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The Emergency Department Role in the US Healthcare Delivery Mechanism

The Emergency Department Role in the US Healthcare Delivery Mechanism. Carey D Chisholm, MD Emergency Medicine & Combined Peds-EM Residency Director IUSM MS4 EM Rotation. Carey D Chisholm, MD. Disclosure. No relevant financial relationships.

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The Emergency Department Role in the US Healthcare Delivery Mechanism

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  1. The Emergency Department Role in the US Healthcare Delivery Mechanism Carey D Chisholm, MD Emergency Medicine & Combined Peds-EM Residency Director IUSM MS4 EM Rotation

  2. Carey D Chisholm, MD Disclosure No relevant financial relationships

  3. Have you (or immediate family member) been a pt. in the ER in the last 5 years? • Yes • No • Never

  4. Which characterizes your impression of care rendered in the ER? • Excessive wait times • Expensive • High medicolegal risks • Impersonal • Mainly triage • Poor privacy • Superficial

  5. Which of these most accurately characterizes US ED care? • Contributes 50% of total health care expenditures in the US • 50% of ED care is non-urgent • Most expensive care in the US • The majority of ED users are insured • All except D National Center for Health Statistics (CDC-P), 2011

  6. Goals • Discuss unique features of the ED in the US healthcare setting • Understand who, how and why patients seek care in the ED • Discuss “quality indicators” of care in the ED • Describe the “ED approach” to rendering care. • 3 pragmatic questions to make your rotation go smoother.

  7. Why the ED???? 1

  8. Why the ED??? 2

  9. Why the ED?? • “True emergency” (how define non-emergency?) • Lack of alternative access • Uninsured/No PCP • No appt. at PCP • Afterhours • Acute problem • Access to technology • Sent by PCP • Travelers • Societal outcasts • “Drug seekers”

  10. What % of non-admitted ER pts are referred there by their PCP? • 1% • 5% • 10% • 20% • 40% CDC 2012

  11. "I mean, people have access to health care in America. … After all, you just go to an emergency room." President GW Bush 2007 • Rush says health care reform is “insidious”, claims there is health care for poor people: “it’s called the ER” Nov 2010

  12. How many EDs are there in the US? • 2,000 • 4,500 • 10,000 • 20,000 • 50,000 National Center for Health Statistics (CDC-P), May 2010

  13. How many patient visits occurred in US EDs in 2009? • 500,000 • 950,000 • 12 million • 70 million • 136 million • 161 million National Center for Health Statistics (CDC-P), 2011

  14. Of 305 million US citizens, how many lack health insurance/year? • 10 million • 50 million • 70 million • 100 million • 130 million

  15. Which demographic group contains the most (total) uninsured?? • AA women 18 – 35 years • Caucasian men 18 – 35 years • Latino men 18 – 35 years • Undocumented immigrants • Urban Children 2 – 16 years National Center for Health Statistics (CDC-P), May 2010

  16. Which of the following characterizes the one year % increase and avg. charge to insure a family of 4 in 2011? • 2%, $5k • 5% , $5k • 2%, $10k • 5%, $10k • 9%, $10k • 9%, $15k • 12%, $10k • 12%, $15k

  17. Why the Uninsured” • ED docs are altruistic? • EMTALA • Any patient who "comes to the emergency department" requesting "examination or treatment for a medical condition" must be provided with "an appropriate medical screening examination" to determine if he is suffering from an "emergency medical condition". If he is, then the hospital is obligated to either provide him with treatment until he is stable or to transfer him to another hospital in conformance with the statute's directives. • Another section [42 CFR 489.20(q)(1)] requires that the hospital post a conspicuous sign which notifies patients and visitors of the right to be examined and to receive treatment. The sign must be in a form approved by the Secretary of Health and Human Services

  18. The cost of emergency care required by EMTALA is not directly covered by the federal government. Because of this, the law has been criticized by some as an unfunded mandate.[4] Similarly, it has attracted controversy for its impacts on hospitals, and in particular, for its possible contributions to an emergency medical system that is "overburdened, underfunded and highly fragmented".[5]More than half of all emergency room care in the U.S. now goes uncompensated. Hospitals write off such care as charity or bad debt for tax purposes. Increasing financial pressures on hospitals in the period since EMTALA's passage have caused consolidations and closures, so the number of emergency rooms is decreasing despite increasing demand for emergency care.[6] There is also debate about the extent to which EMTALA has led to cost-shifting and higher rates for insured or paying hospital patients, thereby contributing to the high overall rate of medical inflation in the U.S - wikipedia

  19. How much EMTALA related care does the avg. EM physician provide each yr? • $5000 • $10,000 • $25,000 • $75,000 • $125,000 AMA 2003

  20. EMTALA “Unfunded Mandate” • AMA Study 2003 • Avg ED physician renders $138,000/year in uncompensated EMTALA related care. • Surgery was #2 • $28,000/year • Avg. $25,000 across all other specialties “One-third of emergency physicians provide more than 30 hours of EMTALA-related care each week.”

