20 April 2009

Crisis in the ER

Our ER is working well in recent months, but being here at the Leadership conference is a striking reminder of how challenged our system is, nationwide. The boarding and overcrowding crisis has not abated for my colleagues in other facilities and other regions, and I am hearing that loud and clear from the other physicians and medical directors in attendance.

So why are ERs so damn overcrowded, anyway?

Turns out that there are a lot of interrelated reasons.  Simple demographics plays a role, of course.  This point has been made in spades before, but to recap: there are more Americans than there were 20 years ago, but there are fewer acute care hospitals and fewer ERs to serve them.  Additionally, there are people living longer with more chronic diseases.

The corollary to fewer acute care hospitals is that there are fewer inpatient hospital beds.  This trend started in the '90s when it was generally agreed that there was an oversupply of hospital beds, and that managed care would drastically reduce the utilization of inpatient capacity.  The result was that the industry went through a wave of consolidation and downsizing.  This may have made good policy sense at the time -- I don't really know -- but it certainly made good economic sense for hospitals.  Like an airline that doesn't want to fly with empty seats, hospitals don't like to operate with empty beds -- it's wasted overhead, and more efficient if you can cut the marginal capacity and operate close to full all the time.  Only problem was that this leaves precious little margin for surge capacity come flu season, and little room for population growth.

The lack of inpatient beds led to inpatients boarding in the ER.  There was just today a nice article in Annals of Emergency Medicine which purported to show that Admitted Patient Boarding Times have a more significant contribution to ED congestion than physical plant size (number of beds).  

Boarding is probably the most significant contributor to congestion in most facilities, but it's not the only.  One insight I drew today from the talk about the Massachutsetts MA universal health plan was that the slow death of primary care is also in large part to blame for the continuing deluge of patients to the ED.

The MA experience was interesting in that there were 600,000 uninsured in that state prior to the reform, about 500,000 of whom ultimately wound up getting health care coverage as a result.  The data shows, however, that ED utilization did not decrease as a result, and in fact, it continued to increase at a pace beyond that of population growth.  Why is this the case?

First, as many have pointed out, there are simply not enough idle primary care physicians out there to absorb all these newly insured patients into their practice.  The hope had been that patients would gain access to primary care services and that this might decrease demand for ER services, but that was not to be the case.   (Given the dearth of medical students intending to enter primary care, do not expect that situation to improve.) 

But when you look back at some of the other data published, the larger point rings through -- that ER congestion is as much due to the insured as the uninsured, and provision of universal health insurance will probably do little to alleviate the overcrowding.  

Non-urgent use of the ED also does not seem to be a large driver of congestion.  Understand, though, that non-urgent patients and low-acuity patients are not one and the same.   A broken ankle, a sore throat, or a laceration are all low-acuity.   They are also urgent, at least in the eyes of a patient who is unable to walk, in pain, bleeding, et cetera.  And the truth is that the ER is better at treating these acute presentations than physician's offices are.

Not better in the sense of skill or quality, better from the patient's perspective of their time and convenience.   We are open 24/7, and for places with functional fast tracks it's possible to be in and out in under an hour.  Even for patients with slightly more complex problems - vomiting or abdominal pain -- two to four hours is the median range of their LOS.   This is awesome from a patient's point of view, compared to trying to get cared for in the office of your primary care doctor.   (Which assumes that you even have one.)

It's challenging to get in for an acute appointment, assuming that same-day appointments are avilable at all: you have to wait for office hours, call in, try to get the nurse, and hope to convince them that you are sick enough to be seen that day.  You may see your doctor, or you may see a doctor you don't know.  Then you have to wait for your appointment time, and if any ancillary tests are needed, you may have to go over to the lab, to x-ray, etc.  Often you then go home and wait for the doctor to call with the results.  It's an all-day experience, frustrating and a hassle.  This is in spite of the fact that many PCPs want to see the acute cases.  The low reimbursement for office-based practice forces them to schedule their clinic so tightly that patient convenience is not something easily accomodated, and certainly not in any large quantity.

