WHITHER THE ALMSHOUSE - OVERUTILIZATION AND THE ROLE OF THE EMERGENCYDEPARTMENT

The problem of emergency department (ED) overutilization or ''inapprop riate'' utilization is commonly conceptualized in terms of inadequate access to appropriate primary medical care. Although medical care acce ss is a critical issue, a focus on increased access to medical care as the sole solution to ''inappropriate'' ED utilization may obscure oth er, perhaps equally relevant, issues from consideration. This article reports findings from an ethnographic study focusing on heavy users (H Us) of EDs in two inner-city hospitals. Drawing on fieldwork and on in terviews with HU patients and ED clinicians, I argue that the emergenc e of heavy ED utilization as both a clinical and policy problem is a f unction not merely of unmet medical care needs for individuals, but of ''almshouse'' needs in a changing health care context. The emergence of ED overutilization as a problem occurs in the context of market for ces that are contributing to shifts in the role of EDs and in the mora l boundaries of accepted ED practice. If the problem of heavy ED use i s more broadly conceptualized in terms of this role shift, not solely in terms of medical care access, a different set of issues and priorit ies for research, policy, and clinical practice emerges.