by Edwin Leap, MD
One of the many questions asked in the health-care reform debate is ‘how do we keep people out of emergency departments in order to reduce costs?’ Simply put, we probably can’t. And 16 years into my emergency medicine practice, I think I know why.
Having taken my own children to the emergency department, even I have been surprised at the charges generated. But we should step back and remember that emergency departments provide care to all, regardless of their ability to pay.
They do this because of a law called EMTALA, enacted in 1986. The Emergency Medical Treatment and Active Labor Act became law due to the ‘dumping’ of patients from hospital to hospital for inability to pay. It was a good idea, in theory. Prior to EMTALA, very sick individuals or women in active labor were sometimes transferred without being medically stabilized, or even accepted by another doctor. Tragedies resulted.
However, like so many government regulations, it grew beyond its original intent. EMTALA has come to mean that anyone, with any complaint, at any time, can seek care at any emergency department regardless of financial considerations. The law creates a safety-net for the poor, and to that extent it is beneficent.
However, when millions of people use emergency departments and can’t pay, aren’t paid for by someone (like the government who made the rule), or don’t intend to pay, the price goes up.
Look at it this way. If you own a computer-store, but only 33% of your clients actually pay for their computers, you’ll either close, or increase the price on the customers who do pay. So, hospitals can either close their emergency departments or raise charges.
Consequently, many hospitals and emergency departments have closed due to the financial burden imposed by well-meaning politicians. And specialists have decreased their availability. After all, the law requires them to see high-risk patients for free, but without even the courtesy of offering those skilled physicians protection from lawsuits as an inducement for their efforts.
In the end, the price of emergency care has risen so that the insured, the paying, can cover the cost of the uninsured and non-paying. Ironically, as we wring our collective hands over the cost of emergency care, it’s actually not unlike the concept of taxing some to pay for the care of others. .
But government intervention isn’t the only reason for expensive emergency care. You see, emergency medicine is a very young specialty, but those of us who practice it have become very good at our jobs. We have learned how to intervene more effectively in the early hours of stroke, heart attack, poisoning and trauma. Our emergency departments, with all of their technology, emergency care specialists and other vital staff physicians, are available 24 hours a day, seven days a week, holidays and weekends.
There aren’t many comparable professional settings. Very few specialized businesses are available around the clock, and provide a service so absolutely necessary, so dependent on education and science and so accessible to all regardless of payment. Even fewer welcome clients who are violent, intoxicated, psychotic or addicted; or who may have communicable diseases like H1N1 or SARS.
And whether the our patients are paying or penniless, we examine them and review their X-rays and lab results. We order stress-tests, we call surgeons. We have a finite window of opportunity, so we answer questions as quickly as possible. And frankly, that’s the way Americans like it. Instant gratification is as much a part of modern American health-care as Penicillin.
So, we have raised the bar in our provision of immediate, urgent and emergent care. Patients are unlikely to let us lower it. Few will suddenly say, ‘I feel sick, but I won’t go to the emergency department. I’ll see my doctor in a couple of days, since that’s best for him, for me and for the economy.’
Increasing the number of primary care providers will help, but unless they can match the accessibility of emergency departments, unless they’re willing to see everyone and bill them later and unless patients learn to accept delays in both evaluation and final diagnosis (not always unreasonable), emergency department usage and cost will not decrease.
Because, quality emergency care, mandated by the government and provided around the clock, costs a lot of money.
Perhaps, from the perspective what emergency departments do, and how they are federally mandated to do it, the cost isn’t so high after all.
Edwin Leap is an emergency physician who blogs at edwinleap.com.
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I am a firm supporter of out need for more primary care physicians. I am not sure though that more will decrease the number of patients going to the ER. The reason is this. People tend to go tothe doctor when there is something wrong, they dont like to go when they feel ok. This is why I think “preventive care saving health dollars is a fantasy”. We know that it is a good thing to change the oil regularly in our cars but how many of us do it? Of our insured patients in our practices, how many are up to date on their health screening exams? The long and short of it, people will procrastinate until they have a health crisis, and then they will go to the ER. They will also wait until their health problem really bothers them, (like not letting them sleep) so they will go to the ER in the middle of the night.