  21. ERs Provide the Bulk of Acute Care to Un-and-Under Insured PrimaryCare MDs ER Docs Specialists Active physicians (597,430)) 4% Total acute visits(273 million)) Acute visits by –Medicaid or SCHIP (39 million) 50% Acute visits by the uninsured (24 million)) 65% Pitts et al. Health Affairs, Sept 2010

  22. Not just the uninsured • Majority of users have medical insurance • Lack of access to their own PMD appointments • Perceived emergency condition • Access to after-hours care • No co-payment at time of delivery of care • “One-stop shopping”

  23. Other “Unique Features of the ED

  24. 24 – 7 • For the MAJORITY of hours for every day of every week in every year, the ED is the ONLY health care available to Americans. Want to live here??

  25. Community Healthcare “Nerve Center” • Referral from PMDs for access to specialized treatments or diagnostic tests. • Access to lab, imaging after hours. • “Specialized” acute care features • SANE • Med Tox / PCC • CVA/MI • Trauma • Environmental • Mass Gathering – Mass Casualty

  26. “The only ‘infinitely expansible’ component of the health care system” ED Crowding

  27. According to the US Govt., what % of ED visits are “unnecessary”? • 5 • 10 • 25 • 55 • 80

  28. How did they arrive at that figure? • Discharge diagnosis • Methodology flawed? • Pts present with a SYMPTOM complex, NOT a diagnosis! • That’s why you’re going to LOVE this month!!!! • YOU get to formulate a diff dx and plan for YOUR patient.

  29. What % of ED Visits are nonurgent? • 8 - 10 • 18 - 20 • 30 - 33 • 45 - 50 • 60 - 66 National Center for Health Statistics (CDC-P), 2011

  30. Which of the following discharge Dx does NOT require EM services? • Acute tonsillitis • Bronchopneumonia • Erysipilas • Herpes zoster • Missed abortion • Salmonella enteritis • Scarlet fever • All of the above WA State Medicaid services, 2011

  31. Which group is most likely to have a non-urgent visit to the ED? • Insured • Medicaid • Undocumented immigrants • Uninsured • All have similar rates National Center for Health Statistics (CDC-P), May 2010

  32. Cost of care in the ED? • Avg charges ER visit $383 (1996), $903 (2008). • Avg PCP office visit costs $60 (2001), $199 (2008). • According to the National Center for Health Statistics, 55 percent of the 90 million visits to EDs in the United States in 1996 were unnecessary (PAIN NOT a “necessary”) • “Emergency room treatment for non-emergency medical conditions is a major contributor to the rising cost of health care” • “High emergency room (ER) utilization is a considerable concern for the increasing cost of health care.  Frequent and inappropriate use of hospital ERs is extremely costly and care could be provided in a less expensive setting.” WSHA

  33. Cost of ED care • “Average ED visit” c/w “Avg office visit”? • How define “unnecessary”? • Cost shifting and McD model. • Incremental visit analysis

  34. Medical Econ 101 • Difference between “costs” & “charges”. • CT scan example • $800 • Pharyngitis example • “costs” vs patient charges

  35. What % of total US Govt healthcare spending goes to ED care? • 2 – 3 • 10 – 12 • 15 – 17 • 20 – 25 • 40-50

  36. In fact, the US Govt spends more each year to have Cardiologists over-read EKGs for Medicare beneficiaries alone….. 2%

  37. CHARGES (EMTC) • CBC • BMP • LIPASE • APAP • UPT • TROPONIN • UDS • $30 • $50 • $75 • $100 • $125 • $200 • $250 • $600

  38. CHARGES (EMTC) • CBC • BMP • LIPASE • APAP • UPT • TROPONIN • UDS • $30 • $50 • $75 • $100 • $125 • $200 • $250 • $600

  39. What is the most frequent Sx complex presenting to the ED?

  40. …Put on your Gowns…How to define “quality” ED care? • Time • Friendliness • Communication • Address concerns • Meet expectations • Cleanliness • Privacy & confidentiality • Bill for services

  41. Which is the single most impt determinant of satisfaction? • Agenda/expectations are met • Bill for the visit • Communication about the treatment • Friendliness of the staff • Time

  42. And the Winner is

  43. Hypothesis • The ED is the FF model in the health care industry … Fast and Friendly • But wait … you’ve got a very bad “stomach flu” …. • And before pts. Became “customers” …

  44. The ED as the “Safety Net” • Fixation on time!!!!

  45. ED Approach to providing care • FOCUSed care Hx, PE, Dx, Tx, Dispo • OK NOT to do the “complete Hx and PE” • ROWCS instead of Baye’s Theorum • One shot approach • Data gathering coincides with Tx and Dx • Definitive answer often lacking at end of encounter • Assure what they don’t have

  46. Time issues: Recall most frequent CC • Alleviate pain and distressing Sx • Assure more serious medical condition doesn't’t exist • Decrease further morbidity by earlier intervention • We fixate on waiting room times • “The sickest patient in the ED is the one waiting to be seen next”

  47. The “3 Questions” • What are you concerned your symptoms may be caused by? • What are you hoping that I can do for you today here in the ER? • What changed to make you decide to come to the ED right now?

  48. Have you had formal education about safe patient trade-off? • Yes extensive (over 2 hours) • Yes, 1-2 hours • Yes, mentioned in passing in lecture • Yes, but informal on the fly • Yes, self study only • Not yet

  49. Patient Change-Over • Under 10% of US MS grads in 2008 had such education. • MAJOR area for medical error, malpractice risk, and patient inconvenience

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