Tuesday, September 7, 2010

Emergency Rooms Used for Routine Care

The Patient Protection and Affordable Care Act (Our government's name for Health Care Reform) may make our already crowded emergency rooms swarm with more patients. A new study from Health Affairs
shows that more than a quarter of patients who currently visit emergency departments in the U.S. are there for routine care and not an emergency.  New complaints like stomach pain, skin rashes, fever, chest pain, cough or for a flare up of a chronic condition should not be treated in emergency rooms.  They are best worked up and treated by an Internist or Family Physician...preferably one who knows the patient.

So why are these patients waiting for hours and spending up to 10 times as much money for Emergency Department care?  The study shows it is a problem of limited access to primary care services.  Patients cannot get in to see a primary care doctor or it is on a weekend when they are not open.  Two thirds of the minor acute care visits to emergency departments took place on weekends or on a weekday after office hours.

Nationwide there is a shortage of primary care physicians and many have closed practices, limit Medicare patients and take no Medicaid at all.  When a patient has stomach pain and is told the next available appointment is in 2 weeks, it is no wonder they head for the ED.  Once there they will likely get a battery of tests that may not be needed and even Cat Scans before they are told to go home with a diagnosis of "gas".

The good thing about the Patient Protection Act is that millions of new people will get insurance of some type.  The bad thing is, unless we address the primary care shortage in a real meaningful way, it may just lead to more expensive care in the Emergency Rooms across America.

Robin Weinick of the RAND Corporation and a coauthor of the study said that urgent care centers could potentially manage between 14-27% of all emergency department visits and save $4.4 billion - or .2% of national health care costs annually. 

We need to expand the capacity and weekend hours at community health centers.  We have already passed the window to increase the supply of primary care physicians by ignoring the crisis.  But it is not too late to change the incentive structure for payment and try to lure more young doctors into primary care.  It worked for Radiology and Anesthesiology and Urology.  The nation would be the beneficiary.

25 comments:

tracy said...

Primary Care Doctors are sooo very important...there must be a way to get them paid what they are worth...which is ALOT! i think many Med students would go in to the field if the money were there and the hours weren't so grueling.
What is the solution?

As you said, Dr. Brayer, so many people end up in the ED for lack of a Primary Care Physican.

tracy said...

Dr. Brayer, if you have a moment, go to this blog http://sarainisrael.blogspot.com/ and look up her article "Explain This American Healthcare". Very well written and thoughtful. She is a physican in Israel.

Funny wedding photos at the begining of the blog....keep searching!

tracy said...

PS Dr. Brayer, i think you would find her post on "Graduation", just below the article pretty funy.

Toni Brayer, MD said...

tracy: thanks, I'll check it out.

Have Myelin? said...

I have MS, renal insufficiency, am deaf (use a cochlear implant) and am on *ick, ick* Medicaid because I can't afford Medicare.

I hate Medicaid. I hate it.

I was dropped by my neurologist ON THE SPOT after three years with her when she didn't like her reimbursement rates. She didn't even talk to me about it. Her nurse told me "she is done with Medicaid".

I was dropped by my urologist after going on Medicaid. People say "go to Denver". Well... University Hospital's urology clinic just dropped Medicaid.

My "new" neurologist can't/won't see me until November. I made that appt in MAY. Quite a wait, no? Especially if you are on Copaxone and having reactions. I am skipping many injections due to adverse reactions. My boyfriend calls Shared Solutions for telephone support. Telephone support for dinner plate size hives but "keep taking the shots until you see your new neurologist in November OR go to ER" they say.

It takes me 4 months to get an appt. to get my cochlear implant programmed.

I see a PA, not a doctor by the way. I had a pulmonary function test last week but it will take awhile to get the results from the PA.

Don't have a renal specialist yet. It will take awhile to find one that accepts Medicaid, then it will be months before I get in. LOL! The PA tried to put me on lisinopril but I have low BP and almost crashed. So much for that.

