What ED Crisis? (And Other Random Thoughts)

Shake that Money Maker

They say there is a crisis in the Emergency Rooms and while I certainly see a little of its effects at my own program, the crisis is not universal. Some Emergency Departments compete for patients, at least this is my understanding from the numerous billboards I saw the other day as I drove towards Detroit. Surely you’ve seen those billboards? You know, the ones with the pleasant looking ethnically ambiguous doctor, stethoscope carried jauntily around his neck, beaming down at a cherubic youngster whose boo-boo he has just fixed with the caption underneath promising a “New Vision of Health Care” with a guaranteed thirty-minute-or-less wait.

And no, they are not advertising for Urgent Care even though they are clearly angling for urgent care patients. The caption clearly indicates these clean, ultramodern medical establishments are Emergency Rooms. Naturally every Emergency Medicine resident must roll his eyes and curse at the idea of attracting even more ridiculoulsy trivial complaints to make his day even more hectic. On the other hand not every Emergency Department is over-crowded and packed with the indigent and uninsured. A nicely appointed ED in a good part of town can generate real income if it has a favorable payer mix. Even if emergency services themselves are not a money maker they can serve as a loss leader to bring paying customers into the hospital (and out of the specialty centers).

I am not against making money and I certainly realize that competition is ultimately good for the consumer in terms of better services and lower prices. On the other hand one can’t help notice that we are, with the exception of the small fraction of the uninsured who can’t bring themsleves to stiff the system, ridiculously over-doctored in the sense that large amounts of health care firepower, the physician’s time being one of the most important, are brought to bear on complaints that are either so trivial as to be laughable or so serious that they are impervious to our best ordinance.

Take, as one example, my patient of last night who the triage note said was a febrile, nauseous, anorexic, dehydrated infant. The nurse rolled her eyes when I picked up the chart which usually tells you all you need to know. Febrile was an axillary temperature of 99 measured at home and 98.7 in triage. Anorexic was a disinterest in feeding earlier in the day but breast feeding vigorously when I introduced myself. Dehydrated was an extremely wet diaper. Not exactly as billed on the triage note.

I have four kids. Every now and then a viral illness sweeps through all or most of them leading to a solid week of vomiting, diarrhea, and sleepless nights as one child after another succumbs and recovers. I have never taken my kids to the Emergency Department and we rarely take them to the doctor, especially for self-limiting things like that. They’re kids. They get sick. They usually recover. I understand that occasionally a “stomach flu” is meningitis so we are justifiably cautious with ill or toxic-looking children but come on now. EMTALA aside, what we really need is the ability to send people home from triage, as in, “Are you crazy? This is an Emergency Department and you ain’t sick.”

We don’t of course, and the large minority of patients for whom we can and should do nothing contribute to the excessive waiting time for patients who, while not exactly critically ill, never-the-less should be seen sooner than the what can amount to a ten hour or more wait in some departments.

On the other extreme, I see many incredibly old, incredibly sick, fantastically complicated patients who all present for some variation of being as old as dirt and sick as stink. Perhaps complicated is the wrong word. There’s nothing complicated about impending death. When you’re pushing 100 nothing is really standing between you and the Grim Reaper except he’s finishing his bagel and latte and he’ll get to you when he gets to you, dammit. We do what we can but we’re hard up against biology. The interesting thing about these patients is that they swim through the murky depths of American medicine accompanied by a small school of physicians who, like pilot fish, dart ineffectually around their decrepit shark picking off an occasional parasite. Between the cardiologist, the neurologist, the internist, the oncologist, the nephrologist, and the nice young girl in physical therapy who manipulates the fins every now and then these patients devour an incredible amount of medical resources.

My point? Nothing really except we get the health care system for which we pay. The current system can not help but be ridiculously expensive because of the way it is structured. Nothing wili ever change, no matter how or to whom you shift the costs because:

1.Patients are not encouraged or expected to take personal responsibility for their own health.

2. As every insurance scheme insulates the patient from the true cost of health care, there is no incentive for patients to make good economic decisions.

3. The legal environment makes it impossible for anyone in authority to exercise common sense. When I was younger, for example, drunks went to the drunk tank at the police station. Now they all come through the Emergency Department where they are expensive, space-occupying lesions. I understand that in our risk-averse society this is necessary to prevent the possibility of a habitual drunk aspirating his own vomit and dying without immeidate medical care. At the same time this kind of risk management isn’t cheap. If the public knew the cost they might be willing to live with slight chance of a drunk or two dying in police custody.

