Another study rebuts the myth that the uninsured are flooding the emergency departments.
Kids comprise about a quarter of emergency visits with a majority of them are for non-urgent conditions. In this study at a single children’s hospital ED, “95 percent had some form of insurance, and 97 percent had a primary care physician.”
The problem was access, such as long appointment waits and problems with communication. Full schedules led PCP offices to direct treatable cases to the ED.
This adds to the growing body of evidence suggesting that improving primary care access can go a long ways to decompressing crowded emergency departments.
topics: pediatrics, emergency
Related posts:
- USA Today op-ed: Poor physician access worsens emergency department crowding
- Emergency department overcrowding
- Poor primary care access drives up emergency department use
- Should we screen for HIV in the emergency department?
- That’s how you cut emergency department use
- Emergency care
- Violence in the emergency department and how to promote ER safety
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{ 5 comments }
Kevin, I have to ask.
Just what the hell does "improving access" mean? If a PCP's schedule is full, it is full. There are only so many hours in the day – or double & triple slots on the schedule.
I've been on both sides of the equation . . . I've worked as a PCP (mostly in rural and suburban areas) and in a big-city ER.
As a PCP in a rural area (on several occasions, I've been the only Ped in the county), you've got to see a full schedule of patients (ballpark 30-50/day), AND cover every emergency/C-Section at the hospital (where your schedule is ALWAYS at the mercy of the OR – or the OB's), AND take all the "Mommy-call" (most of it non-emergent), AND cover nights/weekends.
Hospitals are rarely sympathetic or helpful with any of it – they just keep piling it on.
On top of that, you're on the bottom of the reimbursement food chain (or like the story of me in my own hometown, you wind up getting taken for granted/treated like crap . . . because the executives making three to four times your salary think you're a "dime-a-dozen").
You wind up having no life and burning out. After a while, the question becomes, "FOR WHAT?"
It's only going to get worse (again, especially in rural areas), as more and more medical students decide it's just not worth it.
On the ED side of the equation, you bust your butt all day and night taking care of the real emergencies – along with the PCP's overflow and/or "dumps" (again, because at some point the PCP has to draw a line in order to stay sane – so I do sympathize). The nice thing is, it's shift work and when you're off, you're off. But the risk of getting caught up in a lawsuit – seeing patients you do not know, is much higher.
"Improving access to care". I just don't know what that means. And the way things are (meaning society's increasing sense of entitlement – combined with the demand for instant gratification – not to mention medical perfection), I just don't know how you do it.
The "passing statement" is usually the most telling FP 8:17.
You're spot-on about the "convenience factor" . . . and the need for a seismic shift in what patients expect/demand.
It does seem to be a generational thing. I joke with my Mother (who taught school for thirty years and watched another evolution-of-parental-bad-attitude there) that my head had to be hanging from a large vein in order for her to call the doctor after hours – or go to the ED. The doctor's "down time" was respected – his/her services were valued. But parents/patients these days exercise no such restraint – or sometimes even common sense.
Virutally nobody is talking about it (except anonymously) – because they live in fear that having an opinion/expressing it will "hurt the business".
But in what world does it make any sense for a parent/grandparent to sit in a ED waiting room 12-15 hours for "thrush" or a diaper rash?
I've walked into an exam room . . . exhausted & worn out from busting my butt to see whatever came in the door . . . only to have the adult relative accompanying the child (for a non-emergent complaint) immediately threaten to sue me because she had to wait.
She didn't turn down the cable TV to make the threat – as she gobbled down her "free" chicken strips & frys from the the hospital cafeteria.
There is always a balance between systemic changes and what an individual Physician is attempting to do on their own to simply treat today’s cases.
The Institute for Healthcare Improvement for example has some good research on Primary Care Access and how 1) shape demand 2) matching staffing with demand 3)redesigning the system
http://tinyurl.com/6oqmqj
Although you can’t control external demand (how many patients want to be seen) you can influence how often you bring someone back for repeat visits for example. We know from the Dartmouth studies that one of key factors in the number of visits is simply the number of specialists in an area and not the quality of care provided.
