Emergency care under pressure

On the surface, limiting what has been called "unnecessary use of emergency rooms" seems to be an easy solution to the problem of overcrowding in our nation's emergency care system.

The truth is, people are coming to emergency departments sicker than ever before. Only 9 percent of the 108 million patients who sought emergency care in 2001 were classified as nonurgent, according to the Centers for Disease Control and Prevention.

Included in that 9 percent is a construction worker, with little or no insurance, who injured his back and is worried it may be severely damaged. It also can be a single parent with a kidney infection who has Medicaid coverage, but couldn't get an appointment with a physician for 10 days.

Some people come to emergency departments for what they believe are medical emergencies, but it turns out they were less than life-threatening medical conditions. Some people come, because there is no place else for them to go. Nonurgent conditions can include bladder infections, pneumonia, high fevers, and extremity injuries that could be bone fractures - conditions that need medical attention soon. Emergency departments provide a health- care safety net for these people, as well as for insured Americans, and at no other time has this safety net been more critical.

What are the real issues in overcrowding? An overcrowded waiting room is a symptom of the real problem, which is an overcrowded emergency department - where patients are lining the hallways on gurneys, filling all the beds, because there are no inpatient beds available in the hospital.

This is called "boarding," and it represents the "real" inappropriate use of an emergency department, which is not designed to serve as a hospital inpatient facility.

According to a report released earlier this year from the General Accounting Office, the shortage of inpatient beds plays a major role in overcrowding, because it ties up emergency staff and resources. It prevents emergency staff from seeing more patients - from an ambulance or from the waiting room.

The lack of resources has contributed to the closure of hundreds of emergency departments in the past 10 years. Without relief soon, the nation is poised to lose its access to specialists, its emergency departments and its trauma centers. Physicians who leave the practice of medicine, whether it is because they cannot obtain medical liability insurance or because there are no resources to treat patients, will not return and won't be replaced easily.

Targeting people with nonurgent medical conditions merely diverts attention from the larger system problems.

The American College of Emergency Physicians advocates for tort reform, including caps on pain and suffering, and funding for EMTALA (Emergency Medical Treatment and Labor Act), the federal law that requires hospital emergency departments to see all patients, regardless of their ability to pay. Emergency physicians also support the recommendations of the Medicare Payment Advisory Commission, which advised Congress to replace the current flawed Medicare formula that calculates payments for physicians. Additional support will require a national commitment and recognition that emergency medicine is an essential community service that must be funded.

Dr. Douglas M. Hill is an emergency physician at North Suburban Medical Center in Thornton.

What to do? What to do?
The medical industry is the most corrupt industry there is, IMHO.
While I believe that the doctors, nurses, and staff all have the most noblest of intentions, it's their bosses -- the administrators and insurance companies, that are running health care down the tubes.
My health insurance increased by $11/week this year, and I do not have a choice of whether to pay or not. I'm paying over $200/month for less cvg than I had last year. Noboby competed for my business.
I think that we should survey the staff of the hospitals and find out what their opinions are.

From the inside looking out in a for profit setting the problems are myriad: government regulation, malpractice, cost shifiting caused by indequate reimbursement from payors funded by the government plus indigent care. These
add up to a never ending cost spiral and as bottom line
pressure intensifies even at non profits, the ulitimate
cost is born by the patient in declining quality. It is tempting to call for a free enterprise solution through competition, but the reality is how can health care consumers benefit from free enterprise choices when competition does not exist in the vast majority of communities that have only one hospital? I fear that in the
not to far distant future only the poor through federal programs or the truly affluent will have access to health care due to costs. That is when the average Joe will rally
and demand a national health care insurance program from the politicians. As much as I hate government control--I
see this as the destiny of health care in America. Does
anyone else have an alternative insight to the problem?

I'm a little confused here. The article talks about all the nonurgent patients clogging up the works but they somehow do this by requiring inpatient beds that aren't available. I'm under the impression that if you require an in-patient stay at the hospital that is kinda urgent. Nonurgent would be outpatient types served via the "treat 'em and street 'em" process, no?

We have a new hospital with a separate ER for outpatient type complaints leaving the main ER to handle the true emergencies. After all, people do get sick on the weekends. Ever try to get a doctor who is in your plan on a weekend? THEY are the ones who tell you to go to the ER.

The only way to rectify the situation is through patient training: when to go where for what.
Unfortunately, the vast majority of patients won't do this.
Another possibility would be for the medical center to have some sort of "triage" area: Dog bites go here, indegestion goes there, etc.
It just seems to me that a for-profit business (hospitals, insurance companies, etc) should be doing something to compete for my business.
How about this: "That CT showed nothing unusual so we're not going to charge you for it." (I know that one is a little extreme...)