4. Futile care, which is in no way discouraged, sucks up a vast amount of medical care, everything from the physicians time to the cleaning lady mopping the floor of the ICU. Maybe by the time a patient is being fed through a tube, urinates through a tube, defecates through a tube, and breathes through a tube it’s time to let them go.

5. Doctors don’t know how to say “no” or admit defeat. The temptation, to which we easily succumb, is to shift responsibility by consulting specialists. I understand the need for specialists but by the time a patient accumulates a small platoon of them its time to examine, in terms of mortality versus cost, what all of the hired guns are really buying us.

The true crime is that the zealots believe a single-payer system or some other scheme of “We Swear It’s Not Socialized Medicine” is going to make health care less expensive. Unfortunately, until the structural problems are addressed, health care will just keep getting more expensive. To address them is, ironically, to preclude the need for anything other than consumer driven changes which are the only kind that will work.

36 thoughts on “What ED Crisis? (And Other Random Thoughts)

  1. I don’t really disagree with the fact that all of your points contribute to higher costs of medicine. The extent to which these are unique to the US is debatable, however.

    You also completely neglect the primary reason people point to different systems as being more efficient and that is administrative costs, which are far higher here than just about anywhere else (only France comes close). The fact is that as competition has decreased due to the conglomeration of the insurance market in the past 20 yrs, their profits have risen which gets passed on to us as administrative costs. There are many things not to like about Medicare, but it’s administrative expenses are much less than private insurance.

  2. Panda, you mention your kids in this post. I was hoping you might comment in the future on how your med school journey has affected your family. By the way, I am absolutely addicted to your blog!

  3. Not only did once again “read my mind” with the above post but you also expressed it in a wonderfully colored way the state of American medicine today.

    We are using expensive resources extremely inefficiently just to CYA, people who would benefit from drug / alcohol rehab and social services (to find shelter, etc.) are being paid for through the ED’s at ridiculous rates.

    Doctors are using expensive imaging and labs often without real reasons. In one ED I worked at everyone who came through the door got a EKG, CBC, CMP, UA, and a CT of abdomen and pelvis for good measure. everyone who fell got a miniimum of a CT or head and neck, and usually an MRI of the entire spine as well. Also absolutely everyone got a liter of NS.

    Who paid for this – 80% medicaid and medicare.

    Healthy people who suffer minor illnesses and come through the ED pay through the nose for their treatment and foot the uninsured “self pay” customer’s bills.

  4. BTW his comes to mind

    Why are we paying so much for healthcare as a nation one might ask ?

    The reasons in order of importance as I think…

    1) medicare money is actually diverted in the us budget for other purposes
    2) we are sponsoring pharmaceutical company marketing and research
    3) we are sponsoring insurance companies
    4) we are sponsoring private hospitals
    5) the population is getting older
    6) we are overtreating people
    7) we are not devoting ourselves to preventative care
    8) we have too many specialists
    9) doctors who have a financial stake in the treatment they are administering or prescribing are exploiting their patients. insurance companies and medicare/medicaid. (if this offends anybody, sorry but its all too true).


  5. Physicians at Urgent Care facilities can only bill an office visit level charge (99201-99205). Physicians at “Emergency Departments” bill at a higher level for the same service, plus the hospital or free-standing ER bills a ridiculously high facility fee on top of that.

    So a sprained ankle at an Urgent Care facility may cost the patient or insurer a couple hundred bucks, but at a full-fledged ER it might run up to $1000. So that’s why ERs and physicians who work there don’t mind the ticky-tacky BS problems.

    Give me a dozen snotty nosed kids a night and that’s an extra 2 grand I’m personally billing, and the hospital bills even more than that. So in the right part of town, those minor cases can be a real money-maker.

    Don’t blame me, I don’t get to set the rates. The “government” does. I just work there.

  6. I dont think urgent care and ed care accounts for most of us health spending, so i’m not singling out any onew specialty in particular.

  7. I wasn’t responding to your comments, Dr. Who, although I found them interesting. I was responding to the first part of Panda’s post.

  8. Oh Panda, of great blogging fame, could you comment more on your take regarding the legal pressures that shape our decision making processes? If you have not already, check out Kevin MD’s recent post and news article about Dr.Flea! I also wrote my concerns in more detail on my blog.

    What should we do about a legal system (as an extension of societal expectation) that dictates not only our medical decision making process, but also our personal decisions as well. Common sense is a humanistic trait and we are not really allowed that, are we?