You can also supplement care with NP’s for many conditions (as demonstrated by minute clinics) or even add a family practice or fast track clinic to an ER.
It often helps for entire communities to work together to solve access problems versus trying to control one part of it on your own. In some systems (Group Health for example) up to 25% of primary care visits now take place via the phone or email and open up slots for the more complicated visits.
There are solutions out there and this is a critical issue for us to address.
Cascadia, I’m not trying to save the world as an individual physician in solo practice. I’ve never owned my own practice (please visit my blog if you have any questions as to why). But I can tell you that right now, there is NO good balance between the individual doctor trying to get through the day and the system trying to eat him/her.
Since being employed (as a youngster) by one of those supposedly community-minded, “team-playing” “non-profits” (which ran me out of town after my public service gig was up . . . so it could keep the business for itself and its ED), I’ve been an independent contractor. And I have seen it all.
“You can also supplement care with NP’s for many conditions (as demonstrated by minute clinics) or even add a family practice or fast track clinic to an ER.”
Here again, supplementing care with NP’s is DEVALUING the physician. Adding an all-hours clinic to the ED (I assume a hospital would control that) only FEEDS the expectation/convenience monster.
The “repeat” visits I schedule these days generally need to be re-checked.
Re: Demand. I beg to differ. You CAN control demand if society/communities would take steps to educate those doing the demanding. We’re not. All of our systems are set up to reward bad behavior. But even so, patient populations can be educated . . . in some cases, re-educated . . . to operate within guidelines and appreciate/cooperate with their doctor. I know because I’ve done it in a couple of situations that were WAY out of control when I walked in the door. Alas, it generally takes more time and work than the average healthcare executive is willing to expend . . . and God forbid that anyone give into the notion that “the customer” is not always right.
Until we get some tort reform, I for one, am not going to be practicing medicine by phone or e-mail. Moreover that should not just be about clearing time to get more complicated cases on the appointment schedule. The time on the phone or spent responding to e-mail needs to be fairly re-imbursed (especially if you can get sued for the advice/treatment you provide).
There are solutions out there. Speaking of re-education, it would be very nice if the consultants would spend more time talking to physicians rather than suits.
I tend to follow large population studies versus those with small sample sizes and avoid personalizing any of this. Ie “real emergencies” “instant gratification” “entitlement”
Group Health Cooperative in Washington State for example has been very successful at using online visits and since their providers are on salary they are “Paid” for them. Aetna is also now reimbursing providers for e-visits.
AHRQ study http://www.innovations.ahrq.gov/content.aspx?id=2133
Heavy penetration of EMR, leading to fewer visits and phone calls:
Approximately 48 percent of eligible adults currently use the online medical record. In addition, approximately 30 percent of laboratory studies ordered by medical group members are reviewed by patients online; in certain medical centers, this number is as high as 50 percent.
Approximately 23 percent of encounters now occur via secure messaging.
A survey of users found that the secure e-mail function replaces more time-consuming access methods, including office visits (27 percent of the time) and telephone contact (67 percent of the time).
Less then 4% of medical students are selecting family practice so it is critical that we use the highly trained Family Practice Doctors that are out there for the more complex care and NP’s and PA’s actually improve the prestige of a Family Practice Physician.
“”Now more than ever NPs are vital to solving the lack of affordable, accessible, high-quality care in the U.S. health care system,” said Dr. David Nash, Dean, The Jefferson School of Health Policy and Population Health.
“With millions of our citizens having limited or no access to preventive care, and many more without a source of ongoing primary care, these top professionals truly deserve to be recognized for the efforts they are making every day in helping America get and stay healthy.”
Thankfully I am hopeful and see real progress coming in the next few years. Consumer’s (that includes employers and those that pay for care)and the politicians who represent them in concert with providers will be able to change the system to provide patient centered high quality healthcare.
(BTW – Since I have trained over 1000 surgeons and physicians in both work flow redesign and EMRs I get to talk to them all day long and as a former EMT I also am very aware of the challenges encountered in the ER.)
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