Tragedy of the ED Commons

In his landmark article, Tragedy of Commons (1968), Garrett Hardin asks, “Is ours a finite world? [If so], a finite world can only support a finite population.” In Hardin’s parable, a single group of herders shares a common pasture. The pasture is large enough to support many animals, but not infinitely many. Rationally, each herdsman seeks to maximize his gain by adding to his herd, however, the cost of supporting that animal is shared by all who use the pasture. The herder gains a lot but loses only a little by adding an additional animal to the herd. Thus, he is best served by increasing the size of the herd indefinitely, as long as the pasture remains available. Inevitably, as “each man is locked into a system that compels him to increase his herd without limit – in a world that is limited. Ruin is the destination toward which all men rush, each pursuing his own best interest in a society that believes in the freedom of the commons. Freedom in commons brings ruin to all.” In economics, the commons are defined as resources whose value is shared. They are owned, governed, financed in a shared way and are non-excludable but rival. Thus, nobody can be prevented from using a commons (non-excludable), however, using commons decreases their availability for someone else (rival). Commons are traditionally thought of as natural resources such as grazing land, fisheries, and forests.

In contrast, public goods are defined as resources that are non-excludable and non-rival. One person’s use of resources does not reduce what is available to someone else. They tend to be funded through taxation and provided by governments because the market generally does not do a good job of supplying these goods. Resources such as roads, street lighting, public education, and healthcare are considered to be public goods. In 1986, the Emergency Medical Treatment and Labor Act (EMTALA) was passed in response to “patient dumping” –  the practice of hospitals refusing to treat people with medical emergencies because of their inability to pay. As part of this law, all Medicare and Medicaid hospitals are required to provide a medical screening exam including blood tests, imaging, and consultation with specialists as necessary to decide whether an emergency medical condition does or does not exist. This law pushed emergency care into the domain of a public good – it was considered non-excludable and non-rival. However, as is the case of most artificial categories, this division is more of a continuum rather than discrete categories and upon closer inspection, emergency care might be considered more of a common rather than a public good. It is a shared, finite-capacity resource, and the more someone consumes it, the less it is available for everyone else. It is non-excludable but it is somewhat rivalrous.

Emergency department visits in the United States continue to rise and reached a 10 year high in 2015 with approximately 130 million patient visits a year. The vast majority of these patients were treated and discharged home from the emergency departments as approximately a tenth of these visits required admission. Therefore, by this measure, the vast majority of visits are non-emergent and should be treated in a non-emergency medicine setting.

Emergency departments have made provisions and improved operations to account for this increase in visits but this burden in additional visits are not without a cost. Emergency departments are frequently at or near capacity and the overall quality of care decreases. According to the Centers for Disease Control (CDC), patients in the United States visit a physician approximately 1 billion times a year and of these visits, ~13% take place in emergency departments. Yet, only ~4% of the nation’s physicians are emergency physicians. As emergency department patient visits continue to rise and the number of trained physicians continue to lag, these numbers foretell a serious shortage of 18,600 and 31,800 emergency physicians by 2030.

Emergency care in the United States is paradigmatic of the tragedy of the commons. Patients opt for the quickest, most expeditious route in seeking care rather than waiting an average of 24 days to see a cardiologist, dermatologist, orthopedic surgeon, or a family practitioner. As Herbert Simon stated in his theory of bounded rationality, individuals make reasonable decisions based on the information they have, but since they do not have perfect information nor the cognitive capabilities to process perfect information, individual decisions are rational but short-termed and produce suboptimal results in the long term and for the aggregate. He termed this real-world behavior of ‘good enough’ decisions satisficing.

Although healthcare is generally considered a public good, through the passage of EMTALA and its requirement of non-excludability, emergency care might be better categorized as a finitely resourced common. As Aristotle noted more than 2000 years ago and Hardin noted in his tragedy of the commons, “what is common to the greatest number gets the least amount of care. Every one thinks chiefly of his own, hardly at all of common interest.” Thus arises the tragedy of the commons, where the herdsman maximizes their short-term self-interests based on imperfect information to the long-term decimation of the common pastures. Patients are streaming into emergency departments nationwide and unless the capacity of these pastures are increased or we develop interventions to alleviate the burden (next post), we are headed for the classic tragedy of the emergency care commons.