Stop the war being waged in the emergency department

There’s a war being waged on one of America’s most revered institutions, the emergency room. The ER, or emergency department (ED for the sake of this post) has been the subject of at least a dozen prime-time TV shows.

What’s not to love about a place where both Doogie Houser and George Clooney worked?

Every new parent in the world knows three different ways to get to the closest ED. It’s the place we all know we can go, no matter what, when we are feeling our worst. And yet, we’re not supposed to go there. Unless we are. But you know, don’t really go.

Somehow, we’ve turned the ED into this sacrosanct place where arriving by ambulance is OK, and all others are deemed worthy based on their insurance rather than acuity. If you think I’m wrong, ask any ED director if they want to lose 25% of their Blue Cross Blue Shield volume.

But its true. I hear ED physicians openly express disappointment in people who came into the ED and shouldn’t have.

It’s just a stomach bug, you shouldn’t be here for this. Or, it’s not my job to fill your prescriptions.

Some history

The emergency department is a fairly modern invention. The first EDs were born of two separate, though similar, aims. At Johns Hopkins, the ED began as the accident room, place where physicians could assess and treat — wait for it  – minor accidents.

Elsewhere, in Pontiac Michigan and Northern Virginia early EDs were modeled after army M.A.S.H. field hospitals. They were serving more acute needs.

Today, billing for emergency department visits is done on the E&M levels where level 1 is the least acute (think removing a splinter) and level 6 is traumatic life saving measures requiring hospitalization (think very bad car wreck). Most EDs, and CMS auditors, look for a bell curve distribution, which means there are more level 3 and 4 incidents than most others. While coding is unfortunately subjective, solid examples of level 3 visits include stomach bugs requiring IV fluids, a cut requiring stitches, and treatment of a migraine headache.

What’s my point?

  • Most EDs treat minor needs.
  • There is historical precedent for treating minor needs (accidents).
  • Over use is a concocted problem resulting from a red herring of cost and thinly veiled desire to keep lower paying plans and less compliant patients out of the high profit ED.

There, I said it.

The ED is convenient, it’s open 24 hours, it does not require an appointment. So when the stomach bug or kitchen accident gets the best of you at 9:00 p.m., and your doctor’s office is closed, where are you going to go? And, yet, we still chide people  – via reporting, casual comments and the communication of health systems — for using the ED for “non-emergent” needs.

Who determines what is emergent? But I digress.

What I’d like to see is more hospitals flinging open the doors of their EDs and saying, “We’ll take you, any time, for any reason, and you won’t wait long or pay an arm and a leg.”

Sure, we need to acknowledge that the ED is probably not the best place for primary care. But, whats a body supposed to do when their primary care office has a 3-day wait and is closed at 9 p.m.? Tackle that system problem, and I’ll sing a different tune.

A few years ago, while working for a large hospital, I was part of a team exploring an expansion into urgent care. Urgent care, as the name implies, is like emergency care, only less emergent and more urgent. We wanted to offload some of the lower acuity visits from the ED, but didn’t want to lose the volume.

Urgent care made sense. So where do we put it? Well, on the campus of the hospital was ideal, it had the benefit of being able to turf people out one door, across the parking lot and into the urgent care. But that required new or repurposed space, which is expensive.

What, in fact, made the most sense was to make the urgent care part of the ED itself. In other words, have a bargain sale isle in the ED. You do that by staffing differently, ordering fewer tests, and generally charging less. Which is where the conversations ended.

But, I still think that’s a viable solution. Rather than continuing to wage war on the poor ED, we need to build EDs which are capable and cost effective at caring for every need which walks in the door. That includes being timely, compassionate, participatory, and affordable.

It requires being connected via EMR to primary care offices.

And, above all, it means listening to the desires of communities who have a need for the 24-hour, walk in care option.

Nick Dawson is principal, better.  He blogs at NickDawson.net, where this article originally appeared.

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  • KD

    “We’ll take you, any time, for any reason, and you won’t wait long or pay an arm and a leg.”

    the old rule still applies. availability, cost, quality – pick any two.

  • http://drwhitecoat.com/ White Coat

    “I can’t believe you folks are stuck choosing two of availability, cost, and quality. We’ve had all three for a while.”

    Sure. I bet the thousands of Canadians that flee to the US for their health care think so, also.

