We are the 2%!

False beliefs abound. In few areas of public discussion is this more true than health policy.

One of these false beliefs is that emergency care is terribly expensive, and that we could save a lot of money if we could just somehow see to it that everyone who goes to a hospital emergency department with a problem that is not a true emergency could be re-directed somewhere else.

So ... is that true or false?

As with so many other things, it depends on how you look at it. And, with a complex proposition such as this one, it is important to recognize that it has several interdependent parts.

If you've been a patient in a hospital emergency department (ED) for something that you might have seen your primary care doctor about, if you could get a timely appointment, you surely noticed that the bill was higher than it would have been at the doctor's office. There are, as you may know, two fundamental reasons for that.

First is that the ED has a lot more "fixed costs" (or overhead) that must be covered by revenues. Second is that we have to engage in "cost shifting." We have a lot of patients who do not or cannot pay, and many more whose form of payment (Medicaid, Medicare) does not cover the cost of the care provided. And we have far more of these patients than the typical primary care doctor. So the hospital must bill paying customers more to make up for the ones who pay little or nothing.

Imagine going to McDonald's and finding that the price of a Big Mac had doubled because half of Mickey D's customers weren't paying for their meals, and so the paying customers had to pick up the tab. You might think Ronald didn't know how to run a restaurant, that he couldn't make a burger for a reasonable price. But the cost of making the burger didn't change - just the price he has to charge you to stay in business. That doesn't happen at McDonald's, because they don't give everybody chicken nuggets regardless of ability to pay. In the ED, we do exactly that. We do it partly because we believe in certain principles of social justice and partly because there is a federal statute that says we must.

So the cost is higher after accounting for overhead, and the price difference is even bigger. And if you have private insurance, the insurance company has ways of discouraging you from using the ED when you could go to your doctor's office instead. For example, if you were sick, but not sick enough to be hospitalized, your ED co-pay might be $100, whereas in the office it would have been $10. And yet people go to the ED anyway. There are lots of reasons for that: convenience, resources available in the ED, and perceptions of the quality and comprehensiveness of care are perhaps foremost among them. Even if you could always get into your doctor's office on very short notice, you wouldn't necessarily go there for everything your insurance company thinks, in retrospect, you could have. You had a kidney stone? That didn't require hospitalization, so you couldn't have been all that sick. You could have gone to your doctor's office. Try that some time, and see how well it goes.

But let us imagine that you really could get care in your doctor's office for every illness not serious enough to require hospitalization, and you could get it in a reasonable time frame. Let us further imagine that your doctor's office was actually equipped to distinguish indigestion from a heart attack and serious from trivial causes of abdominal pain. Let us even suppose that your doctor could evaluate and treat minor injuries not requiring a surgical specialist - and could tell which ones do and do not require such specialty consultation.

How much money could we save?

Do you have any idea what percentage of the U.S. health care budget is spent on emergency care? If you read the headline, you know the answer. That's right. Just two cents of every dollar spent on health care in the United States are used to pay for emergency care.

So if we could just get everyone without a life-threatening problem out of my ED, we would slash the health-care budget by ... a lot less than 2%, because nearly all of them would get care somewhere else, and it wouldn't be free wherever that might be.

In the halls of Congress we hear all the time this nonsense about the need to get all the patients without true emergencies out of those expensive emergency departments. And nonsense is exactly what it is.

We are the 2%! Occupy Capitol Hill!