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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  • edwinleap

    Outstanding! You are absolutely correct. The avalanche is upon us. Have insurance? You may not find a doctor. Even if you do, he or she will direct you to the ER when you call with an acute illness or injury. Don’t have insurance? There’s no place but the ER. I like your suggestion for federal primary care clinics, too!

    • Margalit Gur-Arie

      They already have those. Why not require that P-PCMH (public PCMH) is staffed 24×7, and get this over with? Bigger question might be if anybody will actually go there instead of the ED…

      • buzzkillersmith

        24 7. Good one, M. Can I take the midnight to 10 am shift? No more than 6 or 7 days a week though.

        • Margalit Gur-Arie

          Very gracious of you to offer… :-)
          Don’t they have something called nocturnists? Maybe they can budget the hiring of folks that want to work at night anyway into CHCs operations…. Personally, I don’t think this will work unless it’s collocated with the hospital, but hospitals may not want to have such arrangements, unless they are allowed to triage by insurance type….not likely to happen….

    • Mengles

      We have them already – they’re called VAs. Why not let the general public have access to VA primary care clinics.

  • Dr. Drake Ramoray

    The NHS hasn’t solved this problem either.

    And I’ve only seen the billboards and advertisements for wait times in affluent neighborhoods.

    • Margalit Gur-Arie

      and they all say 10 minutes wait or even 0 minutes wait. How is that possible?

    • buzzkillersmith

      Yep. People might not do what we want them to do, but they can be relied on to do what they judge is in their own best interest.

  • Ron Smith

    Hi, Sarah.

    “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.”

    The faster you try to take care of non-emergent cases through the ER doors, fast track or not, the faster they will pour in.

    The only thing that will make the merry-go-round stop is when ERs start really buying into redirecting patients to primary care doctors during regular office hours. I don’t see why a triage nurse in consultation with a physician can’t do that?

    This will stop the expectation that ERs must see all comers! Nothing else you say or do will change the frame of mind of the patients who know that they are going to be seen regardless. People must learn that they are not entitled to be seen as emergency cases just because they walk through the ER doors.

    ERs need to collaborate in some way with primary care practices to arrange for those patients to be seen in the regular office settings.

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • buzzkillersmith

      Redirecting patient to primary care? Good luck with all that. I have enough to do, thank you very much, without being an overflow clinic for the ER. I’ll see my own pts, but I won’t work 13 hours a day to help out the ER.

      They’re at the bottom of the funnel now. At least the docs can leave when their shifts are over–at least a few hours later anyway.

      You can’t stuff 15 lb of sugar into a 10 lb. sack, and that sack is adult primary care.

      • Ron Smith

        Hi, busskillersmith.

        I’m not talking about taking these patients as unassigned overflow. I’m talking about redirecting them to practices that are taking patients.

        They need to be redirected so that they stop using ERs as primary care facilities. They are not for primary care. They are for emergencies.

        There are basically two streams of patients seeking primary care: those that have primary care physicians and who use the ER or urgent care sparingly, or those who use ERs and urgent cares instead of primary care practices.

        I doubt if we can resolve the overuse and inappropriate use of those emergent/urgent resources until we change the mindset of those who misuse them.

        Warmest regards,

        Ron Smith, MD
        www (adot) ronsmithmd (adot) com

        • buzzkillersmith

          Redirection is fine, but in many areas there are very few docs taking new pts. The devil is in the details.

          The mindset is to a great extent a product of the primary care shortage and that shortage, of course, is a product of the nastiness of the job.

          Until or unless this country changes how it funds medical care, this will continue. I expect these same posts 5 years from now.

        • T H

          My ED is in a rural area and all of the practices that are still taking new patients are quite literally flooded now that ACA/Obamacare has fully kicked in. 2-4 month waiting times… until the doors close to new patients, which is certainly happening soon.

          Until then… Fast-Tracks with PAs overseen by the ED doc (because triage doesn’t always catch every seriously ill patient).

          • Ron Smith

            Hi, TH.

            Oh, my. This is a disaster for you! Perhaps there needs to be a hospital clinic for those who don’t have Docs and don’t need to be seen in the ER.

            The point is that an ER should not be the overflow solution to patients who won’t or can’t establish a regular physician relationship. These sources of care are much too costly for routine stuff.

            Until ERs and urgent cares embrace that ERs are for emergent/urgent care and start shifting patients in some legitimate way to practices or alternative temporary care day clinics, I see now end to this black hole.

            Perhaps with the changing attitudes to private practice that this crisis will certainly highlight, we might regain some practice sanity here.

