The vicious cycle of emergency department use

Inappropriate use of emergency departments (EDs) → congested EDs → over-worked staff members → frustrated staff members → speculation of more non-emergent ED usage → expectation to provide high customer satisfaction scores → decreased actual customer satisfaction → decreased reimbursement → higher costs of ED → budget cuts → decreased staffing → return to beginning.

Whose idea was any of this?  None of it makes sense to me.  The idea of providing reimbursement to healthcare agencies based on customer satisfaction scores is a ridiculous scheme.  I’m not saying healthcare providers shouldn’t be kind, compassionate, and practice with integrity.  What I am saying is that withholding reimbursement from hospitals because people aren’t satisfied with their care is dangerous, mindless, and lacks financial and common sense.  It forces healthcare professionals to meet a checklist of criteria rather than empowering them to practice the compassion they have naturally.  It sets them up to enable people who are abusers of an already broken system and reward negative behaviors, all for the sake of making a few pennies on the dollar.  This is not a restaurant or clothing industry.  To treat it the same is preposterous.

Recognizing that many patients abuse the services of the ED, I don’t negate the fact that there is a population of patients who simply have nowhere else to go for healthcare.  For instance, they may be travelling, it may be a Saturday morning with no clinics open until Monday, a patient may have Medicaid and can’t find a physician who will accept that form of payment, or someone may simply be uninsured with no resources.  These patients are not part of the population who blatantly misuse EDs.  The population of patients who misuse EDs are the focus of the root cause in this large problem.

People seek emergency healthcare when they have a health condition that threatens life, limb, or bodily function, right?

Emergency departments have simply turned into 24-hour clinics, not a place where credentialed, licensed, certified emergency professionals take care of true emergencies anymore.  The specialty of emergency medicine has only become a jack-of-all-trades profession where these highly-trained professionals are taking time to do lice checks when sicker patients need their attention.

When people who have non-emergencies go to the ED, they have to wait for the critically ill patients to be cared for first.  Naturally, people suffering from strokes, heart attacks, and septicemia, for instance, should be the highest priority.  The problem is that this is big dissatisfier to non-emergent people who have to wait, and customer satisfaction is a high priority of the corporation and its governing bodies.

As a matter of fact, some EDs have created “fast track” areas to accommodate non-emergent patients.  The idea is to get them in and get them out as quickly as possible.  Treat ‘em and street ‘em.  They go to a separate area of the ED to get their care because that area is not set up to take care of life-threatening emergencies.  While the main part of the ED that’s reserved for the sickest patients is full, the sicker patients in the waiting room are the ones who end up waiting the longest for the appropriate area in the ED that is equipped to handle their situation.

Is that the ethical thing to do just to increase customer satisfaction among the people who don’t need to be in the ED to begin with?  EDs are chronically full with no admission capability because of a full hospital and the ED patients are too sick to be discharged home.  The EDs get stuck at a standstill, holding patients and not getting the new ones in.  Meanwhile, non-emergent patients congest the “fast track” area and wait for minor care, the sickest patients are still in the waiting room receiving no medical care when they’re the ones who need it most, and everyone winds up being dissatisfied with their “care” in the ED.  This result is then reflected on surveys.

Oftentimes, non-emergent patients (uninsured, Medicaid, and insured) call ahead to make appointments to the ED, want to know the wait time to see a doctor, request to be seen quickly because they have somewhere to be soon, or even ask who the staff is on during that shift because they frequent the 24-hour clinic so often they know staff by name.  Is that what EDs were meant to be?  A large population of non-emergent patients request things like prescription refills, referrals to rehabilitation centers, second opinions of chronic conditions, and (not kidding) lice checks.

Every single non-emergent patient accrues an emergency department bill.  If those patients are uninsured, the hospital will probably write off that amount and certainly not generate any revenue.  If those patients are on Medicaid, the hospital can count on being reimbursed a few pennies on the dollar.  Insured patients who are paying monthly premiums, paying a deductible, and being billed for their high-dollar emergency care have larger-than-expected bills because of the inflated costs meant to make up the difference for loss in reimbursement or non-payment by other non-emergent patients.  I do not dispute that these people need healthcare.  The ED is just not the place to seek and shouldn’t be their only resource.  Actually, the ED frequently offers quite limited care that is far from what non-emergent patients need.  Yet they are billed for emergency care.

Medicaid reimburses pennies on the dollar.  Of course, primary care physicians and specialists whose intentions are to make a profit commonly don’t accept Medicaid patients or uninsured patients.  So patients can’t find primary care for their chronic and non-emergent needs.  And they certainly can’t easily find specialists.  So where do they go?  Well, to the only place that, by law, cannot refuse a medical screening — the ED.  And when they go to the ED unnecessarily, they get billed for emergency care, do not receive the specialty care they need, get referred to an appropriate resource but can’t afford to go, go home and get sicker, and land back in the ED with heart attacks, stroke, and septicemia.  More important than reimbursement, this is extremely unfortunate for patients who need healthcare and can’t get it, who have preventable diseases processes but can’t get the proper care, who are simply looking for healthcare.  But it all comes down to the money.

Multiple EDs have attempted to provide the required screenings to deem a patient emergent versus non-emergent.  But where does the ED staff send someone for care when there’s no other place either open or that will accept Medicaid or uninsured patients?

Speculation has been that, while inpatient services will be decreased, use of the ED is expected to skyrocket at the same time hospitals across the nation are closing.  Already congested EDs will now be fewer and more far between and expected to take on even more patients every day.  These patients who are already dissatisfied will now have even longer wait times, have more frustrated and over-worked nurses and physicians, receive less compassionate care, be billed at horrendously high rates for this suboptimal care, and then complete surveys reflecting dissatisfaction.  Does any healthcare corporation actually believe that ploys like advertising wait times to the public helps with the underlying problem?  Or that expecting staff members to go above and beyond to satisfy people with a smile and giving all the small extras will help the matter when all they’re doing is trying to keep their heads above water?

Maybe the easiest solution would be for the government to fund actual 24-hour clinics to avoid misuse of EDs and unnecessarily inflated healthcare costs that seem almost inevitable in this vicious cycle of failure that we’re stuck in.  That seems to be a cheaper solution than just sending everyone to the EDs.

Sarah Jorgensen is a nurse.

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