When patient end up in a ER or hospital, it is usually failure of the outpatient medicine. I am not talking about mistakes in clinical judgement, but failure of the process. It could be non compliance with medication, failure to seek medical attention in time, inability to afford medical care.
Strengthening Primary Care and incentivising the general population to use it should hopefully go a long way in decreasing healthcare cost. Not to mention Tort reform to prevent wasteful test ordering.
Thank you for this insightful article.
Wouldn’t the answer to this depend on the schedule of health screening exams, for which there often is not much of a consensus on frequency, or even whether to do certain screenings at all?
I get people in my office with emergency conditions all the time. Severe hypertension yesterday 200/120 with headache. New diabetic last week. The usual flu and such. Dehydration. Sometimes sent on to the hospital, most of the time followed closely as an outpatient. They come to me because they know I can usually see them on short notice, most of the time the same day. No I’m not open nights and weekends. So they don’t call me at 3-AM because they know they can just come in the next day.
Then again, I’m solo, independent, so I don’t have some boss forcing me to run a mill. And I expect to be paid for services rendered.
I have some Medicaid on a limited basis. They show up at the ER, they get sent straight back to me, teaching them to use the doctor’s office. Uninsured patients learn the urgent care is charging literally twice my fee for the same service. I’ve seen the fee schedules at a couple of the nearby urgent care clinics, it’s right at 2X my fee schedule.
Then again……I understand what some go through. I’ve worked at some urgent care clinics and hospital-based primary care clinics. Fortunately I managed to negotiate out any noncompetes. They like to churn doctors. They are probably kicking themselves for not forcing one on me, but they were desperate at the time. Gotta figure, if they treat the doctors like shit, with so much turnover, what makes you think they’ll treat the patients well? So I bailed after a few months, I can’t understand how people stand them. Well, I guess they don’t, the place was a revolving door.
But I would see patients all the time. 10-AM on a Tuesday, with a cold. “Why aren’t you at your regular doctor’s office?” “They said their next opening is two weeks.”
Even for emergencies. Amazing. I can’t believe how some of these clinics are run. Then again, they have two receptionists in front, two nurses in back, someone just doing Press-Ganey bullshit, middle managers and all that. Somebody has to actually earn their salaries, Lord knows they’re not doing it.
So Atlas shrugged and opened an independent office. Profitable at a third of their volume. The price I pay is, there’s a light out. I will install my own ballast and lights this weekend.
Good trade I say……..
Socialize medicine so payment in the ER isn’t an issue. Fine people who abuse the system.
OR
Get rid of EMTALA. Make medicine a truely capitalistic endeavor. Retail clinics can fill the gap for those non-life threatening conditions. People will gravitate toward the cheapest service.
Primary care doctors can keep some patients out of E.D.’s but they need to change how they practice. Primary care v2.0 will need to serve up care fast food style- cheap, fast and 24/7. A paradigm shift toward telemedicine and home visits is needed. The question is will fast food primary care medicine, like cheeseburgers turn out to be bad for your health; maybe, but done well, it can provide quality non-emergent care and take some of the load off E.D.’s.
Repeal of the Stark Laws would be helpful too. Most ill patients need labwork and x-rays; even if a primary care doc were open 24/7, he couldn’t provide these necessary services.
Why can a dentist provide x-ray services, but not an internist?
I call my own practice of charging the wealthy to subsidise cheaper or even free treatment of the poor “Robin Hood” medicine. I think it’s a good and easily understandable term. If I can do it and survive, others should be able to as well. I hope! But I make sure all patients know why my charges may differ – that is transparency!
You make an interesting case, but we should all prefer fact to theory. To what extent increasing primary care access will decrease ER visits is really unknown.
I can spin a counter-theory. We do a lot of urgent care in our office. When we’re open, pts with 2 cm lacerations or otitis externa see us. When we’re closed, they go to the ER. We’re super busy, in a primary care shortage area. If we could hire another family doc or two, would that decrease volume in the ER ? I bet it would.
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