Friday, January 16, 2009

Emergency Department Abuse

Overuse of the emergency department (ED) is primarily an American phenomenon. While many hospitals EDs are busy worldwide, we Americans simply use the ED for convenience. While we physicians are justifiably wary of socialized health care (a health care system run by the US government would have the efficiency of the US Postal Service and the compassion of the IRS), the current system is not working. There are several things that must change before ED overcrowding will get better:

1. There has to be a network of primary care physicians who truly act as primary care physicians. The current payment scheme in the United States favors doctors who do procedures. So, you see this slow migration of family practitioners away for standard care to procedure-based care. You get paid more to remove moles than see a sick baby. The Advanced Practice Nurses are moving into primary care and doing a good job.

2. There is no true indigent care system in the United States. Here in the land of plenty, the poor still receive inadequate health care. Sure, a few organizations like Catholic Charities and the Salvation Army help, but the only source of health care for some poor people is the ED. The government, through unfunded mandates such as EMTALA and OBRA, require hospital EDs to treat all patients. Even public hospitals are covertly shunning the indigent and trying to recruit paying patients. This is nothing but cost-shifting and it costs hospitals billions of dollars. The most expensive place in the United States to receive health care is the ED. So, why do we send primary care patients there? Even community physicians routinely dump their non-paying and complicated patients on the ED. The ED physician is usually not a great primary care physician. I am the doctor you want to see when you are seriously ill or injured. I am not the doctor you want to see to manage your chronic hypertension or diabetes—I haven’t kept up with that science.

3. Community physicians routinely send patients to the ED who can be managed in their offices or by phone. You see a trend with primary care physicians. First, when out of residency, they are hungry and eager and do a good job of covering their patients. As they get older and their practices grow, they become less interested in seeing patients outside of office hours. Also, some community physicians will dump their patients on the ED when the work-up is complicated or they are not up on the science.

4. Interestingly, several studies have shown that people with insurance are just as apt to abuse the ED as the indigent. They see insurance as something to be used. They can get care immediately and fairly quickly in the ED with a modest co-pay instead of making an appointment with their family doctor. I see both indigent patients and the insured as equal culprits in EM abuse.

5. We can’t talk about ED crowding without blaming the lawyers. Once a patient enters the magic world of the ED, the ground rules change. Because of liability concerns, we have to assume that every patient who comes to the ED has some catastrophic condition. Once we exclude that with costly diagnostic tests, we can then give them a diagnosis and provide treatment. In a family practice clinic, a physician can examine a headache patient and carefully plan treatment. In the ED, we have to scan the patients head, do a battery of tests, and sometimes a lumbar puncture to assure they don’t have a subarachnoid hemorrhage or brain tumor before we can treat their migraine headache. The State of Texas recently received the sole “A” grade from ACEP for tort reform. Tort reform has evidently made Texas a better place to practice medicine. Lawsuits are down there and malpractice premiums are down according to a recent article—and applications for medical licenses are at record numbers according to Emergency Physicians Monthly.

There are no easy solutions to complex programs. The United States emergency care system cannot be stressed anymore--for it is already breaking. Everybody needs to do their part to remedy the situation. If we wait for the government to step in, I’ll walk away and sell manure or raise shrimp.

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