One remedy for ER's crowded with nonpaying patients -- many illegals, is to close our borders. Hard to do, obviously. But if you take everything to its logical conclusion, millions flooding here by hook or by crook, and using medical services along with everything else, the more efficient and better our medical system becomes, the more of a magnet it is for sick people in other nations who can't get either timely or decent care. So what are we to do? Why is it our job to solve everyone else's problems? And okay, I admit I'm a closet isolationist. Why can't the rest of the world...I feel like Professor Higgins here...simply be like us?

Consumer education is part of the answer--but consider this
under EMTALA regs--which call for a complete medical screening to determine whether or not an emergent conditon exists, and a stablization of that conditon--triage does not
fullfill the legal requirements. Say I present at the ER
after eating a vat of chili with the associated gastric pains and distress--the ER doctor-to cover his/ her tail--
will have to consider a potential cardiac problem due to
pains that could be heart related--$5,000 dollars later in
scans and lab work, it is detemined I have a stuck f*rt.
$5,000 dollars of waste that has to be paid for by some one.
Yet the doctor is legally obligated to run the full battery
of tests or face the potential of fines and sanction or
malpractice suits on the slim chance a cardiac event was
occuring. There is the rub !

Yeah, I agree.
How did all these regs get put into place anyways. They are killing the working man.
Too bad none of the candidates are willing to look good and hard into the situation instead of A) letting it fester, or B) crying about how bad we need socialized health care.

Where to start? Perhaps I'll contact my Senetor and Congressman today!!!

I don't know what the actual numbers for illegals are. I'll ask the guy across the street -- he is an E.R. nurse and see what his opinion is.
What I DO know is that my kids' asthma inhalers cost me $60, while at the same time, if I were jobless and benefitless, I would have to pay nothing.
My sis-in-law is a single parent making almost as much as me -- more, if you divide my income by the five people I support. But since the state has sympathy for her, she gets Medicaid or Medicare. She has better benefits than I do, and I PAY for mine.

Great insight on your part-- our small facility has the resources of four full time equivalent employees devoted
soley to Medicare complinace--four FTE's with benefits comes
to about $100K a year--we spend over $25K a year on complaince software--total expense $125K. Multiply this
by the 5,000 hospitals in the nation and you get $625M
devoted to paper work instead of on the actual delivery of health care. Add compliance with Medicaid, Tri-Care, and
private payors, the sum expense would have to be over a billion dollars a year. Some of the money is well spent in
terms of preventing inaccurate billings to the government,
but it adds to the cost of your health care bill and your
insurance premiums.

How is it that both you and buckalfa have the same habits of paragraph formatting?

Anyway, to both of you--your insurance plan sounds like a dream. Enjoy it while it lasts, because it'll be gone before too much longer.

The real problem is hospitalization. The hospital you say you distrust is even more regulated than the docs. They have to buy the best to use on patients even when second-best would still do the job--it's the indirect results of litigiousness. If they don't buy the most expensive (a Ferrari instead of a Honda), they'll be in violation of standard of care and lined up for a lawsuit. This could be the easiest way to slow down costs--allow the hosptial some protection and discretion.

Medical savings accounts should be required of all employees--and all patients should educate themselves to pay for routine office visits. Then some catastrophic care insurance could more easily be worked out.

Enforce our immigration laws.

It's doable.

But it won't be done.

I read on this forum that the ER cost/treatment of illegal aliens in southern California is literally bankrupting them major hospitals in Los Angeles.

Our medical facilities here in Little Rock are starting to take financial hits for this same problem.

If this problem can't even be honestly addressed, how in the hell can you even begin to discuss ER costs?

"They have to buy the best to use on patients even when second-best would still do the job--it's the indirect results of litigiousness."

I think that this is THE biggest cause of the problem. Let's put a cap on malpractice claims and see what happens.

BTW, what is paragraph formatting. I type this the same way I would a letter or e-mail!!!

Well, you are a little more readable now.

Are you sure you want to allow the hospitals discretion in some of their buying and practices? This is a harder decision than you might imagine, although to my mind desireable--

We have been educated over generations to say to the hospital (not really the doc, though we always think its the doc)--"Do everything you can, I'm insured."

Hospitals are not presently allowed to consider costs in their decision-making, only what is best. Sometimes that best is not all that much better than second-best.

I type before I think and I am HTML illeterate. Your idea of medical savings accounts and converting cadillac group health policies to catastrophic coverage only would force
health care consumers to make wiser decisons and might make
a dent in the health care cost spiral. In our area, illegals
are not a problem like the sun belt.

If I had an answer I would sell it and retire to the Virgin Islands. One part has got to be slow down the
demand for health care in the most expensive settings-
hospitals. Bigger co-pays and deductibles--more coverage
for preventative care might play a role in keeping patients
who do not need to be there out of the emergency department.

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