Wednesday, October 28, 2009

Are ERs wasteful or the epitome of healthcare efficiency?

I have seen a lot of criticism of ERs lately. The new House Bill for healthcare reform introduces ways to reduce crowding and boarding in the ERs, and better prepare them for disasters like pandemics and Katrina-type travesties. But they also put the focus on reducing ER use, as if overuse of ERs is responsible for the exhorbitant waste and cost of Healthcare.

There is waste in healthcare, and some of the patients who come to ERs are inappropriately abusing the system. But those statistics state that 10% of patients are responsible for 90% of the visits. So the waste in the ERs is largely out of control of those who run them.

This site debunks some of the myths surrounding the ER and healthcare.

I go a step further, and challenge the criticisms that the ERs are unnecessarily over testing patients:

Why do ER docs do a lot of tests?
1) Patients expect and demand it and we are at the whim of Press-Ganey for job security.

2) Consultants demand it. I cannot get a surgeon to even LOOK at my patient without a CT (cat) scan. I would get laughed at-more accurately-yelled at for diagnosing appendicitis without a CT scan at 3am and waking up the surgeon to inform them of this.

Hospitalists and attendings routinely ask for a complete workup before they will admit a patient. That means not just labs, but followups on labs. CT scans to rule out PE (pulmonary embolism) or surgical entities.

I have found that Admitting docs expect more from us than a simple Admit or Discharge. They want a diagnosis and treatment plan. This is partly because Medicare won't pay for certain diagnoses, so hospitals want to make sure that those who come in will be "paying" patients. That requires full workups to prevent admissions that don't need to be in the hospital. In the past you could admit a patient with minimal workup, and let the attendings figure out what was going on. That's not good enough for the government because Medicare will reject payment for patients if they think it is not necessary. Unfortunately, care has already occurred and money has already been spent. No "social" admits for patients who have nowhere else to go and are too sick to be home alone. No observation admits to see if something shows up. Now the patient is worked up in the ER, gets a diagnosis, and the hospital's job is to figure out how to discharge them as soon as humanly possible.

3) Pts in the ER self select as Emergencies. Therefore an Emergency must be ruled out. I can’t always rule stuff out without further testing. Abdominal pain in an office setting and abdominal pain in the ER are not the same animal. You can't just send someone home; you need to rule out deadly reasons for this pain. Nobody comes to the ER because they want to be there (okay, there are a few, but those people aren't typical). If patients thought their problem could wait until they were scheduled to see their doctor, given a bunch of tests that take a few weeks to come back, get the outpatient study they need in a month, and see the specialist when THEY can fit the patient in, then they would have done so. Instead patients who come to ERs want relief of their symptoms. They want answers and often need immediate action.

4) Sometimes patients have ambiguous symptoms that affect areas that require different types of tests. For example, A patient with abdominal pain in RUQ (right upper quadrant) needs an U/S (ultrasound) because that is more effective for picking up GB (gallbladder) disease. However, if I think the problems is in the intestines, a CT is the best choice. CTs do not do well ruling out GB disease, so on occasion you need to do both tests if the first one is negative.

5) Lots of patients without insurance come to the ER. These patients will not get tests unless done in the ER. They will fall through the cracks. If I don’t do the CT scan, nobody will. If they had insurance, sure, they could see their doctor and get an outpatient scan. But in reality, the majority of my patients are uninsured or underinsured and can’t get these tests unless they come to the ER.

For the arrogant doctors who judge the care of the ER docs, don’t throw stones when you live in a glass house. I deal with your complications everyday. I deal with the patients who can’t reach you on the phone and come in with a preventable ER visit. I deal with the undesirables you don’t want to see. And I don’t cast aspersions upon you and question your training.

ER docs now are better trained for emergencies than internists, family practioners and surgeons. We know the emergency aspects of every specialty. We see the overall picture. Do you know how many times I am the first doctor to give them nutrition and prevention advice? Why wasn’t their primary doc doing that? Why didn’t their surgeon explain to them that their surgery will drive up the patient’s blood sugar and they’ll need more insulin?

Perhaps you shouldn’t be asking what should ER docs do to change things. Perhaps you should be looking at why ERs need to be doing what they must to be the safety net that keeps the strands of healthcare from dissolving into complete chaos.

4 comments:

  1. Good post and agree, I had similar thoughts here: http://symtym.net/2004/10/walk_in_my_shoes/

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  2. It sounds like patients in the USA need to be proactive with their health care.

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  3. A lot of what you say sounds very familiar. I'd add another reason for waste: HIPAA.

    HIPAA was supposed to create a uniform standard for electronic billing (still waiting on that one). It morphed into a privacy standard, because people were worried about their medical data traveling about the world electronically.

    Fair enough, privacy is a huge concern when most of the people using electronic records aren't computer specialists. But it has created inordinate fear of penalties for innocently sharing data with other medical providers involved in a patient's care. Everyone seems to accept failure to forward data as the standard of care, even when it makes no sense from a medical point of view.

    There are common sense exceptions to privacy restrictions, but the larger the institution, the less they are willing to trust their employees' common sense. The end result is that most of that wonderful testing done in emergency rooms and hospitals is rarely forwarded to the primary care doctors by the medical records staff -- even when the ER doctor gets the PCP's contact information, even when the PCP was the one who referred the patient to the ER, even when the patient signs ER forms to permit results to be sent to the PCP, and even when the ER doctor instructs the patient to have his PCP call for final test results. There are no routine mechanisms set up to forward medical records in most institutions, and they generally refuse to send anything unless the patient comes back to sign some different form that no one thought to have him sign while he was in the ER. I'm sure hospital administrators are afraid someone will mess up and violate HIPAA, so it's easiest to just not set up any routine procedures for forwarding information at all.

    It leads to a lot of procedures being repeated by the PCP (or by the next ER the patient visits). And it can mean unnecessary mega-workups for findings that aren't really new.

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  4. Thank you all for your comments. Eileen-I totally agree. HIPAA is a tree killer for sure. Waste of money, trees and does nothing for privacy.

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