Posts Tagged overcrowding

Boy, Do We Need Primary Care

courtesy BillRhodesPhoto on flickr

courtesy BillRhodesPhoto on flickr

I think the 11 year-old in me could say it best: “Well duh.”

A report released last week from the Kaiser Family Foundation, entitled Emergency Departments Under Growing Pressures (PDF), is, to us, obvious. But still, it’s important, because it not only confirms what we all know, but shows that it’s happening everywhere, and worsening. (The Kaiser Family Foundation puts out an amazing amount of work and data about health and health care in the US, and it looks like this month they’re focusing on how the recession is affecting people.)

So what did they conclude, after meeting with a bunch of ED chairs across the country? The biggest ones:

  • ED capacity is strained and almost all EDs report rising volume. We’re trying to cope by adding more physicians, more shifts, and seeing more patients per hour.
  • Most uninsured people have nowhere to obtain primary care but the ED. Few private practices accept uninsured patients and sliding fee clinics are backed up. And even if they have insurance (Medicaid), good luck finding a primary care doctor to accept you. From the report: “Interviewees reported that few private primary care doctors would accept uninsured patients and that current waits for appointments at community health centers and clinics are long – for new patients, 4 to 6 weeks, or as long as 4 or 6 months in some areas.”
  • Similarly, EDs see more insured patients who come because they cannot obtain timely or affordable primary care in the community.
  • ED patients, whether insured or uninsured, face long waits for care. More patients boarding in the ED, and “the current average wait in one large, urban hospital was 18 to 24 hours.” Wow. Just, wow.
  • Lack of insurance and access to primary care leads to repeated ED visits and sicker patients,
  • The inability to arrange for follow-up care for uninsured patients is a huge problem, with impacts on how ED physicians practice and on how patients fare.

Primary CareNote how many of these problems we’re facing in our specialty are due to a lack of availability of primary care physicians. A ton. Let’s forget the uninsured for a minute, since the vast majority of people in the United States have some type of health insurance. We know that overall it’s the insured patients that are causing the increased number of ED visits. Some are impatient and don’t want to wait, sure, but most people probably don’t want to see a strange ED doctor; most would choose their regular doctor if they could see him/her in a timely fashion. So we’re seeing a perfect storm right now:

  • EDs closing while visits are increasing;
  • Lack of primary care physicians filling the spots of those who are retiring;
  • A growing population;
  • An aging population that requires more care;
  • A recession;
  • A possible bad influenza season with fears already high from earlier this year.

We’re in trouble, folks, and it’s primary care that’s gotta make a comeback, or we’re done. Finito. Le fin. Fat lady, sing.

If primary care loses, so do we. Let’s support our colleagues in the primary care fields.



Is Your Public Health Department Planning for Flu Season?

courtesy wikimedia commons

courtesy wikimedia commons

I was excited and happy to see a bunch of epidemiologists and public health folks visiting our Emergency Department last week to speak with patients about influenza. They said they’re trying to understand where people are getting their information about H1N1 and influenza so they can try to better-target people with appropriate health messages for the winter time. Would love to hear in the comments what other EDs or public health departments are doing to prepare.

One interesting idea that would work pretty much everywhere but New York is a drive-thru ED flu screening at Stanford (go Cardinal!). Friend and attending with a similarly terrible/hilarious sense of humor to mine Dr. Greg Gilbert came up with the idea to prevent exposures to other patients while being able to quickly assess people with vital signs in case of a true disaster-level swamping of the ED, which I’m frankly pretty scared of come December/January.

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The Role of Emergency Physicians (and the ED) After Health Reform