    Oh, and the 62.8 MILLION articles found when using the search term “canadian health care problems” might tend to wipe the smudges off of those rose colored glasses of yours.
    https://www.google.com/#q=canadian%20health%20care%20problems

    On just the first couple of search pages, there are titles such as:
    Tens of thousands fled socialized Canadian medicine in 2013
    ‘Free’ Health Care in Canada Costs More Than It’s Worth …
    The Ugly Truth About Canadian Health Care – City Journal
    Problems abound with Canada’s health care; tax dollars at …
    Canadian Health Care In Crisis
    Canada’s health care system has its problems – “wait times and the shortage of doctors top the list pf concerns voiced by Canadians in 2008″
    Canada ranked last among OECD countries in health care …
    Public health care in Canada facing an emergency

    And no, I’m not going to engage in a debate about the content of 62 million articles.

    The US health care has many problems to overcome, but don’t try to pretend that Canada has all the answers.

    • http://www.persjrp.ca/ Ryan R. Persaud

      Ha, I’m not saying that we’ve got a perfect system.

      Most Canadians that I know aren’t interested in reforming our system: They’re interested in improving it. Some people want a two-tier system but it’s largely considered political poison. Drug and dental coverage are probably the two areas we do worst in terms of public coverage.

      I’m saying that our system is more balanced, not that we’ve got perfect availability, cost-effectiveness, or quality. More importantly in terms of this article, there is at least a certain degree of flexibility that we get from being able to coordinate care. For instance, we can build things people need, like urgent care centres, without needing to worry about upsetting corporate.

  • buzzkillerjsmith

    An ED and attached UC 24 hours.

    Can I have the midnight to 8 am UC shift? That way I’ll have time to shower and get to my 10 hour day clinic.

    What if they offered a job and nobody came?

  • Steven Reznick

    This is a convenience immediate need and satisfaction throw away society. Emergency rooms are meant to care for serious acute emergencies. The trouble is no one has a personal physician anymore who is available to handle the minor ailments that occur after hours. No one receives continuity of care or longitudinal care because if they receive their insurance through their employer, their plan and physician panel has probably changed every year for the last 15 -20 years in the name of employer cost containment ( despite the insurance company profits and their executives profits soaring).
    Lets start with improving the publics’ health literacy with the return of common sense first aid and treatment instruction in the schools. The choice of accurate information off the internet is problematic so possibly some highly approved teaching videos on simple first aid for scrapes, abrasions, cuts ,minor skeletal trauma, bites and insect bites and simple infectious disease.The level of instruction can be no more challenging than a Cub Scout or Brownie First Aid Handbook and it would be an improvement on what most young adults know today. Instruction on when to seek help and in what settign will help as well. Restoring public education health and hygiene education would go a long way to improving the situation.
    Encouraging residency training programs and improving reimbursement for the training and support of primary care physicians would go a long way to help the problem as well. Instead of shortening their training period, how about recognizing that there is more data and more technology to grasp now then ever before so allow them to gain more experience and education rather than less.There are programs like the Family Practice residency program in Fort Worth , Tx that added a year of training so residents could broaden their horizons and learn all the procedures and techniques that a well rounded comprehensive physician should be able to perform in an outpatient setting. This is probably the equivalent of the old rotating internship which should have been reinstituted years ago if we wish to have comprehensively trained physicians who can keep people out of ERs. In ER’s , where staff do not know the patient’s ,far more defensive medicine is practiced to cover the fact that they don’t know the patient, don’t have the time to talk to the patient and or don’t really want to and can’t possibly be wrong on anything which is clearly an impossible situation to be in.
    How about a pay differential for outpatient offices that stay open alternative hours. We tried that down here in South Florida years ago, evening and Saturday and Sunday hours. The elderly wouldn’t drive at night. The working people didnt want to take free time and use it for a physician visit when they could use ” sick” or ” personal time” and still have their evenings and weekends. The experiment lasted two years and we stopped it due to lack of volume.
    We do not need bigger ER’s. We need more health literacy and more availability of outpatient physicians to care for minor emergencies during non business hours.

  • http://drwhitecoat.com/ White Coat

    What is the point of this article? You talk about a “war.” Wars have combatants who fight about an issue. You haven’t defined the sides or the alleged issue.

    Your assertions are not only illogical, but they’re flat out wrong. For example, you state”

    “Somehow, we’ve turned the ED into this sacrosanct place where arriving by ambulance is OK, and all others are deemed worthy based on their insurance rather than acuity. If you think I’m wrong, ask any ED director if they want to lose 25% of their Blue Cross Blue Shield volume.”