So it's no wonder that consumers of health care, being rational actors, preferentially elect the more convenient avenue of care.   And two very necessary and very well-purposed pieces of legislation conspire to encourage patients to pursue this quick but very expensive option: EMTALA and Prudent Layperson.   Since EMTALA was passed, most ERs simply gave up trying to screen or redirect patients away from the front door, believing it illegal.  Those that try run terrible PR and legal risks.  So we have accepted the burden of the low-acuity urgent cases, built fast tracks, and tried very hard to make the care for these patients as quick as possible.  In part, this was intended to allow more resources to be focused on the more seriously ill, and in part this was due to the fact that fast tracks turned out to be nice profit centers.   By making ER care faster, quicker, and easier, we have further incentivized patients to eschew the clinic and just come on down.

Similarly, the Prudent Layperson rules have had the same effect.  Prudent layperson was a completely appropriate response to the bad behavior of insurers, just as EMTALA was a necessary response to bad behavior on the part of providers.  Both serve to remove any disincentive to come to the ER for minor conditions.  If the payer could require pre-authorization or credibly threaten to refuse payment, then patients would be more likely to choose a more cost-effective care setting.  But since this is now all but forbidden, patients have carte blanche to utilize the ER as a convenience clinic.

I'm not sure this is all bad, by the way.   If boarding went away as an issue, it's entirely possible that ERs might be able to accomodate the volumes, and despite the expense they incur, the ER does a lot very quickly and efficiently.  If the proposed medicare rules for Type B EDs go into effect, then fast tracks will be a much more cost-effective site for urgent care.  This also frees up the internal medicine physicians to manage complex and chronic conditions, which is ultimately their core competency.  Perhaps this is the future - Emergency Medicine blends into an over-arching Acute Care Medicine specialty.   It might not be the way an ideal system would have been designed, but it looks like that is where we are going, and I don't see any way to put that genie back into the bottle.


  1. I might agree to a certain extent. However, I can't think of ANY PCP who could set a broken ankle - nor would I want them to. Given you can't get a same day appt with ortho, the air splint & crutches come from the ED - not my PCP.

    Sore throats - you bet, but they could also go to the drug store & get a lozenge & a recommendation to take ibuprofen/acetaminophen, drink plenty of fluids & rest. Your laceration example - hmm....depends where it is. My experience is to be sent to the ED or surgeon's office if its of any significance. Rarely do surgeons do same day appts - so, off to the ED - on my PCP's recommendation.

    What's the uniform theme here? PCPs may want to see acute patients, but when presented with things outside their comfort level, it goes back to the ED or gets referred out - not dealt with in 4, 8 or any number of hours later. Knowing this, why even try the PCP?

  2. I feel like a lot of the time you guys seem to assume the populace is perfectly informed and jump to the "time and convenience" hypothesis when often we *just don't know* something isn't a "real" emergency. You've seen tons of broken ankles, but there's really no way that *I* could know that my foot hanging at the wrong angle off the end of my leg isn't urgent.

    I did make good use of the Injury Clinic when I belonged to Kaiser, rather than the ER, though. I used to laugh that it was the "there there, you're not really hurt" service. Which is great if you've got some sprain or minor tear that's just going to resolve on it's own, not so great if you've just been knocked over full-force by some 200lb man on an ice rink and find yourself unable to follow a sentence from beginning to end.

  3. Nice post.

    May I also add:

    1. Changes in ED physician utilization behavior (e.g increasing ordering of CT scans per 1000 patients, etc...)
    2. Changes in practice behaviors which require further admissions or advanced studies (stress tests in the ED, admission of TIA's, etc...)
    3. Changes in the diagnostic expectations of patients themselves (particularly important in our health care world where physicians compete on patient satisfaction instead of price).
    4. Increases in the complexity of reading advance diagnostic imaging (e.g. CT angiograms can have 1000 images to read where V/Q scans had 8)
    5. IT infrastructure has in general tended to DECREASE the productivity of direct patient care providers (even as it has improved the productivity of their administrative supervisors at the same time).

