son is on it. Taking care of my son is my full-time job. My husband is employed, but his job only covers health insurance for him, not any dependents. I haven’t had health insurance since my son was born–I pay out of pocket for yearly checkups and all prescriptions for myself. Even if we did get me some cheapie health insurance, no one would insure my son–it’s a preexisting condition, and a very expensive one at that.

    It’s a very frustrating situation, and though I can’t stand having my son on Medi-Cal, he would never have survived this long without it. –lexi


  1. symtym says:

    Incentivized Behavior

    To answer the question ("Hey you in the ER! Is this really an emergency?&quotwink—of course not! Historically the utilization of the "ER&…