            Warmest regards,

            Ron Smith, MD
            www (adot) ronsmithmd (adot) com

          • T H

            Two of the 4 clinics ARE hospital clinics. And they’re being crushed. Where I live is severely underserved by just about every specialty (except, weirdly, Ophthalmololgy).

            I don’t have to worry about job security. I have all I need…. and since I’m FP trained, when I get tired of ED, I can just open a clinic and work 80h weeks in clinic on days instead of 80h weeks as a rotating shift!

            So… we plug along as best we can. Semper gumby.

    • Dr. Drake Ramoray

      Hi Ron,

      I have the utmost respect for you and your postings but there are several flaws in the divert non-emergent cases from the ER to primary care.

      First is someone has to evaluate the patient to decide to divert them, with minmal or no testing, as you suggest. The Univeristy hospital from my residency program tried this with the nurse triaging to an actual on-site urgent care clinic (granted it wasn’t open 24 hrs.). During my month rotation in the urgent care component I personally had a “fatigue” that turned out to be a relatively critically ill acute leukemia patient, and a weakness that turned out to be an MCA stroke with hemiparesis. From a patient care center perspective at an academic center no less, this turned out to be a less than optimal solution. In both cases I believe “spanish speaking” played a role and in the end other than some bruised ego’s no harm was done because it was pretty easy to wheel them back to the ER.

      The first time this happens to an off site referral where the patient can’t just be wheeled next door you better believe it makes the news.

      Your proposed strategy also assumes that there are primary care docs out there accepting Medicaid or patient’s without insurance (Medicare to a lesser extent) in order for them to be diverted somewhere. This will even be the case with private insurance for an in net work doctor accepting ER dumps… er I mean diversions.,0,5417742.story#axzz2sxT5wsB3

      • Ron Smith

        Hi, Drake.

        I understand entirely that there will be iffy cases. Even if they are seen, it should be standard operating procedure to strongly encourage regular care in a primary care office. The details of the diversion or referral can be worked out.

        But if there is no policy and practice in the ER or urgent care to discourage inappropriate use of those resources, these patients will never get a primary care physician.

        Beyond asking a patient who’s their regular ‘daytime’ physician, I suspect there is no other action to train and teach patients. If there is no incentive, then we can plan on patients continuing current behaviors. I mean why would they want to come to my office during the day when I can schedule a time to see them for cheaper, when they can walk in and sit in the waiting room sometimes for hours and spend three times as much?

        This is about a sea change in attitude both of the patients and the ER staff and policy makes. Yet they are the ones that benefit. How many times have I heard complaints from one of my patients that the ER doc was only in the room 5 minutes but they waited for 2 hours in the waiting room?

        That’s a red flag right there! I understand why it only took 5 minutes, but the patients aren’t being educated about it.

        In Arkansas, when I first started practice thirty years ago, all the primary care Pediatricians saw all their patients that showed up in the ER! I did that for 6 1/2 years all while doing level three neonatal intensive care there.

        Yes, I would educate them and that helped them and me and the hospital.

        Warmest regards,

        Ron Smith, MD
        www (adot) ronsmithmd (adot) com

        • Dr. Drake Ramoray

          We are on the same page, I suppose my pessimism that it will change is showing. It doesn’t effect me greatly given my field, but when I left my program they had abandoned that idea and the ER had taken over the adjacent urgent care to add bed capacity to the ER. I was too low on the totem pole to know/comment on the politics of that change.

          • buzzkillersmith

            It’s not pessimism on your part, Dr. D.,–it’s realism. Things are not going to get better regarding primary care access. They are going to get worse.

  • Thomas D Guastavino

    Only one thing to add, the fact that the more well insured patients with simpler problems are going to urgentcare centers. Otherwise an excellent and very astute article.

  • Mengles

    “Of course, primary care physicians and specialists whose intentions are to make a profit commonly don’t accept Medicaid patients or uninsured patients.”
    No, our intention is to not be in the red so we can pay our bills to keep the lights on. But great way to thrown us under the bus. Just remember, hospitals can’t pay your salary as a nurse, if they are in the red as well.

    • Sarah Jorgensen

      I’m definitely not throwing you under the bus. Perhaps I should have re-phrased to say “not be in the red” because I understand why you wouldn’t want to take Medicaid. It’s a hassle to bill and negotiate just to get pennies on the dollar. I get it. If anything, I was defending you, maybe just not very eloquently. More importantly and specifically to the point of the article was that this problem is just one more that adds to the misuse of EDs and the vicious cycle that keeps gaining momentum.

