The "Emergency" Room
I went to a social gathering this week attended by physicians. With doctors, conversations inevitably turns to our work. Workaholics, or those who consider medicine a calling, compulsively find this sort of conversation common ground when placed in the same room. I spent some time talking with an emergency room colleague, and we lamented about how the ER has become a medical dumping ground full of the uninsured, medically bewildered, and unaffiliated patients of America. We speculated on how things could improve in this broken system and whether the coming healthcare changes will push things in the right direction. My colleague and I are not alone; this same conversation is taking place across America in the healthcare and political community.
It's no secret to anyone who has set foot in an ER over the last several years that things are messed up. Patients with no insurance or medicaid come and go for minor problems, gumming things up for the true emergencies. Wait times are typically astronomical, as are the relative costs for the emergent care of simple health issues. Hospitals have done what they can, lacking any power to change the political forces behind the problem. As a band-aid, they have adjusted to the throngs of minor medical and social issues by hiring physician assistants and primary care providers. Billboards advertise success in shortening wait times, and hospitals have constructed smartphone apps to check wait times. Medical issues aside, the ER's have become unhappy places, staffed by overworked staff and doctors whose caseload lacks the emergencies they're trained to treat.
How Did We Get Here?
If left unchecked, most systems in general will eventually become problematic. In the ER, financial and social issues have been the driving forces. With medicaid, virtually all of medical costs are covered by the government. Though ER visits cost perhaps seven times that of a primary care visit, none of this bill is the responsibility of a medicaid patient. Social programs giving cab vouchers and meals further solidified this as the favored option among the indigent. Why not with free transportation, a warm bed, and a nutritious meal?
Primary care doctors have helped the situation along. With medicaid payments barely covering a doctor's overhead, these patients often have a hard time finding a doctor to establish care. Patients without insurance also have received unwelcome receptions in primary care over fear of non-payment. ER's, according to the law, cannot turn away patients who show up on their doorstep. And according to an expert in this field, " Good luck charging someone extra who doesn't have any money."
As solutions to the healthcare crisis are desperately sought, it's nice to see attention given to the ER situation. Patient trends are being studied in order to get to the root of the problem. In a recently published study, some important trends were noted.
For the working under and uninsured, missing work is not an option. With doctors' offices open almost exclusively 9-5 on weekdays, the 24/7 ER offers a convenience which drives in many. In addition to the meals and transportation, many ER's staff social workers who are quick to plug patients into social programs. ER's further cater to America's "get it now" philosophy where care is there on demand without a scheduled appointment.
Major healthcare changes are on the horizon. In October, Americans will be required to have health insurance or face financial penalties. While expanding medicaid was proposed, it is still under debate. Optimists feel that insurance coverage will open the doors of primary care offices while high ER co-pays will steer patients away. Many of my under-insured patients, however, have expressed worry about being able to afford insurance. Some have wondered what this is actually fixing.
As I see it, behavior is one of the most difficult things to change. I am doubtful that insurance coverage alone will fix the situation. Convenience will not easily yield to inconvenience. Primary care needs to meet these demands, providing walk-in care available evenings and weekends. Often, money is the best thing to curb such behaviors. I do not know why financial disincentives are not in place for medicaid ER visits deemed non-emergencies - other insurance companies do it for their customers.
Our emergency care system is full of non-emergency care. This trend is a financial ball and chain around the neck of our healthcare system. While coming changes are touted to help alleviate the problem, it is hard to be optimistic. Stay tuned...