Are more emergency department patients really a problem?

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By Wesley A. Curry, MD

While the focus regarding health care reform has been on the complexity, cost, and political posturing, one issue hasn’t gotten nearly enough coverage. It’s the very real question of whether health care reform will increase ED patient volumes across the country. 

An internal review of the often quoted Massachusetts experience by our emergency physician group suggests the stated 9% increase over three years may not be a reliable indicator of the impact of health care reform in the future.

For example, our client hospitals almost equal (67) the total number of hospitals in Massachusetts (75).  But we likely see more total patients in the emergency room because the average patient volumes in our client hospitals are higher. Over the past three years we’ve seen a similar increase in patient volumes, as reported from the Massachusetts experience – particularly in California practice locations where there is no health care reform.

As the chart below indicates, we’ve already seen an increase in 30 million patients per year in the past 20 years before health care reform and with declining physician reimbursement for certain patients it seems every year.  Interestingly, this is also about the same number of newly minted insured’s we can expect from health care reform once implemented. I think there is still capacity in our health care system, even if we don’t agree that the emergency room is the ideal place to see more patients. So are more people with insurance a problem? I don’t think so.

It’s likely that in every state there are a number of factors such as competition for market share, managed care, limited primary care access, convenience, less hospitals and fewer insured patients combining to drive up patient volume in the emergency room. It seems unlikely the only thing that changed in Massachusetts was more insured people.

With health care reform and the increasing number of insured patients in the coming years – most, if not all, will still face the problem of timely access to see a primary care provider. If needed, people will seek care in the emergency room as an alternative. This, along with the fact that many professional, social, and government entities are forecasting a severe shortage of primary care providers and nurses, suggests that the challenge is real. 

My view is that many current heath care providers and nurses will leave the industry as the economy improves, and the impact of health care reform on income and working conditions outweighs the economic benefits for those able to retire.

So what does the future look like? I believe there will be fewer, but larger emergency rooms able to handle 150,000-250,000 patient visits per year. Let’s not panic about more “insured people” – what I call “tomorrow’s hospitals-today” already exist. These hospitals function without patient crowding, and with shorter wait times than many hospitals seeing only 30,000-40,000 patients per year.

As a physician still in practice, and the CEO of a large emergency physician group, I believe this new health care era represents many opportunities and challenges for those of us in emergency medicine. If anything should be mandated, it is clinical and administrative systems and technologies that enhance patient care and improve patient throughput in the ED. We should embrace this tectonic shift in our health care system and be prepared for the many predictable – and unpredictable – changes that are certain to come. This is our chance to truly shape the future of emergency medicine.

What are your thoughts or concerns on the future of emergency medicine? Please share your opinions and insights.    

Emergency department wait times are on the rise.

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In the on-going discussion on emergency department wait times, a new report published by Press Gainey states that patients in the U.S. spent an average of four hours and seven minutes in U.S. Emergency Departments in 2009 – a four-minute increase from 2008.  

The study included in Press Ganey's 2010 Emergency Department Pulse Report: Patient Perspectives on American Health Care, found that nationwide, patients today on average are waiting in EDs for longer periods of time than ever before.

While some states have shown improvement or stayed relatively the same, others have seen a sharp increase in wait times. In Utah for example, patients must wait eight-and-a-half hours in emergency departments, on average. That's nearly an hour and a half longer than the state's average time spent the previous year.

The data is based on evaluations of more than 1.5 million patients treated at 1,893 hospitals in 2009. The findings and observations highlight progress being made in hospitals, emphasize areas for improvement, and explore the path to improving the quality of health care in the United States.

Interestingly, the findings showed that despite longer wait times, patient satisfaction with U.S. hospital emergency departments stayed about the same in 2009, following a five-year upward trend. More than half the states were able to improve wait times or keep increases to a minimum.

The report found that communication is imperative in providing patients with satisfactory emergency department experiences. Patients are willing to wait for care as long as they are kept informed about wait times. Patients who waited more than four hours, but received "good" or "very good" information about delays were just as satisfied as patients who spent less than one hour in the emergency department.

How is your ED dealing with wait times and patient satisfaction? Is your emergency department bucking the trend presented by the study? Please share your thoughts and experiences.

Are emergency departments drowning with insured patients?

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By Ellis Weeker, MD

I just read an interesting story on Kevin.MD.com that discusses the idea that emergency department waits are growing as more people become insured. 

The premise being presented is that due to expanded health care coverage, more people are now going to the doctor. However, because expanded coverage doesn’t mean an expanded number of physicians, patients are finding that they have to wait weeks to see their provider. When this happens, they inevitably find their way into the emergency department.

As an emergency physician, I don’t doubt this scenario. But I don’t agree that emergency department waits necessarily have to grow as more people become insured.

