Welcome to the Up Scale Hospital Emergency Department. It's the latest thing in New York City health care. Renovating Emergency Departments so they are more comfortable and can accomodate patients who are:
- Uninsured,
- Don't have a regular physician,
- Have an acute condition that really shouldn't wait the 2-3 weeks to get a new patient appointment at a doctor's office.
- Have a regular physician, but their acute condition really shouldn't wait the 6 days to 2 weeks to get an established patient appointment at their doctor's office.
- Need care, but can't wait for the doctor's office to open.
It's a good thing. These people are more comfortable while they wait for care, but from another perspective it's just another band aid on the gaping wound created by our broken health care system.
Insured vs. Uninsured? Emergency? Urgent Care? Routine Care? It doesn't matter, you're gonna wait.
Waiting 6 months for a mammogram...a year in some areas is normal. Having to wait a week to see a doctor about a cold turned into something nasty is a regular occurance. A friend of mine called to schedule her annual physical with her gynocologist 4 months in advance. Another friend who had a perimenopausal period lasting 3 weeks was told to go to the emergency department because her gynocologist couldn't get her into the office for another 2 weeks.
Don't believe me? Call a physician's office, and listen to the automatic phone messages. "If you are experiencing en emergency, hang up and call 911, now." Physician employees are instructed to tell any patient who complains about how long it takes to get an appointment to go to the emergency department at the hospital if they can't wait the 1-3 weeks it will take to see their physician.
Routine care for hypertension or diabetes is schedulable, but the complications? not so much. There are people who have jobs that make it impossible to take time off to seek care. Their choice is go without care or go to the ED. A third possibility of a retail store clinic that has extended hours is a recent innovation. These retail clinics are working. They are pulling away the routine sore throat, UTI and URI care from the ED. The cost of going to a retail clinic and spending about $80 including medication vs. going to the ED, waiting 5 hours and racking who knows what in a medical bill is attractive.
The Hospital Fights Back
The response to retail store clinics dealing with routine care are hospitals renovating ED's to make 3-20 hour waits for care more comfortable. ED's feature art therapists (to reduce children's fears), fast food restaurants, coffee/snack kiosks and better reading materials. They have private waiting rooms with limited cable television and wireless internet hook ups for your lap top.
If you are acutely ill after hours, you can try out a store based clinic for a run of the mill sore throat, or go to the ED, they are prepared to make you comfortable while you wait. ED managers have multiple strategies to deal with more patients.
The hospital makes more money from emergency department visits than they do with their out-patient clinics. It makes money sense to give the patients a positive ED experience that will spread by word of mouth and bring in more, profitable patients to the ED.
This is the US health care system. Solve the symptoms, leave the underlying condition for later. It's the fast food approach to health care. See it, fix the simple problem, just do it, move on.
We don't get the problem right.
A recent opinion piece in the NY Times said:
The nation’s failure to provide health insurance for all Americans seems to be harming even many of those who do have good health coverage. That is one very plausible interpretation of a disturbing increase in waiting times at emergency rooms that are often clogged with uninsured patients seeking routine charity care.
Try thinking about it this way: The uninsured don't plug up the ED's so much as the general lack of primary care physicians and the lack of appropriate reimbursement for primary care does. Primary care physicians work longer, more stressful hours and make significantly less than specialists, so doctors in training choose a more lucrative specialty. Furthermore, some types of specialists are more likely to have regular office hours that don't require long, unscheduled hours at the hospital. Dermatologists don't have "drop dead" emergencies, which makes that specialty very attractive.
Routine Care in the Emergency Department
People who use emergency departments for their "usual source of care" are an ever changing, dynamic group. It's an old problem that has become worse as fewer doctors choose primary care and more ED's close. People don't have primary care physicians for multiple reasons. Retail store clinics might be a reasonable solution to some of these needs because they offer the ability to establish a relationship with a medical care giver and a level of continuity of care.
Can a hospital ED give effective primary care? A redesigned ED can take on greater patient loads, but could the results be longer wait times and poorer patient outcomes? What happens to the quality of care?
According to Barbara Starfield when she wrote Primary Care: Concept Evaluation and Policy in 1992, Primary Care should emphasive seven important features:
1. Continuous Care / Continuity of Care - Someone needs to have a big picture of the patient's overall health care status.
2. First Contact - Ideally, the patient's primary care giver should be the point of first contact and the point where the overall health status records are kept.
3. Comprehensive Health Care - The intersect point where the patient receives care or is referred out for specialized care, but results are returned and tabulated at the intersect point.
4. Coordinated Health Care - where the business side of medicine meets the clinical side. The patient's needs for multiple providers are scheduled from one point of service.
