10 February 2009

Going on Diversion

Via Chicago Tribune

U. of C. emergency room to get more selective

New version of patient triage aims to cope with spiraling costs and long waits for treatment

Key Points:

UC's ED sees 80,000 patients annually -- they estimate 40% of those do not need ED level care. That sounds consistent with my experience in an urban facility.

UC has had to lay off 5% of its workforce as their financial situation worsens, and IL Medicaid payment rates are among the lowest -- and slowest -- in the nation.

"The emergency department will be reorganized to provide more evaluations from doctors and nurses before care is provided." This sounds like a nurse and doc (resident?) in triage performing the MSE right there, and then deciding whether to allow the patient back to the ER or redirect them elsewhere.

"In some cases, patients will be referred to any of about two dozen community health centers throughout the South Side or to either of two community hospitals, Mercy Hospital and Medical Center and Holy Cross Hospital, which have agreed to be partners in the initiative. For some patients, The U. of C. will provide transportation or schedule appointments."

I've got to wonder why on earth Holy Cross and Mercy would agree to be part of this. I'm assuming that the patients redirected there would not represent great revenue, and I don't know of any urban hospital that is operating at under peak capacity these days. It sounds like those are representing inpatient transfers, from the example case cited in the article. But what's their incentive to be UC's dumping ground?

As for sending patients out to community health clinics -- it looks like a great plan on paper, especially when the hospital goes the extra mile by assisting with scheduling and transportation. But it's a big gamble -- the first time a patient is inappropriately redirected away, or has a bad outcome, the media, the regulators, the lawyers, and Chuck Grassley will be all over them like flies on stink. So they had better be very careful in developing and adhering to their triage protocols, I think, to survive the extra scrutiny that this move will engender.

Ultimately, this is a desperation move for an overwhelmed ER. Hospitals don't pull this sort of stunt lightly, especially hospitals with such a high profile and reputation. I expect to see more of this in comping years, if current trends continue -- hospital and ER closures in the face of increasing utilization of the ER. But with the slow death of primary care and the dearth of community health centers, it's an open question whether other institutions will have receiving facilities to offload these non-urgent ED patients to.


  1. The example in the article doesn't really make sense, so I can't comment on that. But in general, once a facility has done the MSE, they don't need any "partners" or (free/cheap) "community health clinics" to accept the patients they turn away. If a patient doesn't have an emergency medical condition, they can be referred anywhere - it doesn't matter where. In practice, if the patients are referred somewhere that will cost them money, they probably won't go at all or won't stay for treatment, and they'll go to another ER instead. Either way, the ER doing the MSE has successfully passed the buck.

    Many facilities in Texas have been using this system for quite a while already, but in practice we focus more on the repeat abusers of the system than patients with a new but questionably emergent medical issue.

    The Baytown example seems heinous to me, personally.

  2. I developed a huge packet of low-cost clinics and dental clinics for my dept that take people on a sliding fee basis, and it seems that people who are newly uninsured from the economic problems or the working uninsured really appreciate this info. Drug seekers and Medicaideurs with entitlement issues obviously aren't going to care too much. A lot of people still think that no insurance = No medical care except at the emergency room.

    Luckily, there are a good number of choices around my hospital, many with same-day appointments. I think every hospital in any sort of urbany area should have a similar packet 'o info.

  3. I'm a student here at U of C and can testify that "desperate" is an understatement for a typical day in our ED. And things are only going to get worse since as part of the recent cost cutting we are closing a general medicine unit. We haven't been given any more information than that in the article, but a decent summary of some of the issues that have been going on around here can be found here:

  4. The comment you made about Medicaid being slow to pay is pretty funny. I just got a bill for some chemo treatment my father underwent 2 years ago that medicaid and the hospital finally worked out.

  5. are they doing this around the clock or only during business hours? how much will it help to divert these patients from 9am-4pm monday-friday? given how much the volume tends to go up at 4-5pm?

    it'll all be fine and well until the first bad outcome. then u of c will be crucified.


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