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 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 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.

Nick Dawson, MHA (@nickdawson) has more than 15 years experience in work in hospitals in strategy and operational roles. He currently focuses on helping health systems develop a modern strategic focus based on human-centered design. He is President-elect of the Society for Participatory Medicine. You can follow Nick at his personal website, nickdawson.net.

13 replies »

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  4. Some neighborhoods do not have much in the way of urgent care.

    Urgent care can cost $125 in a heartbeat and it usually must be be paid up front. Some people do not have the cash.

    Generally to have telemedicine you must a have a mainstream health insurance policy. Some persons cannot afford that.

    ER’s are only expensive because of the way we expect hospitals to cover their budget from user fees. ER’s should be paid for with annual allocations from local government, just like the fire department.

    bob hertz, The Health Care Crusade

  5. “But, whats a body supposed to do when their primary care office has a 3 day wait and is closed at 9 PM?”

    1. Telemedicine
    2. Convenient care clinic
    3. Urgent care clinic

    ERs are about the most expensive possible setting for primary care. We shouldn’t be encouraging people to utilize them for care that can be better delivered in other settings.

  6. Bob – what a terrific view! We spend civil money on other public safety needs, why not health too? That also opens the door to discussions on socionomic determinants of health – e.g., would spending an extra $10 per student per year lesson our overall healthcare spend downstream?

    Peter1 – thank you for highlighting that our concept of overuse is uniquely American.

    “Only in the U.S. is sickness considered a positive economic driver.”

    Wow! If that doesn’t highlight what’s wrong with our collective thinking, I’m not sure what does. The smart money is on viewing our health, as a population, as a economic driver. In other words, the more healthy we all are, the better off our society is.

  7. “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.”

    Only in the U.S. is sickness considered a positive economic driver. Treating anything in a hospital is the most expensive method while most people can wait for their GP – if he’s covered by insurance.

  8. Every single medium to large sized city in the US collects taxes to pay for its fire department.

    No one expects fire departments to meet their payroll by collecting from the fire insurance policies owned by the victims of fire.

    We need similar ‘moments of clarity’ about ED. Federal funds should cover the normal expenses of emergency rooms. The patients should only be charged enough to discourage frivolous usage.

    Privatization of ER’s is a nightmare from which we need awaken.

    Bob Hertz, The Health Care Crusade