stop the war on the emergency room (fix the system failure)

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 primetime 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…

Today, NPR’s Julie Rovner published a synopsis of recent findings from Oregon’s Medicaid expansion and its effect on ED use:

“Medicaid coverage increases emergency department use, both overall and for a broad range of types of visits, conditions, and subpopulations,” says Amy Finkelstein, an economics professor at MIT and one of the authors of the study. “Including visits for conditions that may be most readily treatable in primary care settings.”

“When you make ER care free to people, they consume more of it. They consume 40 percent more of it,” says Michael Cannon, head of health policy for the libertarian Cato Institute. “Even as they’re consuming more preventive care. And so one of the main arguments for how Obamacare was going to reduce health care costs is just flat out false.”

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.

What the Oregon study tells me is that the ED represents a clear desire path for consumers. Healthcare economist Austin Frakt put it well in his reaction:

Ultimately, my view is that “overuse” of the ED reflects the broader problem that the health system is not very responsive to consumer demand or sensitive to all types of consumers. (The disparities literature is relevant here.) In other words, it’s not consumers making “bad” choices, but the system offering poor ones.

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 PM, 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 PM? 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…you know…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.

  • Mark Harmel

    So the urgent care solution is better to reduce overall costs, but reduces hospital profit? Does that mean there is a desire for insured patients to come into ED for minor concerns, but not uninsured?

    Mark Harmel

  • Nick

    Mark – not sure I know enough to universally say that urgent care reduces profits. Certainly, if a system can generate enough urgent care volume, it can be quite profitable and even help feed higher acuity cases to the ED.

    I do believe there is a willingness to allow insured patients to come to the ED for minor concerns. That’s a slightly different word choice from desire, if you catch my drift. Often, at least anecdotally, when we hear about ED “over use” its from Medicaid, uninsured and other unprofitable patient populations. My belief is discussions about non-compliant patients returning to the ED is a proxy for the same disregard.

  • MightyCasey

    Compared to attempting to make an appointment with a practice, a trip to the ER is a much more predictable time cost for a patient, emergent-need or not.

    If you’re actively sick, waiting the [however many days/weeks] time it takes to get on a doctor’s calendar isn’t patient-centered medicine.

    If you’re bleeding profusely from an unfortunate kitchen accident, or your kid’s been hurt in a soccer game, waiting seems nuts, so off to the ED you go.

    The ED may not be the palace of patient-centered-ness, but it’s at least that palace’s waiting room. As in a patient knows s/he will be seen that day, not in three weeks.

    I think hospitals would be wise to examine the idea of urgent-care “common problems” clinics – if you can walk, you walk in there. If you’ve got a critical issue, the trauma-level ED is just down the road/through that door/whatever.

    That might address the system concern about revenue. Urgent care clinics don’t have to have all the appurtenances found in a full-on ED, reducing cost for the care delivered there. The ED itself can better focus on the critical level of care needed for, say, a massive MI or a gunshot wound.

  • Carla B.

    >> 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. <<

    Nail on head there Nick!

    Thanks much for the added perspective on this. It contains a lot of the nuance not obvious to we civilians out here.

  • David Morf

    I think you’ve just nailed the reason urgent care centers exist. UCCs fill the niche you described as an access point leading either to case closed, or to proper transfers to primary care, community
    (FQHC funded) care, or hospital/ED care as needed. But then that works best if a regional population has the support of a cross-silo regional HIT so all regional providers have current person data. Oops, that means building the HIT around the person and the providers, not the billing code. Wait a minute; it’s built already — some $9 billion to date for the VistA system, and in the public domain; Medsphere is the largest civilian installer. VistA holds millions of active online VA records. It’s one of the largest HIT systems on earth, based on actual provider activity, not wrapped around billing codes, serving some 175+ VA hospitals plus some 3.5 million Native Americans in sites all over the US. In addition, the South Anchorage story shows how primary population care can be run via integrated service/admin pods to drive down hospital admission rates some 40% — not what hospital and insurance CEOs want to hear.

  • Nick

    Thanks for your insightful comment. I know several thinkers in this space who wished the PPACA had made Medsphere available for free to all providers – talk about meaningful use!

  • David Morf

    Absolutely, Mighty Casey: the neighborhood UCC is directly accessible for car or walk-in bumps, cuts, scrapes, burns, simple non-head fractures, other first-level care. Then the ED/ER for serious urgent wounds/med issues, primary for scheduled remedial, preventive, and wellness care, UCCs co-located with ED/ER and/or primary offices based on population density, care demand, and urban/rural context, specialists for vetted subject-matter expertise, VNA care and/or monitoring tools for home recovery and preventive observation and predefined intervention, hospitals for operations, complex recoveries, pandemics, other serious matters, and elder centers for maintaining healthy contact—i.e., the whole infrastructure for healthy life cycle living in a neighborhood, town, and regional context across community size, need, transportation infrastructure, and language array.