  9. You definitely hit on a whole bunch of the problem points causing the high cost of health care. And I agree that putting “US government” in place of “Insurance Company X” is going to do anything to fix the mess that we’re in…essentially you’d be re-consolidating the administrators from the insurance companies into a bigger insurance bureau of the executive branch. The cost of simply creating the infrastructure to handle a bureaucracy of that size would be insurmountable for our economy that already drops about 17% of GDP into health care. And then imagine trying to sustain something of that magnitude on tax revenues in a society that is loathe to part with any if it’s hard earned money…it’s just not feasible.

    If people just took care of their own health, or had some inkling of an incentive to do so (tax breaks for those with healthy cholesterol, a healthy BMI and a normal waist:hip ratio…kind of like those hybrid drivers get), the costs would be lowered over the next 20 years. If we could learn to let go at the end of life, we could save needless years of agonizing medical intervention keeping the functionally dead alive, physiologically speaking. Changing any of those problems would help the problem a little bit, but instead we’re stuck here bemoaning a problem because we cant get through the politics to reach a solution.

  10. My husband and I have a strict “no ER” policy for our kid. (Laugh.)

    I’d say that pediatricians (for example) should educate new parents about what constitutes an emergency, but then I guess if people substituted such a list completely for their own judgment, doctors could get sued. Sigh. I’d share my own personal guidelines for making these judgments (hint: the ER is a dangerous place, with lots of germs), but then maybe I’d get sued.

    But economic incentives (your item #2) trump all. People suddenly get very smart where (their) money is involved.

    Where judgment fails => education. Where education fails => economics.

  11. I hope someone gives you a book deal mate – you deserve it – you *really* know how to turn a phrase:

    “Maybe by the time a patient is being fed through a tube, urinates through a tube, defecates through a tube, and breathes through a tube it’s time to let them go.”

    I have never heard it put so succinctly – beautifully simple.

  12. I see the advertisements on the billboards that go something like, “The doctor will see you within 29 minutes” or something. And I can’t help but feel that that’s a bad idea. It’s basically encouraging patients to bring trivial complaints to the ED because the wait time is shorter than it is with their regular doctor.

  13. I note with interest that Graham (from Over My Med Body) does not allow comments on many of his articles, particulary those about me which indicates that he knows I would eat him for breakfast like I do most of my critics.

    I will just say that it is a sad day indeed when we stop even paying lip service to the idea of personal responsibility, a character trait without which civilized life is impossible.

  14. Oh, and I don’t rail, rant, or any other such nonsense. I merely comment on the conventional wisdom.

  15. i often enjoy your blog, panda, but you haven’t really addressed overmymedbody’s arguments. i would enjoy your analysis of the idea that competition in healthcare has lead to higher prices and worse care.

  16. There is no competition in health care, at least at the consumer level. If you had to pay for a test you might listen to your doctor’s explanation of why you don’t need it.

    I guarantee if you had to pay out of pocket for routine health care you would shop around for the best combination of price and service that suited you.

    And putting aside the cost, Americans get excellent care in our system. I don’t know why you think it has gotten worse. Forty years ago half of the patients who we send home at the end of their stay would have died from the things that we laugh and snap our fingers at today. Maybe you don’t get the same warm fuzzy feeling as you did chatting with your elderly country doctor who was a pleasant enough fellow even if all he could do was look charmingly grave as you died.

    Expensive? yes. Bad care? No. That’s part of the problem. We try to do everythng for everybody all the time.

    There is also not another profession as regulated and litigated as American medicine. Until those problems are solved (and they will never be)we will continue to make what otherwise seem like irrational decisions except that they make sense in the current dysfuctional environment.

    Like dumping eighty thousand bucks for three weeks of medical care in the ICU for a 88-year-old stroked-out nursing home patient who we will return to a zombie-like health and send back to the nursing home until we do it all again.

  17. But I do link Graham on my sidebar which should tell you something. He’s in love with single payer (although we’ve finally got him to admit that it will be more expensive than our current system) but other than that his blog is pretty good. I read it regularly to see what’s going on in The Man’s head.

  18. As for how to implement personal responsibility, something Graham does not think is possible, I guess he doesn’t really read my blog.

    The way to make people personally responsible for their health is to have people pay for their health care. I call it, “No Pay, No Play.”

    If they want insurance, fine. If they just want to pay for the occasional urgent care visit that’s fine too. Now, there would be some kinks to work out weaning the dependocracy from the gubmint’ teat and we would need a safety net of some sort but most people in our country are not poor and if we start now, in fifty years maybe we’ll have the first generation of Americans in 100 years who don’t expect their doctors, nurses, techs, and janitors to work for free.

    The ignorant, however, will always need somebody to wipe their asses.

