It Can Always Get Worse

From the newspaper “The Hill:”

"Health reform threatens to cram already overwhelmed emergency rooms
By Jay Heflin - 05/15/10 12:20 PM ET
The new healthcare law will pack 32 million newly insured people into emergency rooms already crammed beyond capacity, according to experts on healthcare facilities. ..."

I’ve been seeing more headlines like this appearing on my BlackBerry lately. It seems that now the healthcare bill has passed, the people that passed it are actually reading it and understanding has started to sink in. This horrible legislation will cost billions and not actually result in anyone having any increased access to healthcare.

The ER is a sort of barometer of the state of the nation’s healthcare delivery ability and as this article notes, the ER is the last place you want to be if you are in need of honest-to-goodness healthcare and maintenance. People die when the ER gets crowded. I spend just as much time watching the waiting room as I do tending to the patients that are actually in the department.

People crowd into the ER for a variety of reasons, but the most important and common reason is convenience. Where else can you go at 1:00 a.m. for your earache or your toothache or your diarrhea? People have to work and kids are in school and people don’t want to interrupt their schedules to make an appointment with a doctor during normal business hours. The ER is the only place where people are guaranteed to be seen 24/7 whether or not they have insurance.

The science of swell and surge capacity demonstrates pretty consistently that the busiest time in the ER is the late afternoon and evening. That’s when most people show up expecting to see a doctor quickly and expeditiously. That means ER doctors wind up having to work more 3 p.m. to 11 p.m. shifts and 5 p.m. to 1 a.m. shifts and 6 p.m. to 2 a.m. shifts (in addition to nights and weekends) which means less time around the dinner table with the family, less time to help with homework. Most first year ER residents and students haven’t considered that aspect of their chosen specialty.

The article goes on to say:

"Rep. Jim McDermott (D-Wash.) suspects the fallout that occurred in Massachusetts’ emergency rooms could happen nationwide after health reform kicks in.

Massachusetts in 2006 created near-universal coverage for residents, which was supposed to ease the traffic in hospital emergency rooms.

But a recent poll by the American College of Emergency Physicians found that nearly two-thirds of the state’s residents say emergency department wait times have either increased or remained the same."

American emergency departments are victims of their own success. Patients prefer to go to the ER because they believe that they get more comprehensive care.

“My doctor doesn’t have a lab or a CAT scanner or an MRI machine in his office, so I came here because I think I need a lot of tests to figure out why I’ve had these headaches for the last 14 years.”

We strive harder and harder to try to decrease wait times and teach residents the practice of “patient throughput” and getting patients in and out as quickly as possible.

Patients don’t care that compared to seeing your primary-care doctor at a scheduled appointment in the office, it is three times as expensive to be seen in an ER because they aren’t paying for it - the insurance company is. The reason for the higher cost in the ER is multifactorial, but malpractice insurance premiums are five times higher for ER doctors than for family practice practitioners.

There is no legislation that will decrease use of the ER unless it creates a situation that makes it less convenient for patients to go to the ER and that will never happen.