    I tend to simplify the explanation to people with the rather contrite statement: "complexity begets complexity".


  4. The reduction in a PCP's ability to handle acute cases are two fold.

    1) Lawyers. If the PCP has the confidence and training for a procedure but is not termed an expert, he is opening himself up for a large lawsuit. Why go through the hassle of a lawsuit, even if it is a 1 in a million chance? It is better to refer to the ED or a specialist rather than risk a career for $100 reimbursement.

    2) Due to #1 above and lack of specific training to handle procedures like the setting of broken bones, PCPs are not comfortable handling those acute cases.

    Tort reform combined with CME programs which teach physicians how to handle the 10 or 20 most common low acuity problems would reduce the congestion in the ED. Proper reimbursement would also help Physicians setup extended hours of care.

  5. Last summer, I stepped on a nail, and being long overdue for a tetanus shot, I headed to the county health office which is around the block from my house. They were conducting a special clinic in a town 30 miles away, so I went to our town's medical clinic. No, they said, I could not get in for a tetanus shot, but I could go to the emergency room. I determined that it was cheaper to make the 60-mile round trip drive than to use the emergency room. The county health nurses apologized for not being in my town when I needed them, but when it's a 9 to 5 Monday through Friday non-emergency, why should I go to the emergency room, the only option my town's health clinic provided?

  6. I don't understand why some of the more enterprising health care systems fail to build freestanding 24-hour almost-full-service urgent care centers? If insurers slapped hefty co-pays (say, $1K) on non-emergent ED use if an urgent care center was obviously the more appropriate setting for care, maybe some of the jokers with sore throats and broken ankles would have the incentive to do the theoretical"right thing". Of course, I live in an area where Engulf & Devour Health Care just buys up competitors, rather than building new facilities, and Large Multispecialty Group touts same day and after-hours appointments.

    Given the choice between an E&D urgent care center (not that that will ever happen), and an after-hours appointment at LMG, I'd rather go to LMG - my PCP is a member, and all of their facilities have EMR access.

    Disclaimer:I admit to being an idiot for walking around for.a week on a laminar ankle fracture - a weekend of RICE convinced me it was a sprain. After the pain got unbearable, I got a same-day appointment with my PCP, who looked at the ankle, sent me over to Invision at Swedish for an x-ray, then issued me an aircast, crutches, and some Vicodin. Nothing to set, really, although she would likely have treated it differently if I'd come in right after I injured it.

  7. Shadowfax, I hope you don't mind if I answer on your blog?

    Anon, you ask a very good question. I am asked stuff like this often and your question illustrates very well how most of us think about health care in paradoxically what is both an absolutely correct and absolutely incorrect way simultaneously.

    The "trouble" you MAY be having in understanding the answer to your "I don't understand why... " question is you always need to ask the question from more than one point of view- and when it comes to a common good like health care, it is always at least three perspective (our own perspective, the perspective of the people who provide the care or service and "society's" perspective).

    I assume you have asked this question from the perspective of a patient who has heard urgent care centers are cheaper (and you may have seen the bills charged to you by an urgent care and seen that they too are cheaper than the bills you have received from a prior experience in an emergency department) and so you rightfully conclude "I can save money" means "everyone can save money".

    The problem is this is most decidedly not true. Your perspective is not the same as providers or society.

    From a system perspective, building more of these urgent care centers would most definitely cost us all more money in the end (just like is a society builds more buildings, it spends more money building).

    Many people see these kind of economic "loops" or "paradoxes" for many things but they seem to be harder for them to otherwise grasp when it comes to health care because we all have such a primal mental block around "I want what is best for me".

    You simply need to understand that when it comes to health care, "what is best for me" is not at all the same thing as "What is best for US."

    The best way I have found to think of almost all issues in health care is to contemplate the analogy of The Tragedy of The Commons.

    Anyway, I hope this helps.