Are more emergency department patients really a problem?

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.    

Are emergency departments drowning with insured patients?

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?

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?

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.

Accountable Care Organizations: good for emergency medicine?

By Ellis Weeker, MD

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.

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.

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.

 

Talking to ourselves: does Peer Review in Medicine really work?

By John Ruffner

If you're a physician, physician assistant, or nurse practitioner, you probably have a definite opinion on peer review.  Personally, after 25 years of participating in peer reviews I'm convinced that there is definite practical /clinical value for these programs in medicine.  That said, the question is: how can we maximize the benefits of the effort?

It's my viewthat organizations that can learn from within exhibit significantly higher levels of effectiveness.  They are better at discovering error or opportunities for improvement - and translating that knowledge into action or changed behavior.

It seems obvious that organizational culture is key to successful efforts at improvement from within - where frank, specific and sometimes pointed discussions are encouraged

The literature is replete with examples of very sophisticated organizations where, notwithstanding a lot of very skilled individuals, the culture actually discourages accurate and open discussion of problems ("Skilled Incompetence",  Harvard Business Review).  NASA culture has been criticized on this point and the Shuttle accident was blamed on the organization's unwillingness to hear ‘bad news'.    

While most medical peer review operations start by looking for ways to improve best practices, a number of factors often erode the effectiveness over time.   These include:

• Medicine requires professional training and practice where complete information may not be available (Medicine is still an art)
• Professional behavior is often protective of its own
• Legal consequences are always a risk factor
• By definition, peer review is considered ‘Monday morning quarterbacking'
• Sociology of the Group or Group Think - what's ok to talk about and what's not
• Talking ourselves into the picture we want to see (related to the above item)
• The discussion focuses on how to shift blame self reinforcing thinking (sometimes appropriate)
• The discussion focuses on how to classify the case
• Focus on getting through the agenda

So, with these forces at work, what can be done to maximize the benefits (improve clinical care) of peer review? In my opinion, establishing a culture of openness and inquiry - one that encourages questions and scrutiny - is key. If a peer truly does not feel that the culture allows for honest comment, they will never speak up. 

That's why it's imperative for a practice or healthcare organization to establish a mechanism for clearly stating and presenting ‘lessons  learned' or the conclusion with differential explanations.  This can most often be accomplished by a summary of findings at the end of each review and a clear statement of the conclusions with everyone's attention turned to this activity.

What are your thoughts on peer review? Do you have a system in place where you practice?  Please share your thoughts.

 

Mr Ruffner has served in many roles both in acute care and physician organizations over the past 25 years.  He holds a MPH degree from UC Berkeley and has served on the faculties of several universities.

As emergency physicians age, how to we prepare?

By Joel Stettner, MD 

As a now-seasoned emergency physician, I started my emergency medicine practice in 1974, moving directly from a rotating internship and internal medicine residency to a community hospital emergency department.

The transition was easy, since I had done ER moonlighting during my residency (back in the day, I guess), and I really enjoyed the practice. As you might imagine, I have accumulated a few years since then, and I continue to see patients - although with reduced clinical hours. Not surprisingly, I have noticed that many practicing ED and community physicians' colleagues are also aging. In fact, in some specialties, including emergency medicine, there seems to be a developing shortage of younger doctors who will be there to take over what promises to be a growing workload.

When I first started, emergency medicine seemed to be a young person's game. Especially given the stress and shift work requirements that came with the job. Over time, emergency physicians  found ways to continue practicing with the help of mid-levels and creative schedules. But as more and more physicians make the decision to retire, who will be there to step in and do the work?

Several developments are especially worrisome in this regard. Population growth in the United States continues its upward trend and health care reform legislation will add millions of newly insured patients who will be seeking care. A widely recognized lack of primary care physicians, coupled with a shortage of boarded-certified ED physicians - as well as retirement for many in these and other specialties over the next few years -  portend a growing demand for services in the face of a declining ability to deliver. And new organizations, including ACOs, Medical Homes, and Foundations, will need to meet their health care service needs.

We can hope that technology (telemedicine, EHRs, Internet applications, etc.) will help, and that mid-levels can take on greater responsibility. But I think we need to take a careful look at how we train young physicians, and the environment in which they are expected to practice. Then perhaps we can develop a more comprehensive approach to what will happen as our physician population continues to age in emergency medicine and other specialties.

I look forward to hearing your thoughts on the topic!

Is the iPad® about to change emergency medicine?

As noted recently in Emergency Physicians Monthly, the iPad is causing a growing number of emergency physicians to think about ways to use the device in the emergency room.

Hype aside, just as the iPhone® changed mobile phones and the iPod® revolutionized the music industry, it's likely that the iPad will change the way work is conducted in the emergency department.

How? Because of the pace, the interruptions, and the need for information, the tried and true pen and paper method of operation denies emergency physicians easy access to patient data and decision support. Some EDs are using electronic information systems, with doctors sometimes more focused on the computer screen than on the patient. Still other EDs use scribes.

However in the not-too-distant-future, the iPad could potentially change everything, allowing emergency physicians and staff to use iPads to tap on elements of the history of the patient - all very quickly at the bedside. These tablets would also enable physicians to go over images and lab results with patients, and review diagnoses and instructions.

It will all come down to the buzzword of 2010 "apps". At present there are no fully integrated and comprehensive ED information system apps on the iPad. For now, an emergency department could use existent apps for patient education, interfacing with  PACS, or discharge instruction templates.

But once ED-specific apps are made available - and they will - it's likely that emergency physicians and nurse practioners could have a tracking board to monitor patients' bed status or vitals, voice transcription software that can export transcriptions to charts, and many more. Some experts are predicting that a vendor will eventually release an app that does it all, seamlessly interfacing with the enterprise, offering charting, computerized order entry, bed tracking, results review, and admission and discharge pathways.

So even though the iPad is currently in its infancy, stay tuned. Before you know it, the technology will likely liberate physicians and have them chuckling about the "old days" of desktop ED information systems and paper charts.  

Any thoughts on the topic?  Please share!