In anticipation of the upcoming ACEP Council meeting, prospective counselors have been engaging in some email jib-jab on health reform on the council e-list.  Until recently, this discussion focused on the proposed shape and form of our new health care system:  much ado about something that emergency physicians (EPs) and ACEP will likely and unfortunately have limited impact.  However, the topic has now shifted a bit towards the question of the future role of EPs and the Emergency Department post health reform, something we ought to be able to impact, and which, though equally political, is an in-specialty debate really worth having.  Of course, the lack of a health reform crystal ball necessitates bald conjecture when it comes to imagining how our future health care system will evolve; and this complicates the debate considerably.  Nonetheless, given the Republican’s belief: ‘government can do no right, so let’s do as little as possible and declare victory over rabid socialism’, and the Democrats imperative: ‘we must to do something, even if it is the wrong thing, so we can declare victory over heartless capitalism’; one can make a reasoned guess about the likely provisions of health reform legislation and move on from there.  To wit: something like 90-95% of citizens (and very few undocumented aliens) will have some form of health insurance (I wish they would stop calling it health care – insurance is not care); there will be higher deductibles and co-insurance payments to deter utilization; the ‘medical home’ concept will be promoted to control costs; the private health insurance industry will be a bit more tightly regulated (but still very profitable); likewise the drug industry; doctors and hospitals will take a hit (perhaps not the primary care docs); states will be given leeway to experiment with Medicaid; Medicare Managed Care plans will take a hit (they deserve it) though capitation in general will persist; some effort will be made to control cost and utilization through outcome based payment rather than task based payment; and there will be no real malpractice tort reform.

So where does that leave the role of the EP and the ED in the new health care paradigm?  If you listen to the debate in Congress and in the media, the ED has become the poster-child for the type of unnecessary and cost-ineffective health care services that characterize the worst aspects of the current health care system.  ACEP can hardly get a word in edgewise in hearings on health reform in D.C. and elsewhere.  When the ED is discussed by legislators, you rarely hear anything about what EDs and EPs do right, what we contribute to improving the health of the population, how important we are for surge response, how under-funded the emergency care safety net is, how we are the finger in the dyke.  Common sense would say that ignoring the role(s) of the ED and EP in discussions of health reform is at best imprudent, at worst, (I hate to use the word, post-Gates-gate) stupid. However, I think we can only blame ourselves if we fail to get on the radar screen – and to do so; we must go beyond moaning and groaning to providing answers and solutions. We aren’t there yet.  Solely for the purposes of promoting this discussion, I will try to delve a bit deeper into a few relevant topics, some of which have started to appear on the Council’s e-list:  cost containment, care coordination, appropriate ED utilization, error prevention and pay for performance, health promotion, and surge response in a post-reform health care system

Cost Containment
Let’s face it, ED care is expensive.  If there is one thing driving health reform today, it is the looming financial disaster that will befall the US if we don’t find ways to rein in the cost of health care.  If we don’t like being the poster child for the problem, EPs have to be part of the solution.  Granted, cost-shifting to cover the care of the uninsured might diminish post health reform; but EDs will still be the provider of first resort for the remaining uninsured, and it will be hard for hospitals to roll back ED charges even if most patients have coverage.  Perhaps having readily accessible EMRs will allow us to cut down on unnecessary and redundant testing; but as mentioned, don’t look to tort reform to mediate patient demand for the ‘definitive’ diagnostic workup.  Cost containment in the ED will require (first) a change in the incentives that pay more for doing more, something that is really at the heart of the entire health care problem and thus will get short shrift in D.C.  Payment reform, particularly for inpatient hospital services under Medicare, is already changing the way hospitals perceive the impact of the EP on their revenue stream.  It will also require a lot of hard work on our part – to collect the data (thus the push to resurrect ACEP’s Emergency Department Data Institute), derive best practices that incorporate cost containment strategies while maintaining good outcomes and patient satisfaction, and implement these strategies in everyday practice, not just for EPs, but for the entire ED team.

Care Coordination
Every time I hear about the Medical Home I have to laugh.  When it comes to the costs of health care, the hospital is really where the big dollars are spent; but when was the last time you saw a primary care doctor come in to coordinate the care of a sick patient in the hospital?  It happens, but not often any more (and I have to admire the docs that still do it).  If continuity of care and prior experience with the patient (the raison d’etre for the medical home) is so all-important, why isn’t it even more critical when the patient is in the ED or on their way to the OR or the ICU, and who is doing this coordination now?  Emergency physicians, that’s who, it’s what we do every day, and we are pretty damn good at it. Let’s be frank, the real push behind the Medical Home is the redistribution of payments to primary care providers through capitation, which in real practice has been less about managing care than it is about managing payments, managing investments, managing paperwork, and managing enrollment.  I’m all for paying primary care providers more so we can grow more of them to do the real work of improving and maintaining health. However, particularly for EPs and on-call specialists who work under the EMTALA obligation, capitated payments to managed care medical groups is an invitation for primary care docs to stick it to their specialist colleagues and put their patients on the hook for the underpaid claims.  Groups like Kaiser may be able to delegate acute care work and reimbursement within their organization in a fair and appropriate way, and perhaps that is where health reform must ultimately lead to be successful; but in the interim, most ‘managed care’ organizations will continue to pay lip service to the concept of care coordination, especially when patients are really sick.