  • Rob Burnside

    The most public face of healthcare is the ED. It’s what we see most on TV and in the movies. It’s “where the action is.” Isn’t it natural and normal, under the circumstances, for the public to believe this is where the best medicine is too, no matter what the problem? Can we actually expect the public to distinguish between “emergent” and “non-emergent” when the experts don’t always agree? This piece is very well-written, but I’m afraid it borders on healthcare hubris, and we’ve all had enough of that, thank you.

  • medicontheedge

    Hospitals are directly marketing TO the non-emergent patient. I have come to accept that our ED is a walk-in clinic with the capability of handling emergencies. It makes it easier to come to work every day.

  • Guest

    Hi, Mike! You raise a very valid point. Your wife had a significant problem with significant symptoms, including severe pain. Her going to the ED is completely justified, even if she had been to her PCP multiple times. I’m glad her diagnosis was found in the ED, although it sounds as if her PCP could have diagnosed it as well had the proper tests been ordered. Correct me if I’m wrong, but it didn’t necessarily take the ED to find it; it’s just that severe and persistent pain drove her to the ED. These circumstances are well understood among the medical community. The problem arises when people use the ED because it fits into their schedule on a Sunday afternoon after golf to have cholesterol testing done (which we don’t do). Or to have a pregnancy test to verify the eight positive ones at home (EDs often use a simple urine pregnancy test just like the ones from Walmart). Or the people who want to know if they have fibromyalgia because they’ve had a multitude of symptoms over the last three years (which we don’t test for, nor is there even a test invented for). Or a mother who brings her child in to have us check for lice (which is most definitely NOT an emergency). I know sometimes it’s difficult for non-medical people to distinguish between emergencies and non-emergencies. We’re not asking you to do that. The situation you described puts you in the population of people who appropriately used the ED. We’re asking that people think a little bit about whether their symptoms are urgent/emergent (meaning life, limb, or bodily function is in immediate danger) or if their health needs could literally wait a few hours or days. My husband (who is absolutely non-medical) is frustrated by the fact that weather, Super Bowl, local events, etc. sometimes determine how busy an ED is. What frustrates him the most is that if people believe they have an emergency, these events [hypothetically] don’t stop them from going to an ED; if it were TRULY an emergency, no event would stop them from going to the ED for whatever health issue is at hand. If you’re having a heart attack, would the fact that you have a concert to go to stop you from going to the ED? Right, you would skip the concert and hopefully have your heart muscle saved. If you can wait for an event to be over, you likely don’t have an emergency. What seems to be a pattern is that people use the ED as a convenient option for non-emergent healthcare, choosing to go in when it works for them so they don’t miss important events such as Super Bowl or work or a child’s concert. That being said, I’ll always stick by my statement that the most predictable thing about an ED is its unpredictability. Keeping that in mind, this most recent Super Bowl day was extremely slow in my ED and immediately picked up as soon as the game was over. Coincidence? Perhaps, but it’s a pattern that seems to repeat.

  • Margalit Gur-Arie

    Neither are the ER docs, and they staff 24×7. What’s the difference?

    • T H

      Because only ED docs actually LIKE to work nights. It’s what sets us apart from the rest of the physician sheep out there (i.e.: we LIKE our black coats).

  • Margalit Gur-Arie

    Well, yes, but there are plenty of IM grads that choose to be hospitalists. Maybe they can choose something like this, or maybe they can staff with residents. We are talking about a federally funded entity, so they will be salaried anyway.

  • Rob Burnside

    I think you’re partly right, but I would submit to you that the patient has his/her entire skin–and all it contains– in the game. Another problem: many patients my age and older remember the ER staffed by regional family physicians. The modern ED, with all its bells and whistles, is foreign to them, especially if they haven’t paid a visit in twenty or thirty years. Still, where confusion exists (and there’s plenty of it here) they’ll go where they’ve always gone when pressed–to the hospital ER, now the ED.

  • Marian Gray

    I have a 70 year old friend from Chicago who has a Medicare Advantage plan with some connection to AARP and UnitedHealthcare. (There must be a simpler/cheaper way to organize health care.) Except for emergencies, her health insurance is “inoperative” outside of Illinois.

    Problem is she came to California a couple months ago to care for a 97 year old friend on hospice care. So, even though she paid into Medicare while working in Chicago hospitals for over 30 years, she has no useful health insurance right now. Except for emergencies. She has gone to an ED for “non-emergent” reasons and she may go again.

    No good deed goes unpunished. This is nuts.

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