    This is a ridiculous argument and it makes no sense. First, you try to project the whims of a patient population onto the legal obligations of emergency medical providers then somehow tie those to how “we” think about emergency medicine. The emergency department is not “sacrosanct” because people arrive by ambulance. Our country has a system where people who pick up their phones and dial “911″ get taken to the emergency department. EMS and EDs have no control over whether patients call ambulances and EDs are required by law to provide an evaluation to anyone who shows up in the ED asking for care.

    We don’t know the insurance status of a patient when they walk through the door. Patients are deemed “worthy” because they come to the emergency department for help. Asking an ED director whether he would choose to voluntarily lose 25% of people who pay for their care proves nothing other than that you don’t have much insight into how emergency medicine is practiced.

    And how do ambulance rides, sacrosancticity, and insurance status tie into whatever point you’re trying to make?

    You seem to argue that the emergency department should provide prompt and efficient care to any person at any time. Government should run within its budget. Everyone should get along. You should do your job for free and stop worrying about being paid. Now that we’ve gotten past the warm fuzzy feel-good social directives, how about proposing some plans on how to accomplish your directives with a shrinking health care budget and skyrocketing federal health care regulations? Or are you just going to sit back and “chide” the hospitals for failing to provide unlimited services on shoestring budgets?

    The emergency department is “high profit”? Want to provide a source for that hogwash? If emergency department care is so “profitable,” then why do so many emergency departments close each year?

    Lets “build EDs which are capable and cost effective at caring for every need which walks in the door. That includes being timely, compassionate, participatory, and affordable.” Great idea. Let’s also build massive restaurants that serve up every type of food people could ever want. Regardless of whether people want falafel, chicken makhani or sushi at 3AM, they should have the right to receive it. And it better not be expensive, either. Who cares if hiring all the people costs money, purchasing all the different types of food costs money, and the food would spoil if not used within a week or so? People deserve to have what food they want, when they want it, and for what they want to pay for it. Hey – if we do it for healthcare, we should do it for all industries, right?

    You seem to allege that all emergency department ills could be cured by being connected via EMR to primary care offices and by listening to the desires of the communities. How? I have worked in an emergency department for 20 years. How would performing these tasks cure the ED ills? One of the hospitals at which I work has an EMR system connected with doctors’ offices. Has it helped? Perhaps a little. Does it prevent ED overuse? Not at all. We listen to the communities all the time. How does doing so improve emergency department care?

    ED overuse wouldn’t be a problem if medical care was like most other business entities, but it isn’t. You don’t hear about overuse of restaurants or garages or grocery stores or plumbing services or gas stations. Ever stop to think why that is?

    The reason that you hear about emergency department overuse is because payment for the services provided in the emergency department often is less than the cost of providing care, yet federal law mandates that patients receive at least an evaluation and sometimes tens or hundreds of thousands of dollars in care — even if they have no money. Ultimately, the hosptials or the doctors eat the cost of that care. Regulation has created a duty for private entities to provide advanced and sometimes costly services to anyone who needs them under the threats of fines, lawsuits, and even imprisonment if we don’t do our job correctly. When are such burdens imposed on any other private entity?

    We do the best that we can with the resources we have. But to suggest that we can or even should build larger emergency departments to provide more and faster services with fewer resources and dwindling payments is absurd.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Agree with some things you say, but less so with two particular points. First of all EDs are profit centers for hospitals, and according to the latest projections, Obamacare is going to increase those profit margins from the current 7.8% to 12.2% (strange but true http://content.healthaffairs.org/content/33/5/792.full ). Otherwise you would probably not see so much advertising for ED waiting times all over the place.
      Second, we hear about overuse of restaurants, grocery stores and gas stations all the time, perhaps from a slightly different perspective though. That’s why we have a chronic disease epidemic and why our planet is slowly but surely turning into a furnace….

      • http://drwhitecoat.com/ White Coat

        I’m not going to pay for the access to the article, but realize that the “profits” you cite are projections, not hard facts. Those same “projections” were wrong about “keeping your doctor,” about the costs of insurance premiums, and about whether presence of mandatory insurance would decrease emergency department visits. We’ll have to wait and see about the profit margins, but so far, hospitals are losing money on the program. Here’s one example:
        http://www.mercurynews.com/breaking-news/ci_24998439/san-pablo-hospitals-fight-survival-grows-more-desperate

        Hospital on verge of closing because “the Affordable Care Act has exacerbated the short-term funding problems — by driving down reimbursement rates for Medicare.”