5. Community Oriented Health Care - the needs of each community are unique and the primary care is different. For instance, South Florida has a large HIV+ population but North Central Florida has a large eledrly population.
6. Family-Centered Health Care - health care must take into account the family's needs. Sending an elderly person home to be cared for by an equally incapacitated elderly spouse is inappropriate.
7. Culturally Competent in the approach to patient care - An example of good primary care would recognize the cultural differences of Haitian American patients from Black American patients vs. other ethnic groups and religious groups.
The ED is for emergencies. Medical problems that can't wait until you see your regular doctor, but people without a regular doctor have fewer options. The transient nature of an Emergency Department precludes the continuity of care and the comprehensiveness of care standards. They might be culturally sensitive and community minded, but they don't know your name, they might not care about your religion and they don't know your medical history - they don't know you... and there's no guarantee you'll receive appropriate primary care in an ED.
For Instance:
This happened to a couple I know who have "good" insurance. They were visiting me in South Florida from South Carolina a few months ago. The 40-year old wife had an old history of epilepsy, but had been off medication for years. She also has a medically necessary high protein diet. She had a siezure while shopping in a supermarket. The supermarket insisted she go to the ED to be checked out (a legitimate concern). 12 hours later (10 too long to hear the patient speak of it) she had: no other siezures, a head x-ray, a head ct scan, multiple blood tests and a total of 30 minutes with a physician.
The ED doc came in (convinced there had to be a tumor, stroke or something) and told her he was going to admit her. He had scheduled an MRI for the next morning and lined up Dr. So-and-so to be her neurologist to see what caused the siezure. During that same 12 hour period she and her husband had been on the telephone with their regular physician in South Carolina and had the ED physician speak with him. 30 minutes after that conversation she was discharged from the ED. The primary care physician was able to supply the continuity of her medical history that justified the discharge.
They went home to South Carolina. The neurologist there decided not to do any more diagnostic imaging tests due to the fact that she had no more siezures and some strange blood chemistry levels from the ED blood tests could explain the siezure as an isolated incident. I'm happy to report that she has had no siezures since that day last November. The total cost? The South Florida hospital bill was over $7,500, the couple paid only a $100 copay. (Update 3/3/8 - The hospital now wants the entire $8000 as the write off is not contracturally required.) The ED physician billed her another $700, but she only had to pay a $50 co-pay for that. (Update 3/3/8 - The ED physician now wants the entire $700+ as the write off is not contracturally required.) The South Carolina physician visits were $30 a piece for 2 of them and no additional charge for diagnostic blood tests done in South Carolina for comparison. The ED was there and helpful, but it took the primary care physician's input to give perspective to the health care issue.
Without insurance the ED is a very different animal. At about the same time within the same hospital system, an uninsured woman I know had an accident at home during the weekend. She thought she had sprained her wrist. Two days later, she was still in quite a bit of pain, so she went and sat in the ED for 6 hours. She got an x-ray that showed the fracture at 9pm, the ED physician put a splint on the wrist and advised her to take Ibuprofen for the pain. He told her to make an appointment with the orthopedic physician in the morning (the surgeon's office was closed and he wasn't on call that night).
The ED visit was $400 and another $1,200 had to be paid to the orthopedic surgeon 3 days later for her wrist to be set in the office....that was the earliest appointment available. So she spent 3 more days in excrutiating pain. She was asked to pay for the orthopedic office visit in advance in cash. Then, 6 weeks later, the wrist still wasn't right and still painful. She had to pay another $750 to have another X-ray that resulted in an in-office procedure that required her to wear a cast for another 6 weeks. The woman still complains about the waste of money the ED visit was. She swears now that if anything like that happens to her again, she'll wait for the orthopedic surgeon and skip the ED visit.
Neither case is a stellar example of quality of care or customer service. The insured woman could have ended up with a lot more expensive care that in the end, wouldn't have produced a better patient outcome. The uninsured woman got poor service and inadequate care because it was assumed they wouldn't get paid for it.
Making emergency departments more comfortable and less scary is a good thing. It's the profit seeker's solution to a health care delivery problem, but it doesn't address the underlying condition that too many people don't have adequate access to primary care or after hours urgent care. It isn't integrated and it doesn't adequately address continuity of care issues.
A Universal Health Care System would have to have an integrated solution to this mess. Medical school loan forgiveness for Primary Care physicians. Increased numbers of nurse practioners and physician assistants. A second level of emergency care - urgent, unscheduled care.
We need to create a place to go for a quick tetanus shot on a Sunday or a Wednesday night. A real, fast-track side to the emergency department that quickly deals with fractures and pneumonia. We urgently need to find a way to give urgent care after hours, because getting sick doesn't happen 9-5, Monday through Friday.