Why the Consumer “Loves” the Emergency Department

The article US Emergency-room Visits Keep Climbing posted in the Wall Street Journal reports the not unexpected rise in Emergency department visits.  This was an easily predictable event.  Despite the official pronouncements that the Affordable Care Act would limit such events, there are multiple reasons for the rise:

1. Lack of access.  With the addition of multiple new Medicaid patients, without the adequate primary care infrastructure, these patients are voting with their feet.
2. High deductible health insurance plans that are de facto catastrophic self-pay policies.  The consumer cannot afford both the premiums and the deductible on their salaries.  They make the choice of care, which the Emergency department provides without mandatory upfront payments.
3. The Emergency departments, in general with all their technology, access to specialists, convenience, and board certified/experienced physicians, make an attractive package.
4. Private practice phone trees start out with call 911 and then, go to the Emergency department.
5. The Emergency department has the capacity to do an extensive medical evaluation that might take 4-6 weeks with multiple appointments in under 4-6 hours.
6. Immediate gratification of the consumer.
7. Emergency departments advertise wait times- patients will be seen in under 30 minutes and special Fast-track aka Urgent care areas for low acuity patients.
8. Call ahead or online appointments in the Emergency department.
9. Primary physicians' use of the expertise and technology of the Emergency department as an extension of their practices.
10. Emergency department 24/7 hours of operation.

 

The problem is the cost associated with the ED visit.  The consumer is paying for the 24/7 infrastructure, which is massive.  These include the staff, physicians, Nurse practitioners, Physician assistants, techs of various types, on-call consultants, etc.  The prices are a reflection of the disconnect between charges and costs that are rampant in hospitals and insurance company contracts.  With an appropriate cost and charging scheme, the Emergency department could be quite cost-effective because everything and everybody is already there.

Hospitals and EDs compete for business because they are the main driver of hospital admissions where the money is.  The Fast-Track low acuity patients help pay the freight to generate more admissions. 

One of my prior blogs offers the suggestion that the Emergency department become the center of health care with primary care, specialists and urgent care as the spokes of a wheel.  This would provide constant direct interaction directing the consumer to the best logical point of care.  This is controversial, but reality is when the family member is ill, the first impulse is to go to the Emergency department.

Is Lack of Interoperability a Factor in Emergency Department Revisits and Readmissions?

In the revisit rates and associated costs after an emergency department encounter article, discusses the results and they are complex.  One interesting fact stand out.  The number of patients who seek further health-care from another ED is extremely high.  It is worth reading, but it is difficult to make sweeping judgments or generalizations.

People who return to the ED have multiple forces and motivations in play, including but not limited to:

1.      Convenience

2.      Impaired follow-up access.  For example, even though a patient may be instructed to recheck or follow-up with a primary care physician within a certain time frame, many cannot get a timely appointment without an established primary care network.  Many specialists will not see them without cash or health insurance, and those with coverage may have their access limited by policy requirements and unaffordable co-pays.

3.      Treatment failure.  Some patients do not get better.

4.      Dissatisfaction. Patients may feel their care was inadequate: questions were not addressed, testing was insufficient, or prescriptions given were inadequate or unaffordable.

5.      Narcotic Overlay.  If the patient was previously prescribe a narcotic(s) and/or wanted to receive a narcotic prescription that was not given, an added dimension for returning to (some) ED, is present.

6.      Mental Disturbance.  Many individuals have underlying psychological problems along with inadequate local community psychiatric/social support.  When a social worker is not available, some patients seek this kind of support from the ED, despite an actual need for individualized social services.

7.      The patient likes the ED or a particular ED doctor. 

These are extremely complex system level problems.  A potential solution may be to provide a social worker to help sort out the medical system, in addition to simply handing the patient discharge instructions.  Some institutions have established a system along these lines, called a medical advocate system.

Going to a different Emergency Department for a second or third visit seems to be a part of this phenomenon.  And there, in particular, is where the issue of interoperability arises.  Let’s assume that your EHR system is inherently good enough for internal interoperability, and that you have access to all the prior records- Right??  Now what about when the patient shows up across the river?  Would life not be simpler if each emergency department’s electronic health record had the interoperability capacity to talk to each other, to share data, and relate to the second ED what the first encountered and found?  This might lessen the need for repeating the entire work-up and admitting the patient.

