Will more primary care doctors keep patients out of the ER?

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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