A good example of this is the emergency physician partnership in which I belong. We’ve developed our Rapid Medical Evaluation® (RME) program that enables emergency departments to evaluate and treat patients faster, i.e. see more patients. Over time, RME has been shown to improve an ED’s Time to Provider performance regardless of volume – which decreases overcrowding.

In my experience, it’s also very important for an emergency department to have excellent physician-nurse-PA collaboration that enables all members of the team to respond effectively, quickly, and provide the best patient care possible. Think of it as a NASCAR team servicing a car as it comes into the pit. It’s amazing what communication and a team effort can do to facilitate the highest levels of productivity without burning everyone out.

The fact is no matter how many primary care physicians there are, patients will always desire rapid, unscheduled medical care when they have minor medical problems. That means a certain amount of primary care will continue to be provided in the ED.  This is not necessarily a bad thing – with the right efficiencies and systems in place, an emergency department should be able to handle higher levels of patient loads without breaking.

What are your thoughts on the topic? Are you seeing increased numbers of patients in your ED? Please share your thoughts.

Are emergency physicians ready for patients reading their notes?

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In the news this week, an Associated Press story authored by Lauran Neergaard raises the question of patients using electronic means to gain access to their doctor's medical notes.

That includes emergency physicians.

The article reports that a study called "OpenNotes" is underway and is testing whether patients will fare better if they're given fast access to the details of their medical chart. The test program is taking place at three hospitals, with 115 doctors and up to 25,000 patients taking part in the study.

Up until now, many patients didn't know they could access their charts. But with more hospitals, emergency rooms and practices implementing EMR – they most likely will soon. So the question is being asked – what will this mean to physicians?  And with growing use of electronic records making access easier, will doctors feel compelled to write easier-to-understand notes to help patients understand their treatment?

So the debate is on – some of which you can read in today's New York Times.

Meanwhile, the Annals of Internal Medicine has posted a survey that addresses the concept of open access progress notes. 

What’s your perspective? Is this the coming of a brave new world for emergency physicians? Or creating a world of trouble? And if this system takes hold, how will it affect the way you take notes?

Is your emergency department a radiation hotbed?

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By Joel A. Stettner, MD

As an emergency physician, I’ve certainly had to deal with patients who seem to equate more tests with better medicine. “What’s that you say, you bumped your head last week and you’ve heard that a CT scan is needed to make sure there's no serious injury?”

For patients like these – and you know the one’s I’m talking about – I have no problem drawing the line with a gentle but firm “no” accompanied by an explanation.  Granted, denying unnecessary tests that most patients in the United States are accustomed to requesting is not always the easiest road to take. But it’s the right road. And it’s one more emergency docs need to take.

According to a recent story reported by the Associated Press, the U.S. accounts for half of the world’s most advanced procedures that use radiation, and the average American’s radiation dose has grown six-fold over the last couple of decades. That also means that American patients receive the most radiation in the world.

To which I say let’s help get a grip on this problem.

I understand the reticence to say no, with fears of malpractice lawsuits driving a good portion of unnecessary tests. However, there’s a real danger since it is almost impossible to keep track of the number of CT scans and other exposures to radiation patients accumulate. A patient with, for example, renal colic symptoms could easily accumulate multiple scans over a short period of time, especially if multiple ED visits are required for evaluation and pain control. We now know that up to 2% of cancers are due to radiation from diagnostic tests, so these patients could well be at high risk for malignancy later in life. 

In my view, managing a patient’s testing expectations and warning them about the dangers of potential high levels of radiation due to non-mandatory tests should be emphasized. 

Efforts to do so must go beyond the ED and extend to private physician offices, health-related publications, and the popular press. Of course it would be helpful to reduce litigation fears, and the associated defensive testing, but healthcare tort reform remains an elusive goal, at least for now.

Please let me know how you deal with this problem in your practices.

The U.S. Census report on Diversity: is health care keeping up?

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By Wesley A. Curry, MD

Almost a decade before health care reform is scheduled to be completed, the United States is on the verge of a powerful demographic tectonic shift. One that’s impossible to stop.

We’re becoming a nation of minorities.

While the focus of discussion today in health care reform has been on the complexity, cost, and manpower issues of health care reform, it’s clear the diversity of the population in the near future will also be a major factor.

Conor Dougherty has reported on this population trend in a very insightful article. The graph below is based on data from the Census Bureau which shows the top ten states where the population has reached or soon will reach the status of a “majority of minorities”.

What does this mean to future emergency health care manpower issues? Will the health care providers in the next 20 years reflect the diversity in a population of majority minorities which is likely to be a reality as early as 2011? Will health care reform mandate that new job creation be distributed to all “minorities” in this new majority, i.e. a requirement for a more diverse health care workforce?  Does any of it matter?

