One way to control health care costs — as well as keep emergency rooms from being overrun — is to fundamentally change the way that primary health care services are delivered. The traditional model dictates that patients with a chronic condition, such as diabetes or heart disease, must book an appointment with a physician between 8 a.m. and 4 p.m. Monday through Friday.

But many working-class patients are not able to leave their jobs in the middle of the day unless they're "sick." Inaddition, fewer primary care physicians want to see patients who are insured by Medicaid because of low reimbursement rates. Even for well-insured patients, the model is under severe strain. Family physicians have moved toward limiting their practices to patients signing up for premium, or "concierge," service.

A new statistical analysis by the Atlanta-based Centers for Disease Control and Prevention released last week illustrates the extent of the problem. Emergency room visits at American hospitals rose 32 percent from 1996 to 2006, up to 119 million. That's not due to a huge increase in the number of patients arriving at the ER via ambulance or other emergency transport.

Because of the influx of "ambulatory" patients — those who simply show up — Americans now have to wait about an hour to get seen in an emergency room, the researchers said. That's almost twice as long as they did a decade ago.

The study also found that Medicaid patients — the poorest of the poor, those whose bills are paid for by the federal and state program — are four times more likely to use the emergency room than patients who have private insurance. The conventional wisdom holds that many of them aren't really sick or in need of immediate care, but that's not true. Only about 12 percent of the visits could not be classified as true emergencies, the researchers said.

The vast majority involve patients who are severely ill and need emergency treatment for chronic conditions. For too many of them, their illness has gotten worse because they were unable to get timely or affordable primary care, the research suggests.

"The ER has become the front door to the hospital," said Dr. Stephen Pitts, an Emory University associate professor of medicine and the lead author of the CDC report.

The problem weighs heavily on large public hospitals like Grady. The hospital's bleak financial picture will turn around only if Grady is able to coordinate services between the hospital's outpatient clinics and the ER, enabling it to move patients quickly into its surgical and acute-care wards.

The new governing board and Grady's new CEO should start with a top-to-bottom review of staffing at the hospital's outpatient clinics, as well as their operating hours and their ability to coordinate services with Fulton and DeKalb county public health clinics and federally funded primary care centers in the two counties. Incredibly, most of these facilities still operate on Monday through Friday daytime hours.

Savannah and a handful of other cities around the country have assembled a consortium of public and private hospitals, county health department clinics, homeless shelters, schools and other social service agencies to provide basic after-hours health services around the community. The facilities are easily accessible for patients needing to control high blood pressure, diabetes, allergies, asthma and other chronic conditions.

Providing more accessible primary care won't solve all the problems of overcrowded ERs. The chronic shortage of nurses has forced hospitals to close down beds on surgical and acute-care units nationwide, backing up patients in the hallways of ERs while they wait for a room to become available. Since more patients than ever are being admitted to the hospital through the ER, they tend to stay longer and need more intensive services.

Breaking this cycle will be difficult, but it will never be accomplished by following traditional medical models. Insurers — both in government and the private sector — must also recognize that primary care physicians should be adequately reimbursed for keeping their patients well.

The door to the hospital emergency room must remain open 24/7. But it should never become the only gateway to the American health care system.

— Mike King, for the editorial board (mking@ajc.com)

THE HOSPITAL ER: WHERE AMERICANS GO FOR CARE

A new study provides some startling facts and figures about hospital emergency departments.

• More than one-third (37.7 percent) of all medical visits by African-Americans are in hospital ERs, compared with 17.2 percent for whites.

• Medicaid patients are nearly four times more likely to use the ER than privately insured patients.

• Nearly two-thirds of all ER visits happen after regular weekday hours.

• Hypertension, arthritis, high cholesterol, diabetes and depression are the most common reasons for visiting a physician. Heart disease (including chest pain and fainting), abuse of drugs, pneumonia and depression are the most common reasons for going to the ER.

Source: Centers for Disease Control and Prevention

For full report go to www.cdc.gov/nchs