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Stop the War on the Emergency Room (Fix the System Failure)


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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 Howser 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 percent of their Blue Cross Blue Shield volume.

But it's 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...

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, a place where physicians could assess and treat – wait for it – minor accidents. Elsewhere, in Pontiac, Michigan and northern Virginia, early EDs were modeled after U.S. Army MASH field hospitals. They were serving more acute needs.

Today, billing for emergency department visits is done on the E&M Levels where level one is the least acute (think removing a splinter) and level six 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 three and four incidents than most others. While coding is unfortunately subjective, solid examples of level three 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).
  • Overuse 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. Health care 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 what's a body supposed to do when their primary care office has a three-day wait and is closed at 9:00 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, 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 aisle 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 that are capable and cost effective at caring for every need that 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.

This post originally appeared on Nick's self-titled blog on January 3, 2014.

More Blog Posts by Nick Dawson

author bio

Nick Dawson has more than 15 years experience in hospital strategy and operational roles. Today, he’s focused on helping health systems develop a modern, strategic focus based on human-centered design. He recently worked with Augusta Health, an independent community health system in Virginia, and was the Director of Community & Physician Engagement at Bon Secours Virginia Health System. He has worked for other multi-hospital systems and been a consultant for a major health care consulting firm. Nick is a member of the American College of Healthcare Executives and speaks nationally and writes on the topics of innovation, community engagement, revenue cycle and patient-focused design in healthcare. You can follow him on Twitter at @nickdawson and on his website

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Health Care Access   Health Care Cost   Find Good Health Care   Make Good Treatment Decisions   Get Preventive Health Care   Health Care Quality   Accidents and Safety   Inside Healthcare   Health Insurance   Medical/Hospital Practice   Medicare/Medicaid  

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