Increasing racial and ethnic diversity among health care professionals is important because evidence indicates that diversity is associated with improved access to care for racial and ethnic minority patients, greater patient choice and satisfaction, and better educational experiences for health professions students, among many other benefits. 

Many groups have worked to increase the preparation and motivation of underrepresented minority students to enter health care careers. But there’s more work to be done.

As part of a recent panel discussion sponsored by San Francisco’s Commonwealth Club, it was agreed that the state of California’s health care workforce has failed to keep up with its increasingly diversified population. According to the speakers, diversity in California health care professionals has remained flat for years. In fact, about half of the students entering California medical schools are from upper-income backgrounds, with less than 6% coming from families in the nation’s lowest income group.

Diversity is an issue that virtually all businesses must grapple with, and health care is no exception. In fact, I would propose that diversity in health care needs to be embraced as a major focus.  A more diverse health care workforce will enable better communication and care for underserved groups. It will help our “minority majorities” (including women) climb the ladder to attain management positions. And it could very well lead to new ideas and business/clinical practices that come with fresh thinking.

So as we see health care reform evolve over the next several years, I look forward to the issue of diversity in medicine becoming a larger and more important discussion. It’s an issue whose time has certainly come.

What are your thoughts on diversity in health care? Please share your views.

What does Specialty Certification mean to PA’s?

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By Natalie Schmitz, PA-C

In emergency medicine, any decision that has the potential to impact a large group of people, can elucidate many pros and cons.  Such is the case with specialty certification – which is a very contentious issue right now. 

On the one hand, it seems like a good idea.  After working in emergency medicine for some time, obtaining a certification to attest to one’s level of experience seems like a natural progression.  Furthermore, with the estimated emergency physician shortage, PAs will be called upon more than ever to fill the gap in the ER.  It seems logical that there should be some standardization of what it means to be an Emergency Medicine PA!

On the other hand, although not the intention, specialty certification may hinder the very flexibility that has made the PA profession so versatile and allowed PAs to fill a much needed niche in extending healthcare to a growing population.  After attending several SEMPA conferences it’s truly apparent that PAs are utilized very differently in various practice settings.  Some PAs practice only in fast-track settings, while in remote access emergency rooms, a PA may be the only on-site practioner.  This wide range of utilization makes standardization very challenging.

Also to be considered, are there unforeseen consequences of such specialty certification from outside organizations? For example, will certification or lack thereof affect reimbursements from insurance companies?  How will hospital credentialing committees deal with PAs who do or do not have certification in their particular specialty?  If specialty certification is offered, will your hospital or employer require certification and will it affect pay rates?

Regardless of opinion, it’s important to be involved in the decision making process.  For example, when NCCPA approached SEMPA and our ACEP liaisons for input, a focus group put together a proposal of requirements for such a certification.  During the recent AAPA House of Delegates (HOD) meeting, policy was almost unanimously approved to recommend that PAs not take specialty certification exams, but instead have a committee appointed to look at alternatives to specialty recognition. 

As the discussion continues to evolve, it’s necessary to voice your opinions. I urge you to contact your representatives from NCCPA, SEMPA, and/or AAPA and let your voice be heard! 

I look forward to your comments.

Note: The opinions of Ms.Schmitz are designed to encourage discussion and do not necessarily reflect the viewpoint of SEMPA.

Accountable Care Organizations: good for emergency medicine?

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Those of us in emergency medicine have been hearing a lot about Accountable Care Organizations (ACOs). The accountable care organization model has taken on far greater significance since being unveiled as one of Medicare's pilot programs in the Senate's health reform bill.

In an ACO, groups of providers share a financial incentive to control costs and improve quality by closely coordinating care. By being reimbursed a fixed fee for the entire care of such select medical issues as a heart attack or a car accident, providers have financial incentives to keep costs down and quality up. 

For example, ACOs would not receive additional payments if a person is readmitted for that same medical episode within 30 days. Theoretically, this encourages providers to eliminate medical errors. 

Some people say ACOs are nothing more than HMOs in disguise. But when you dig a little deeper, there are differences:

• The "accountability" rests with the providers. Providers or provider groups, rather than insurance companies, are evaluated on the quality and efficiency of care.
• Physicians can contract directly with provider organizations without the reliance on a health plan intermediary.
• The ACOs allow for flexibility in the type of organization. Some regions may prefer independent practice associations (IPAs) while othersmay prefer a physician-hospital organization (PHO).

So what does this mean to an emergency physician or emergency department? In my view   there is risk and opportunity. Single specialty groups such as emergency physicians could find themselves contracting with ACOs instead of hospitals or insurance companies in the future. If they do, they must make sure they are at the negotiating table whenever possible.

