04 March 2009

Modern Healthcare vs ER Docs

May you be fortunate in your enemies, the old saying goes.

Apparently, we are.

There's an op-ed published Tuesday in a throwaway rag called Modern Healthcare, written by its editor, Dave Burda, it's a piece of work. Such a magnificent combination of ignorance and idiocy I haven't seen outside of Deepak Chopra's web site. It begins:
As you read this, special-interest groups are crawling over each other in our nation’s capital to grab their share of federal bailout money, using the current economic crisis as justification. One of the more distasteful displays of self-serving behavior is being put on by the American College of Emergency Physicians. The Washington-based group is manufacturing a crisis to ensure the full employment—and added reimbursement—of its more than 25,000 members. We urge federal lawmakers to look beyond the group’s alarmist rhetoric and kill the proposed Access to Emergency Medical Services Act before it even gets a hearing.
It's hard to know where to start, and this is only the lede. Apparently, Mr Burda has never heard of the Institute of Medicine's report, "Emergency Care: At the Breaking Point," and he's missed the Emergency Medicine Report Cards issued the last two years running. It's a manufactured crisis! (Shades of Phil Gramm's "mental recession"?) But perhaps I'm being too harsh -- it's not fair to expect him to know about every little ongoing collapse of a major health care sector. He's only the editor of Modern Healthcare magazine!

And added bit of evidence that Mr Burda couldn't find his ass with two hands and an ass-finding device is the implication that ACEP in trying to "ensure full employment" of its members. Um, what? Seriously? The field is understaffed by 40% -- over ten thousand ER docs short. There're no ER docs on the unemployment rolls -- quite the opposite; there are recruiters being paid $25,000 a head to put ER docs into positions.

Maybe he thinks we're sitting around in empty ERs twiddling our thumbs. Well, given that ER volumes have skrocketed by a third over the last decade (in concert with a contraction of the number of operating ERs by 5%), that assumption would be bass-ackwards as well. Quite the opposite; we're the victims of our own success, and quite literally drowning in business.

Oh yeah, and ACEP is based in Dallas, not Washington, asshat.

It goes on:
According to ACEP, hospital emergency rooms across the country are being flooded with patients who have lost their jobs and health insurance and have “suffered medical emergencies as a result.”
Yes. And, according to ACEP, water is wet and the sky is blue. The implication is not accurate that the current economic crisis is causing the crisis in emergency medicine. It's too soon for the 3 million newly unemployed of 2009 to have had much impact on ERs. There are many contributing factors to the ER overcrowding crisis: the uninsured are only one part. There's the slow death of primary care, the practice of boarding admitted patients in the ER, the closure of many acute care hospitals, and the growing and aging population of the United States, all combining to overburden a strained safety net. The fundamental truth of the claim is undeniable: if emergency care was "at the breaking point" in 2006, the economic crisis is predictably going to make things worse.
At the same time, according to ACEP, hospitals are reducing their ER capacity through tougher treatment policies to reduce their operating costs. Mix the two forces together and you have a catastrophe waiting to happen, ACEP says. And it’s a catastrophe that only the federal government can solve with legislation.
Well, that's just bullshit - a complete and utter distortion of ACEP's positions. Yes, many ERs have closed -- actually, it's more that the hospitals that used to host ERs have closed. But most hospitals are scrambling to increase capacity (with limited results) in order to better handle the deluge of patients. Perhaps the "tougher treatment policies" line is a reference to the University of Chicago situation, but this is not a wide-spread practice, and in fact, were it true, would support the contention that the nation's ERs are overwhelmed. I'm not sure which orifice he pulled the "only the federal government" bit out of, because the fix for the overcrowding problems goes well beyond a legislative patch. Did he even read the bill? It's as if he thinks the act is a sweeping reform bill, rather than a call for standards, a commission, and some extra funds. It's a small step towards fixing a very big problem that will require many stakeholders' participation.

