Why deferral of emergency care is risky and unethical

Boondoggle – a scheme that wastes time and money. Perhaps this is not the best way to describe the many efforts that are being made to try to keep patients with non-urgent problems from using the emergency department, but from where I sit, deferral of ED care is a cost-saving tactic that not only fails to deliver much in the way of cost savings, it also is a strategy that can be both risky and unethical. More importantly, the focus on deferral of care and “unnecessary ED visits” as a cost-containment tactic is a distraction from efforts that would yield far more savings at far less risk to patients, and to our fragile emergency care safety net.

Recently, I worked with one of the major health plans to look at over 637,000 consecutive commercial and Medicaid California ED patient visits over a one-year period (excluding ED patients who were admitted to the hospital). Based on the data below, it is clear that those 20% of patient visits that represented the least costly visits (facility plus professional ‘allowable payments’) accounted for less than 4% of the total cost for all non-admitted ED patient visits.

Rank            Total Allowed             % of Total Allowed
1                 $520,314,096                       54%
2                 $195,156,385                       20%
3                 $129,376,962                       13%
4                  $84,949,393                          9%
5                  $33,929,559                          4%

Remember, this data just represents patients who were not admitted (facility costs for ED care of admitted patients are bundled into inpatient payments). Thus, it is likely that the bottom 20% of admitted, discharged, and transferred ED patient visits likely represented between 2 and 3% of the total cost of care for all ED visits. ACEP has been saying for a while now that (depending on the source of the data) ED care accounts for around 2% of the $2.4 trillion spent on all health care costs. Now the estimates of the percentage of ED patients who ‘don’t need to be there’ or have ‘non-urgent’ or ‘non-emergency’ problems is a bit more wide-ranging, depending on the agenda of the estimator; and numbers as low as 10% and as high as 50% get thrown around all the time. The Rand Corporation put the number at 17%, the CDC at 8%, and HCA Gulf Coast Hospitals put the number at 40%! Clearly, no one seems to be able to define this group in a standardized way, but it is clear that as the poster child for unnecessary and expensive care, the ED has become the target of many attempts to reduce costs by keeping patients out of the ED, or sending them away, based on screening criteria that may, or may not, meet EMTALA standards. Much has been written about the down-sides of the deferral of ED care strategy, and ACEP has a policy that opposes deferral of care, especially when it is not accompanied by adequate access to alternative care venues and carefully designed programs to arrange for timely and appropriate care for those whose care in the ED is deferred. Most ED physicians agree that the way to reduce unnecessary visits to the ED is by improving access for non-urgent care in clinics and primary care offices. However, my issue with all the hubbub about cost-containment through deferral (or denial) of ED care goes beyond the ethical and risk issues: it simply is not a cost-effective strategy.

Let’s assume that it is possible to accurately identify and screen the patients that do not need ED care without missing the patients who really do have an impending medical emergency in the early stages of presentation, and that we could reasonably eliminate the 20% of ED visits that use the least amount of ED resources. I don’t actually believe this is possible, but let’s make this assumption. If it were, we could reduce the US health care budget by something like 3% x 2%, or 0.06%. But wait- surely some money would have to be spent caring for most of these patients in the clinic or PCP’s office. So perhaps the actual savings from deferral of ED care might amount to 0.05% of the health care budget (50 cents for every $1,000). Probably, the number is even lower. Yes, I know, it is real money, but in relative terms, they call this ‘budget dust’.

The study on ED visits in CA that I mentioned above also looked at costs by procedure and costs by diagnosis for those 637,000 patients. I was surprised to learn that renal and ureteral stones accounted for $25 million of the $963 million spent on all these patients. So, roughly, the same amount of money was spent taking care of 7,900 patients with kidney stones as was spent on taking care of the 127,000 patients who might have qualified for deferral of ED care. In fact, the data from the Anthem study suggested that we could save as much money by reducing the number of CT scans done in the ED by 1 out of 12 scans as we could by barring the door of the ED to every single one of the 127,000 patients in this study who accounted for the lowest 20% of ED costs.  My point is that all sorts of legislators and health plan executives and government regulators are screaming about, and scheming about, reducing unnecessary ED visits, and distracting us all from focusing on where the real money gets spent, and the real savings could be achieved. You want to talk about saving health care dollars: let’s look at back surgery, depression, end of life care, obesity. But no, the focus of TENCare and HCA and the Dr. Thompson’s in Washington State and elsewhere is on the ‘imprudent’ parent who takes their screaming, vomiting, febrile 2 year old child into the ED at 3 AM, only to be diagnosed with a lowly ear infection. And to top it off, the solution to this problem that many Medicaid program directors and legislators have lit upon, the best way to keep these patients out of the ED, is simply to decide, after the fact, not to pay the ED physician for having provided this care. Yep, that makes a lot of sense.