If the local IPA moves in this direction, emergency physicians should seek to become part of the governance structure in order to have a voice. If not, we will have as little control as we currently have by contracting with the insurers. If we do, we might actually increase our influence!

Whether the ACO model is the panacea for runaway heath care costs remains uncertain. What is certain is that our current fragmented system incentivizes providers to offer neither cost-effective nor coordinated care. The status quo has got to go.

What are your thoughts on accountable care organizations? Please send me your comments.

The never ending road to reforming healthcare reform.

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By Marty Ogle, MD

"Those who cannot remember the past are condemned to repeat it", George Santayana said. He wasn't talking about healthcare reform. But he could have been

As an emergency physician, I deal with our still-broken healthcare system every day. Which got me to thinking about the long and winding road that started 17 years ago surrounding "healthcare reform". The road has not only been long, it's been bumpy.

Let's venture back to 1993, when the "architect" to fix the broken American Health Care System was none other than the US Health Care Insurance industry!

Right out of the gate, President Clinton assigned Hillary to drive the overhaul of healthcare in the U.S.  Ms. Clinton plowed ahead, soliciting no input from those involved in delivering healthcare as they may biased. Instead, the ideas was to use policymakers (surely they are unbiased) and academic "experts" in health policy (certainly they know how to deliver better care to Americans). Then create a diagram that resembled UFO landing coordinates to explain it to the American People.

I remember thinking that I needn't worry because the plan would collapse under its own weight.

What I didn't see coming was the insurance companies coming up with "managed care" as the final wooden stake, just in case the Plan regained a pulse. "No need for sweeping reform", the Insurance Industry would claim. "We can control costs".       

Over the years, managed care established it's "footprint" across much of America - similar to how a tornado establishes a footprint when it takes out a trailer park.  

Then came 2009. The players changed, and now "ObamaCare" was here. Sort of. The bipartisan version of ObamaCare didn't work so well and the Dems and their colleagues across the aisle couldn't agree on anything. So the President took things into his own hands, developed ObamaCare and put on a bipartisan summit. Great news, except that the Dems and Republicans still couldn't agree to agree. In fact, the Democrats had trouble agreeing with each other.

But wait - let's try politics! Get the AMA's support by promising an SGR fix. Mollify the Hispanic Caucus by providing Immigration Reform (yeah, that worked).  And so it went.

Sadly, it was not to be. And ObamaCare limped to a halt. Except a gaffe by the Insurance Industry gave the plan an 11^th hour "elixir of life".

Public indignation caused by Anthem Blue Cross's announcement that they were raising premiums 39% for thousands of policyholders pushed ObamaCare across the finish line, with the assist of some questionable procedural footwork in Congress.

So there you have it; a rather truncated history of U.S. healthcare reform over the last 17 years. Don't you feel better off?  Or maybe we should start over. I hear Bill Clinton is looking for work!

I look forward to your comments.

Hospital and ER turn a $25 million loss into an $8 million gain.

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In these challenging economic times for healthcare and emergency medicine, it's nice to report a story with a happy ending.  

One such story emanates from this week's Healthcare Financial Management Association's annual ANI conference in Las Vegas. As reported in healthcarefinancenews.com venerable Natividad Medical Center has announced that they've turned a $25 million loss into an $8 million gain in just four years.

Natividad, a 172-bed acute-care safety net medical center owned and operated by Monterey County, California has been a fixture in the community for more than 100 years. Over time, a series of poor management decisions had the hospital on the verge of closing in 2006.

Natividad CEO Harry Weis and his team took over the hospital in 2006, instituting team-building changes among staff, setting financial perimeters through data collection, renegotiating contracts with HMOs and receiving a $10 million private donation from the communities' doctors to launch the recovery. Since then, the hospital has not only recovered, but prospered.

Natividad's emergency department has focused on ways to save money instead of cutting more. Triage was improved so that emergency patients are now treated and sent home if they have low acuity illnesses, freeing up beds for those with more severe problems.

Thanks to the changes, patient wait times have gone from around four hours to roughly 30 minutes. Patient satisfaction spread by word of mouth and the ER has increased the volume of patients, with fewer leaving before being treated.

In addition, the emergency department's billing system and fee scale underwent an upgrade for the first time in 10 years, matching the fees to those of surrounding hospitals.

"We want to debunk the myth that public safety net hospitals can never make money," said Jeffrey Bass, MD, who was director of Natividad's emergency department during the turnaround. "We don't think we're a fluke. This is a model that can be reproduced over and over again."

Part of the overall recovery, according to Weis, has been due to changing the culture of the hospital from "what we're doing is good enough" to one focused on pride in performance. Nurses are made key members of the success team. Employees are held accountable for the first time in years. And poor performers were let go.

Any comments or personal experiences on the topic? Please share.