OF COURSE I'm going to use the ER, what am I to do? There are no doctors accepting Medicaid. I don't blame them a bit.

To make matters worse, my 34 year old daughter died June 10, 2009. She waited all day in ER to be admitted. All day.... and after she was admitted she crashed 3 hours later and never regained consciousness. She died 10 days later.

We have a problem. I am afraid for our country's health care system. Health care reform might work for some of the doctors but it is not working for this patient since I can't find any doctors to accept Medicaid. That is the plan of "NO".

My son was thrilled when the reform happened (haha) but when he sat in on one of my visits with the PA he was alarmed when she gave me a less desired medication for my breathing problems because "Medicaid would not pay for it". Yeah, that too.

My problem is there are not enough specialists accepting Medicaid.

KM said...

I always thought if someone was having chest pains during closed hours of their doctor's office was a good reason to go to the ER to rule out it was not a heart attack, depending on the intensity and severity of the pain. I know their doctor can be called or someone would be on call for him or her, but in some cases it seems like that might take too much time if you don't know if it is a heart attack going on.

Toni Brayer, MD said...

Have Myelin: My heart goes out to you and to so many others who have insurance but still cannot get care. You are so correct about Medicaid in California the access is even worse with MediCal. If you live in a state with a good academic medical center that can often be a good solution. Also some hospital/medical groups take Medicaid and you have access to good specialists that way because the physicians are "blind" to the payer.

Toni Brayer, MD said...

KM: Certainly severe, sudden chest pain or chest pressure that is worsening should be seen emergently. But lots of "chest pain" does not fit into that category and can be evaluated by the physician in the office. Most chest pain is non-cardiac.

Have Myelin? said...

FYI: I'm in Colorado, not California.

Doctors are dropping Medicaid right and left in Colorado. For some reason it hasn't made it to the national news. The University Urology Clinic's decison to drop Medicaid in Denver made the "local news". You can find that by googling.

We hear all about the California Medicaid peeps unable to see doctors but it is happening everywhere.

We get what we pay for and since I pay nothing for Medicaid...well, I am feeling/seeing the effects of it.

I want the government to stay out of my health care, that's for sure. Never thought I'd miss my private insurance company so much...at least I could hold my head up high at the front desk. Ya know?

Michael Kirsch, M.D. said...

The same Health Affairs article stated that nearly $56 billion is spent yearly to fund the medical liability system, most of which is accounted for by defensive medicine. Some claim this is but a small percentage of health care costs. Perhaps, but is it money well spent? I suspect it is an underestimate as defensive medicine tests, such as CAT scans, spawn a cascade of additional testing and treatment.

stock market for beginners said...

Primary Care Doctors must be prioritized, they are the ones that is needed, and something must be done to draw attention to students and have the interest to be part of this career. although taking career is not by choice but by calling, there are some who have the passion to be a Primary Care Doctor but just losses its interest because of money matters.

ERP said...

Interesting is that many people who go to ER's for minor and routine things report that we see them faster and they feel like their issues were addressed more fully than their PMD's are able to. This is more often the case with those who only have Medicaid or go to some crowded clinic. I am not saying at all that we are better at this but that PMD's are totally overwhelmed and can't dedicate the time to them. (plus the patient's have to wait for an appointment).

medtale said...

Sad reality for primary care physicians and the patients. The problem is worsened by our culture of "rule out everything" rather than "find out what's wrong with the patient"

Shreya said...

The sad thing is that it's really the patient that pays through the nose for ER visits that diagnose non-emergency issues! I feel strongly that the ER should be treated as just that -- a place for emergencies.

Read more: Consumer health

Anonymous said...

Frequent and inappropriate ER use also comes on the heels of a poor social/economic situation.

Here is an article addressing that from research done in No. Calif.

http://www.humboldt.edu/ccrp/blog/complex-chronically-ill-addressing-needs-frequent-patients-and-inappropriate-emergency-room-use

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