Myles Riner is an emergency physician who blogs at The Central Line, the blog of the American College of Emergency Physicians.  Reprinted with permission from the ACEP.

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  • Anonymous

    Yup, Dr. Riner gets it right.  The idea that our society will save lots of money by keeping otitis media patients and drunks out of the emergency department is simply wrong. Cost-cutting is much more complex than that.  It requires a multi-faceted approach, including lower payments to doctors and hospitals, decreased drug costs, less hospital care, fewer expensive procedures and lower reimbursement for those procedures.  The list goes on. 

  • Anonymous

    I believe a large part of cost savings would happen if providers would be willing to practice cost conscience care, but in the ED there is so much CYA (Cover your A… you get it. ) You come in with abdominal pain suggestive of Appendicitis, you automatically get a CT Abdomen. Couldn’t you use your clinical judgement and labs and exam to see if a CT would be needed. NO…. because if this person has a perforated appy, you could get sued for missing it. So they get the CT… and the money is spent. Colicy abdominal pain with + blood on a UA and h/o renal stones.. do you treat for a suspected kidney stone.. Nope, you get the CT Abdomen to see if you missed anything… 

    Also there is the customary practices of the area that providers must follow. Even if there would be a lone provider who is willing to practice cost conscience care, he could be found liable for now following customary practices. Even if he has evidence backing up his claim of not getting XYZ test or image. Unless the change is made on a larger scale, no physician will risk their livleyhood to stand out. If you spent 8+ years training for something, how caviler would you be on risking loosing it?

    Changes need to be top down to give providers reassurances that if we practice good medicine with the patients interest in mind, that should be enough and we should be protected from the rare zebra that bucks us and risks our jobs. To expect perfection in medicine is to welcome failure.

    My 2 Cents…

  • Anonymous

    Dr. Riner, you wrote: “Based on the data below, it is clear that those 20% of patient visits that represented the least costly visits (facility plus professional ‘allowable payments’) accounted for less than 4% of the total cost for all non-admitted ED patient visits.”
    What’s more clear, as you point out elsewhere, is that a lot of those people, along with others that maybe don’t even fall in your “least costly” group, had no business being at an ED at all – but they (and frequently their employer, or other 3rd party payer) were quite likely charged as if they did. 

    And many people are not so much concerned about budget dust as behavior ‘friction’ – the bad habits both people and systems adopt when they do things that don’t make sense; like, for example, getting care in inappropriate settings, and at inappropriate prices.

    No one really wants the ‘triage’ to fall on the shoulders of ED physicians or staff. There are easier, more appropriate paths to coax people to get care where it makes more sense, most of the time. And a variety of initiatives are underway to encourage that kind of better habit. Will they succeed or fail? who knows. But they’re worth trying.

    in other words, Dr. , Riner, you’re missing the point of the ‘diversionary tactics’ you mentioned at the outset of your essay. But we have a hunch you already know that.

  • http://profiles.google.com/molly.ciliberti Molly Ciliberti

    Excellent post.
    As the mother of 5 kids and also a critical care nurse, dealing with a baby
    with a temp of 104, screaming and vomiting is terrifying especially if it is
    your first. My husband, and ED doc, used to say when a patient develops
    belly pain at 5 PM and thinks they can tough it out until 0900 the next morning
    and go see their doc, finds that at 3 AM when the pain is worse and they are
    alone and scared finally can’t take it any longer and comes to the ED for help.
    They tried to be the good patient and now they need help. Isn’t that what the
    emergency department is there for? 

  • http://pulse.yahoo.com/_EM4LH5YBE3THRPAPEEGUMK572M russ

    “Boondoggle – a scheme that wastes time and money.”
    Three-word response OWE BAM A

    What about illegals? What about all those nice Medicaid folks who smoke, dope, booze, etc. and expect others to pay for their problems? Who have 2+ kids and expect others to pay?

    How about caring about those without kids and live healthy, Mr. OweBama?

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