Of course, from a practical standpoint, patients who are evidently sicker and return to the same or different emergency department usually get admitted to the hospital.  Repeat discharge happens, ut it does so with peril, as there are frequently solid medical, medical-legal, and logistic reasons, to keep the patient the second time.  Because beware willing to send home potential high risk bounce-back patients overall costs are inevitably driven up.
True interoperability, particularly by the establishment of industry-standard and required electronic documents, would greatly enhance patient safety by giving the next provider a better feel for what might have occurred at prior visits.

We're on the "Eve of Destruction"

In the song We're on the Eve of Destruction, singer Barry McGuire laments the end of western civilization due to endless worldwide strife in the 1960-1970's.  In the article The Awful (and not so creative) Destruction of Medicine, a similar argument is made for the end of private practice medicine in the United States.

The author of the article states that only 30% of physicians remain in private practice and that the "Marcus Welby Era" is long deceased.  The endless new government mandates are eliminating the private practitioner.

The physician is now part of interchangeable puzzle where everyone especially the payers have a say in the patient care and reimbursement.  The physician is no longer the centerpiece of healthcare.  The article makes a strong case that the modern day era of medicine from 1960-present is essentially over and rapidly changing.

What's a classically trained physician to do???

The best solution is to view the rapid change and chaos as an opportunity rather than a huge negative.  Realize that before Medicare started paying physicians in the 1960s that medical care was totally different.  Periods end and new approaches need to be analyzed and taken advantage of.

Potential Solutions:

1. Take some business classes or get an MBA
2. Attend some coding and reimbursement classes
3. Analyze and embrace your technology
4. The age of automatic physician entitlement is over.  This doesn't mean it still cannot be fulfilling and financially sustainable.
5. Your Medical degree is a ticket to multiple opportunities
6. Attend a meaningful use lecture or two
7. Understand that the accountable care organization (ACO) is code for 21- 1st century HMO.
8. Rethink your hiring practices.  Get professional consultations to get improved financial situations.  Hire consultants not employees.
9. Pick software that pays for itself downstream.
10. Learn the new rules and adapt
11. Realize to succeed you will need the proper software, highly trained medical assistants, and possibly voice activated technology such as Dragon to make one complete medical technology unit.

The future is still bright for the agile and well informed.  Make your theme song, The Future's so Bright, I Gotta Wear Shades.

Avoiding the Potential Legal Quicksand of Opening ann Urgent Care

Opening an urgent care can be a fulfilling experience but to be successful takes more than good medical care.

The Top Four Legal Issues to Consider When Opening an Urgent Care Center article describes significant legal issues that need to be considered during the planning stages. In addition to the usual components of a business such as location, leadership, work-flow processes, and timing; the medical business has certain legal concerns.

1.       Corporate practice of medicine is outlawed in some states and mechanisms including a “friendly PC” model can be used.

2.       State licensure requirements including a CLIA certificate of waiver for laboratory testing, x-ray permits, and any other licenses needed in that state.

3.       Understanding any EMTALA requirements is key to the viability of the center. Particular attention needs to be paid to the “naming of the center”.  Adding the word Emergency will imply, the center is a 24 hour practice that is specifically under the EMTALA laws. Hospital owned urgent cares must have their legal team evaluate any responsibility to the law.

4.       Have your insurance contracts in order prior to opening or face a potential cash flow issue. These negotiations take time.

Some other issues of particular significance are:

1.       Location, Location, Location

2.       Times of service

3.       Types of providers

4.       Credentialing those providers. This is a cumbersome time consuming task which may need to be outsourced.

5.       Marketing-Establishing contact with the local community by providing school physicals, blood pressure checks, flu shots, etc.

6.       Being undercapitalized and suffering cash flow issues

7.       Picking an Electronic Health Record and Practice Management system that is efficient and pays for itself.

8.       Understanding the difference between using a billing company and doing self-billing.

9.       Hiring the right practice manager.

10.     Not expecting a “paycheck” right away.

11.     Fill in the blanks

12.     Hiring a consultant to help with the start-up, if these steps are too daunting or too much aggravation.

With a proper vision, an urgent care can be an enjoyable way to provide quality medical care. This can lead to career longevity and adequate reimbursement.