For many medically valid and financially sound reasons, the ED has become the hub of the acute care wheel and the epicenter of diagnostic evaluation.  EPs are the primary diagnosticians and principle coordinators of episodic and high-resource care for those who need to access the most expensive health care services. We have more experience with a wider range of specialists, imaging and testing services, ancillary providers and programs, social services, and, of course, patients, than any other physician.  Why, then, would legislators not insist on hearing from us about health care reform?  EDs aren’t inappropriately expensive, they are necessarily expensive;  and the success of health reform will depend as much or more on the way the ED of the future operates and the skill of the EP in managing, distributing, accessing, and even denying access to some of the most expensive services and care the system has to offer.  Even so, the cost of the EP’s services is relatively meager.  Failure to integrate the ED hub and EPs into health reform, and the wheel of acute care will simply spin disconnectedly.

Appropriate ED Utilization
Few would argue that the ED is an appropriate place to dispense primary and preventative care services (with perhaps exceptions like tetanus immunization), but the debate as to whether the minimal marginal expense rationale for providing urgent care in the ED is valid is a very important debate to have.  When you analyze the ‘true cost’ of ED care for lower acuity patients, you can’t simply compare acuity adjusted charges; you have to look at all the costs, and who bears them. What is the cost of having to lose a full day of work running between the PCP’s office, the x-ray office, the lab, and back to the PCP’s office?  What is the added cost of going to the PCP’s office for early abdominal pain only to be referred to the ED for further testing?  What is the cost of delaying care and discouraging the ED visit with a high co-pay, only to have the appendix rupture or the TIA progress to stroke?  On the other hand, what is wrong with deferring care in the ED when more appropriate venues are readily available?  Do EPs tend to over test and over treat because we are used to seeing sicker patients?  I will tell you what’s wrong with deferral of care:  most of the time, there are no readily available alternative venues.  I’ll tell you what’s wrong with primary care in the ED:  we aren’t that good at it.  This particular issue (economic triage and deferral of care) calls out for great caution and careful implementation under health reform, rather than the knee-jerk reaction that is more likely to prevail.

There is also the question of the role of the ED in the care of the uninsured, and the underinsured.  Health reform will not cover everyone with insurance, but more importantly, it will leave many with inadequate insurance coverage.  These folks might have coverage, but they won’t have access, certainly not timely access.  EPs have long been purveyors of charity care, four times more than any other physician, upwards of $150,000 worth per year.  Unlike most providers and venues, we never limit the number of Medicare or Medicaid patients that we agree to treat. Is providing urgent or primary episodic care for the poor and underinsured an appropriate role for the EP and the ED post health reform?  Perhaps, perhaps not, but I don’t see many others stepping up to volunteer. Do you hear anyone talking about that question up on the Hill?  I doubt it.  Mr. President, Congress men and women: COVERAGE IS NOT CARE!!

Error Prevention and Pay for Performance
I am all for reducing medical errors, who isn’t? The ED is a great place to work on this issue – the climate for errors is ripe.  If error prevention is one of the mandates of health reform, why, we can all definitely get on board that train.  Give us systems to manage our patients more effectively and with greater safety, and errors in the ED will certainly diminish. Refuse to pay for ‘never events’ that we have little hope of preventing, however, and you will have lost us. The hardest thing to do in medicine is to meet unrealistic expectations.  If health reform were to result in payment only for services that make people better (don’t worry, it won’t); who would want to work in an environment like the ED, where the odds are stacked so heavily against us?  So how should EPs and EDs be reimbursed post health reform?  A recent story out of Vermont hyped the cost-effectiveness of a hospital that employs physicians.  Is this the appropriate new model for health reform? If so, say goodbye to the corporate bar on the practice of medicine, and one more layer of protection between the patient and the all-mighty bottom line.  Personally, I don’t think hospitals have to employ physicians to get them on board with cost-effective care:  they just have to stop having such a schizophrenic approach to hospital-medical staff relations.  Another health reform proposal involves global payment schemes, but giving hospitals all the money and letting the CEO decide how much to pay each physician and how hard to work them is not likely to improve those relations.  The payment machinations of managed care are not going away, they will just become more devious.  I am afraid we are in for some rather unpredictable changes in the way EPs are compensated under health reform, and my greatest fear is not that compensation will go down, but that it will become even more politicized, and even less rational.