  19. And putting aside the cost, Americans get excellent care in our system. I don’t know why you think it has gotten worse. Forty years ago half of the patients who we send home at the end of their stay would have died from the things that we laugh and snap our fingers at today. Maybe you don’t get the same warm fuzzy feeling as you did chatting with your elderly country doctor who was a pleasant enough fellow even if all he could do was look charmingly grave as you died.

    Expensive? yes. Bad care? No. That’s part of the problem. We try to do everythng for everybody all the time.

    American health care is excellent, probably the best there is. The main problems most people see (with respect to people who seem to be unhealthy) has to do more with timing and accessibility (i.e. getting the right health care when you need it, and knowing when you need it). On the one hand, a lot of people don’t prioritize health over other issues in life that they have to deal with (employment, family, etc.), and on the other hand, when people are showing signs of being sick, sometimes they’re very reluctant at first to seek medical help (i.e. stroke patients, since the average time from onset of symptoms to arrival at the ED is, what, almost 2 hours?). While some people might scramble for freebies, I wonder whether even more uninsured/underinsured people really dislike going to see the doctor because of the inconvenience and being looked down upon for not taking care of themselves or being uninsured (and then, they only come in when things are really bad).

  20. At the ER I work and several others in the area the Physician group has promoted a program called “Provider is Triage”. By putting a PA in Triage they claim a nearly zero “door to provider” time. Used to be door to doc time. This is a system that caters to the least acute patients who in many cases do not need to be there, I feel at the expense of sicker patients. The chest pains and serious cases always got back right away and were seen quickly but now the focus has clearly changed to the lower acuity patients. Patients not discharged in Triage by the PA are walked right back and the MD makes themselves immediately available to see the patient. Sounds great but to accomplish this many corners are cut. For example, some of the MD’s will stop suturing to run and greet the next patient. Exams are rushed and the back end treatments and ongoing care is compromised to be available on the front end. I have seen patients that should have been worked up by the MD get a quick dispo by the PA, occasionally with bad outcomes. Their stats look great on paper and the low acuity patients love it but others are loosing out. No one is tracking the 72 hour returns that appear have increased since this program started.

  21. Panda,

    Why do you think that American healthcare receives lower ratings in lists than other countries? Michael Moore seems to make much of that. I’m curious whether the stats are biased, whether we fail to spin the data, or whether our legal system forces doctors to practice sub-optimal CYA-centered medicine. What are your thoughts?

  22. Michael Moore is an ingnorant ass who knows as much about Medicine as I know about making documentaries, that is, nothing.

    Our legal system does not force sub-optimal care, it forces zero-defect care. Getting a CT scan on everybody who bumps their head, for example, is not suboptimal because we will not miss the one person in fifty thousand who despite not hitting hard enough to lose consicousness have an intercranial hemorrhage for which some action needs to be taken (because small asymptomatic ones can be watched and managed conservatively). The problem is that our level of care is too optimal as we have decided that money is no object for avoiding risk.

    Key concept: The Europeans in their Freeloader Kingdoms across the Atlantic are not nearly as risk-averse and actually let people die at the point where we are just getting into gear. I have a friend in Greece who is a physician and he assures me that they have nothing like the level of intensive care that we consider mundane. And dialysis for the demented? Fuggedaboutit.

    That’s the point. It costs what it costs. Almost every American, when they get really sick, expects and gets top level care whether they can pay for it or not.

  23. Ok, but how do you feel about the lists that show that American healthcare isn’t rated #1? It hasn’t been #1 on any list I’ve seen in the last 10 years. I can understand why our life expectancy isn’t the highest, because Americans like lots of rich food and aren’t very risk averse when it comes to playtime. But what about those lists? Are they all biased or is there something to the fact that people in other countries get better care?

  24. An ER doc can spend 73 minutes of his time trying to save the life of a critically ill patient, and (whether he succeeds or not) he can bill about half of what he could bill if he saw a half dozen runny nosed toddlers or if he repaired a couple of 3 inch lacerations in the same amount of time.

    Critically ill patients are not money-makers for emergency departments.

  25. Most of these lists heavily weigh “indicators” such as “health equity” and “citizens with coverage” as benchmarks. If you define criteria in a way that automatically defines a universal system as superior, then the list will show the system to be superior. It has nothing to do with what happens when you actually get sick.

    Life expectancy is much more proportional to eating habits and social problems than healthcare. I once saw a stat that correlated obesity rates with life expectancy almost perfectly. In fact, living in a large heterogenous society spread out over an entire continent in which 33% of the population is obese, the fact that life expectancy is within a decade of these other nations is a testament to how good our medical care really is.