Moving on:
Here’s where things get a little fuzzy in terms of verifiable information on which to support the legislation. How does ACEP know that hospital ERs are seeing more patients who have lost their jobs? That conclusion comes from a survey of 1,734 ER doctors...
I agree that the survey was of limited value. I've been watching our payor mix carefully and have seen only a small uptick in the uninsured -- from 16% to 17.5%. But is Mr Burda stupid enough to suggest that this historic recession is not going to increase the number of the uninsured? Do we need proof of that?
The second part of ACEP’s argument is equally shaky. Based on a handful of stories in the media, ACEP says hospitals are diverting patients away from their ERs because, according to the hospitals, they’re not presenting true emergency medical conditions. In a news release criticizing an urban medical center for doing so, ACEP said, “If other community hospitals follow suit, it will be catastrophic for the growing ranks of the poor, uninsured and underinsured, especially during this financial crisis.” Again, the financial crisis is being used as a rhetorical hammer.
Again, the wrongness is obvious to a passing glance. It is not that "ACEP says hospitals are diverting patients" away -- there's no dispute as to the fact that ONE hospital IS doing so. There's no he-said, she-said to be had there. And ACEP strongly criticized this practice, citing data from the CDC that only 12% of ER patients are non-urgent.
For as long as anyone on our veteran editorial staff can remember, hospitals and ER doctors alike have criticized patients for using ERs as outpatient clinics to address nonemergent medical conditions. They blame ER overcrowding on patients who should be seen at their doctor’s office.
No, you are the one making that error, or projecting it onto us. Yes, it would help if those ten percent of patients went to a more appropriate avenue of care. But it would help a ton more if ER beds had increased to keep pace with the growing and aging population, and if my ER wasn't choked with patients who should have gone upstairs 24 hours ago.
And hospitals, physicians and other emergency caregivers have been encouraged to come up with solutions to unclog ERs by diverting patients to the most appropriate and more cost-effective settings for care. That philosophy gave rise to urgent-care centers and, more recently, the boom in retail clinics. Leave the emergency rooms open for patients with true medical emergencies. For anyone with a real emergency, that’s great. But now, ACEP says that’s bad. It says hospitals are going too far and patients with emergency medical conditions are being shunted away to other facilities.
Yes, because it has happened and because there are policies in place which make it inevitable that it will happen again.
So what’s ACEP really concerned about? It’s money. If hospitals are reducing the physical capacity of their ERs or limiting care to truly emergency treatment, it could mean less work for ER physicians.
I wish I knew what bizarro world he's inhabiting. As I said before, we don't have enough people to do all the work we have now. We'd gladly offload some of it if we could -- but not at the expense of patient care.
In ACEP’s news release announcing its support of the bill, it says the legislation recognizes “the need for additional resources in support of care delivery.” What does that mean? The translation can be found in the actual legislation. A provision in the bill would mandate a 10% increase in Medicare and Medicaid payments to ER docs.
He's half right -- there would be an additional payment for all physicians providing EMTALA-mandated care. (How odd -- did you notice that the unfunded EMTALA obligation is completely absent from his article?) This payment would be directed to any physician, not just the ER doc, who provides uncompensated care in the ER. This is a critical measure in reinforcing hospitals' on-call specialty rosters. Specialists don't like to take call for the uninsured patients that come in through the ER, so they often drop out of the ER call rotation, or demand compensation from the hospital in return for taking call. Under this act, there would be an incentive for specialists to remain available for ER duty. ER docs would disproportionately benefit from this section, but then, we've been taking care of the uninsured in a disproportionate fashion for twenty years now, so that hardly seems unfair.
That’s what makes this piece of special-interest legislation so distasteful. ACEP is stepping on the backs of the sickest and most-injured patients to reach for its government handout.
How are we "stepping on" their backs? In what way does strengthening the safety net and providing a small offset for uncompensated care harm patients? How can any un-biased person suggest imply that improving the availability of on-call physicians is a bad thing?

A better question: Who is this clown, and why does anybody let him out in public, let alone write for a healthcare publication?


  1. Excellent smackdown SF. I don't know that I would have phrased it that way, but once in awhile you have to put aside the euphemisms and uncork.


  2. Excellent. Glad Grunt Doc retweeted this. Clearly, this writer hasn't spent quality time on the front lines. I work in the local Level 1 and my docs are a great group.

    You all are good. Appreciate the oppt to know you and work with y'all.


  3. Bravo! Hope you were able to get this to the source.

  4. What a douche-monkey!

  5. We are thinking of you and supporting from the other side of the world!
    We have a 'Call To Arms' over a series of similar series of incompetent statements/memos/directives and oversights in the management of emergency departments and the provision of emergency care in Australia.
    We have a voice - shout it loud and shout it proud.
    Well done

  6. ACEP has a credibility problem with the rank and file. They are widely viewed as favoring the needs of the large ER groups over the individual doctor. The attitude that permitted the Stephen Dresnick saga to last is still present. I quit years ago in disgust.

    They DO NOT speak for me. They do not speak for most of the physicians that I work with. (In my group, there are only 2 ACEP members)

    ACEP is not the way we should follow.

  7. Anon,

    I agree that ACEP has, in the past, been too corporate. However, they are our voice and our seat at the table. You remember two years ago when the E/M RVUs were revalued upwards by 10%? Who do you think was responsible for that? The ACEP members of the RUC (in coordination with others - it was not a solo affair). Got prudent layperson legislation? Another ACEP project.

    Quit if you like, but then who will represent your interests? AAEM? I admire them, but they have far less respect and clout than ACEP (and ACEP is not a terribly powerful lobby itself).

    It's all fine to be "disgusted" but nihilism is not a helpful response.

  8. The hell with AAEM. While they started with good intentions, they have been taken over by the people they originally opposed. How many of the top people are members of large multi-site groups?

    Investigate it and open your eyes!

  9. My company provides services to almost 1/4 of ED's across the country. We have seen an increase in volumes in our customer base by 9 percent this year, 18 percent over the past three in a lot of places.

    I speak with doctors that are up to seeing over 4 patients per hour because there is nobody else. Unfortunately, under those circumstances, mistakes will get made, and people are going to get hurt. I applaud you for getting the word out in advance, so that when this starts to happen, the public appropriately attributes this to the overcrowding and miserable conditions.

    Another scary thing to think about is New York medical care. A very large number of media companies are there, they get an "F" on their liability situation, and a very large number of docs there (even ED docs) are nearing retirement age.

    The public needs to know that the next time you go in to the ED, have a seat, and I hope you are not sick, because there's a lot of folks in front of you, and they are just as sick or sicker. The ankle sprains are out the door in 15 minutes, and they don't use the resources that are keeping you waiting...


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