Health Promotion
Here is where I believe the ED may have an expanded role under health reform.  There is a lot more that EPs and ED staff could do to derail bad habits, interdict social circumstances that undermine health, educate the ill informed, reinforce healthy choices, and generally promote wellness in the community.  However, since we are running up against the headwind of cost-containment in an ‘expensive’ venue; chances are few will be interested in paying for EDs and EPs to play in the health promotion sandbox.  Never mind that the only time stubborn smokers might finally be willing to quit smoking is when their T-waves look like tombstones, or that high schools quit teaching parenting skills in the 80’s. The best chance for this to happen would be if, in the process of bumping up primary care compensation, the cognitive skills of EPs also get boosted.

Surge Response
This one is really perplexing to me – how is it that in the aftermath of 9-11 and SARS, the ED’s role in disaster and pandemic response has gotten so little attention and financial support?  Getting ED Boarding legislation through Sacramento has been a real grind, and we can’t even talk about transfers to inpatient hallways without getting everyone in a snit.  How important will health care reform seem to the victims of the next Katrina, if surge response and the fragility of the ED safety net continue to be neglected in the halls of Congress during this great debate?  You think a scarcity of ventilators might be a problem if H1N1 gets nasty:  try finding bed space and nursing staff in the ED.  Actually, forget the big disasters for a minute, and think on the every day disasters, when ED overcrowding gets BAD, on-call docs disappear from the rosters, and no one gets the service they deserve.  How does that scenario, playing out in hundreds of EDs throughout the nation every day, comport with the objectives of health care reform in the US?  Can we really claim to be ‘fixing health care’ if we don’t fix that?!?   Considering the Massachusetts experience, providing ‘coverage’ for every citizen is only going to compound the problem of ED overcrowding, and diminish, not enhance, ED surge capacity.

ACEP, and the State chapters, have a lot to talk about in the next few weeks and months; let’s just hope that those intent on their own particular version of health care reform might take a few moments to listen between rounds of pugnacious advocacy.

Myles Riner, MD, FACEP

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Next Steps at Home

Now home in Dayton for me and wherever you are today, the real work begins.  We had a strong start at LAC this year in Washington DC with over 400 hill visits, but that is just the beginning.  Now comes the grassroots ground effort to obtain more sponsors, gather support, and lobby for a hearing.  Whether or not you were at LAC, emergency medicine needs your help!

Write a letter.  Take the time to thank those that you met with in DC if you had the opportunity to travel.  If you did not make it to DC, write to your legislator and senator and encourage them to support the Access to Emergency Medical Services Act of 2009 (HR1188, SB 468) this year.  It does not need to be long.  Just tell them the problem of overcrowding, given them a story of their constituents, and the benefits of the bill.  For those that may not be as familiar, this bill studies the problem of overcrowding, works to develop and implement the suggested solutions, and provide funding for those that provide emergency care to encourage on call coverage and access to emergency services.  A few minutes to write a letter can make significant change!  I encourage you to lobby your partners to do the same.

Write to the papers.  It is truly amazing how willing the papers are to publish a letter to the editor from a physician.  There are standard letters that you can obtain from the ACEP advocacy folks, or write your own.  Most have a word count around 250 words, so you can make it short.  Just take the time to get the word out.

Talk to your friends/colleagues/administors/etc.  Start the conversation on the overcrowding problem.  If you suffer right now from overcrowding, use this as a launching point for change.  If you are among the lucky few who have not experienced significant overcrowding, work toward a prophylactic solution and get some of the solutions in place.

In the end, the work on DC is only a start, the real work begins at home.  Keep up the progress and the hardwork.  Make a real effort to build on the success and relationships you have formed.  We need to remind those that are going to define health care reform that the emergency department has been and will be the national safety net.  We need a seat at the table.  That only happens with your support and dedication!

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