  26. The ugly truth is out. 2 things are driving our mess.

    The massive national gullet: where’s the drug to safely kill the urge to eat? We need it!!! Where are the fucking drug companies when we need them?????!!!!

    Doctors need to talk more to families and patients, and to eachother, for fuck’s sake. I was the only intern in my program who even TRIED to talk 90-yr-old COPDers out of being ventilated. This even worked once, with a patient whose face was heavily scarred from an accident involving a cigarette and an O2 canister..she actually let us let her die, and believe me, it was ONLY because someone REALLY discussed her choices with her. when she was admittedly probably hypoxic, but really, who cares?

    I can’t even talk about this without starting to gag and sputter. O GOD, please let just a fraction of the IT talent going into videogames be diverted to increasing paperwork efficiency in medicine, please….

  27. The difference in levels of care in different ER’s amazes me.

    I went to 2 ERs this week, as a patient.

    In the first one I didn’t wait at all. I puked and had a blood sugar of 57 mg/dL in triage, which apparently gets you a bed right away. I dunno. In this ER I had a private room, that was nicely decorated, and had a TV and it’s own bathroom. The nurse was constantly checking on me, and I saw the doctor frequently. It wasn’t that the ER wasn’t busy- it was. They just seemed genuinely concerned.

    Now, ER #2 was much busier, but the difference was still shocking, especially considering that they were both different locations of the same hospital. Here I waited on a gurney in the hall for 7 hours. I had one doctor tell me I wasn’t sick enough to be there, while another doctor started looking for a bed to admit me (I was admitted, so I’m assuming I was sick enough to be there). My liter of fluids ran out, and it took 2 hours before someone replaced the bag (I could have done it myself if they just handed me the bag, but they generally frown on that, obviously). When they did replace the bag, they failed to notice that it wasn’t dripping, and I wasn’t on a pump, so had I not known enough to point it out, I doubt I would have gotten more fluids till I was admitted. In the hall I had no pillow, or blanket, and was told there was a good chance I would be there all night until they found a bed for me. Sick, and spending 24 hours in a gurney in a loud, bright hall? My gosh, we have to be able to do better than that.

    The lady next to me in the hall was an 80 year old women with a hop fracture (that’s the other thing about loading patients in the halls- throw HIPPA out the window), and no one got around to medicating her before her x-ray. You have got to be kidding me. Her family was pissed, and rightly so.

  28. I have to comment on personal responsibility here. Another drain on our system are the non-compliant patients who completely disregard their doctors’ warnings about not eating the HFCS-laden, high-sodium, loaded-down-with-trans-fats McDinner and then end up in the ER in DKA with hypertensive crisis and impending MI. We fix them, discharge them, and send them off to do it all over again. No accountability on their parts.

  29. NurseGlynda- I’m sure you’re aware that you get DKA from lack of insulin, not McDonalds, and that DKA is extremely rare in type 2s- much rarer than say, HHNK. Though no doubt non-compliance can easily lead to DKA.

  30. Christine, checking yourself out AMA probably didn’t help. It’s hard to criticize the ER when you made the choice that got you right back there again.

  31. Moose, I don’t doubt that for a second, and take full responsibility for my actions. I wasn’t judging the ER for what happen there, simply stating that it was a less than ideal situation at ER #2, and contrasting what a difference it was from ER #1, especially considering that they were run by the same organization. That’s all.

  32. I’m a little late coming back to this discussion, but I want to add one thing.

    It is very tempting to make fun of patients like this (the neurotic new parents), but it is not easy being a new parent. One reads so much crap (“failure to thrive”! mild flu-like symptoms that are really a deadly virus! SIDS! well, SIDS is not crap, none of this crap, but the way it is often portrayed … you know what I mean), that fear can hinder common sense. And you’re a doctor! It’s easy for you to tell what’s an emergency and what it isn’t. The less trained (or “educated”?) one is, the more a judgment call like this becomes either a leap of faith or (as you often see) a fearful refusal to make any judgment at all.

    I understand that some medical students go through a phase in their studies where they suddenly think they have every disease in the book. Then they get over it. I would liken new parenthood to that. For a while, you act just crazy. Then you mellow out. And yes, some act crazier than others; some never quite mellow out. Some have more common sense than others, so it takes longer for (crazy) fear to tip the balance …

    My point is: It pains me to think of babies going to the ER when they really don’t need to be there. But I also understand the parents, who after all may just be struggling with a brief period of weakness.

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