        You see advertising for ED waiting times in select places, not “all over the place.” The advertising occurs in markets with good payer mixes, not in markets where the predominant payor is Medicare/Medicaid.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          Sorry about the paywall. Here is the pertinent paragraph, which largely agrees with you:
          “We estimated that hospital revenue from ED care exceeded costs for that
          care by $6.1 billion in 2009, representing
          a profit margin of 7.8 percent (net revenue
          expressed as a percentage of total revenue). However, this is primarily
          because hospitals make enough profit on the privately insured ($17 billion) to cover underpayment from all other payer groups,
          such
          as Medicare, Medicaid, and unreimbursed care.
          Assuming current payer reimbursement rates, ACA reforms could result in
          an additional
          4.4-percentage-point increase in profit margins for
          hospital-based EDs compared to what could be the case without the reforms.”

          However all in all, the hospitals manage to balance the underpayments, with overpayments from the private sector, hence the ads…. No argument here….

          • T H

            In many places in the rural US, there is no way to ‘balance’ payments because there is less than 15% private sector insurance.

            The hard facts of my hospital are that the ED loses nearly a million USD/month for the hospital in its own costs (mainly unreimbursed Medi-Cal and indigent care). The reason the hospital keeps it open is that it generates 85-90% of the admissions for the hospital now that none of the local primary care doctors care to have admission privileges.

            Indeed, many of of the PMDs – frustrated by the lengthy process at getting meds, imaging, specialty care, and procedures approved by Medi-Cal – send their patients to the ED to ‘get the work-up done because this could be a serious issue.’ Things like lung nodules, unexplained weight loss, chronic headaches, or they just don’t give intramuscular injections of medications (i.e. Toradol or, surprise, Dilaudid) in their clinics for pain.

            Is this representative of all hospitals in rural and/or primarily MedicAid reimbursement areas? I do not actually know. But I suspect it is.

    • http://www.persjrp.ca/ Ryan R. Persaud

      “You don’t hear about overuse of restaurants or garages or grocery stores or plumbing services or gas stations. Ever stop to think why that is?”

      If you can’t afford a plumber, you could try fixing your pipes yourself or get a neighbor to help.

      If you’ve got cancer, I seriously doubt that you’d be able to fix yourself up or get Bob the plumber to help. Not that there’s anything wrong with plumbers.

      Without healthcare people would end up dead. It’s not like people decide to have cancer or diabetes or get into car accidents.

      Of course, I’m assuming that your obligation to the health of the public is stronger than your obligation to your corporate shareholders… but some people prefer to put their priorities in different orders.

      • http://drwhitecoat.com/ White Coat

        The article talks about emergency department care, not about cancer care or diabetes care – both of which are managed as outpatient care.
        A serious car accident would not be considered an example of “overuse” of the emergency department.
        Keep on point.
        Your response still does nothing to refute my assertion that you don’t hear about overuse of other services or retail ventures.

        To engage your tangent for a moment, implying that I should just give away my services for free because I have an “obligation” to the health of the public is as ridiculous an argument as the author of the post presents. From where does this “obligation” stem and where does this alleged “obligation” end?
        I have no corporate shareholders. However, I do have several hundred thousand dollars in student loans as well as thousands of dollars in licensing and CME fees to pay each year. Medical malpractice premiums also cost about $50,000 per year. I suppose I could just go print some money to pay for those debts while I fulfill my “obligations” to anyone who needs my services.
        You can go look at my blog and see the post about how teachers earn more than doctors over their careers if you want to argue that point further.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          You don’t have an “obligation”.
          We, i.e. society, have the “obligation” to pay you fair fees to perform these services for all our members that need services.
          Does this sound better?

          • http://drwhitecoat.com/ White Coat

            I do agree. Thank you.
            And thank you for your well-supported, well-reasoned comments.
            I sincerely enjoy reading and responding to your input.

  • http://www.persjrp.ca/ Ryan R. Persaud

    It’s too bad corporate profits don’t translate into better patient care, or your health system would shoot up to the top of the UN rankings. I guess it does improve the health of shareholders, though, so there’s that.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Glorious remark!!! Someone should stratify the OECD health rankings for “disparities” on top. I bet our 1% is the healthiest in the whole wide world….

      • http://www.persjrp.ca/ Ryan R. Persaud

        Go look up some important outcomes (lifespan, neonatal mortality rate, etc.). You’d be surprised at how many countries are ahead of the United States in individual outcomes.

        Canada isn’t doing so great either, but we do have problems with dental/drug coverage compared to other nations.

  • SteveCaley

    Somebody I worked with said that if it weren’t for drunk and damnfool, it still would be an Emergency Room. Go in and dust it every once and a while.
    Appropos to nothing, really, but….