Solving the problem of access to care will require new thinking about how to meet all patients' needs, and the first step should be rethinking the role of emergency rooms.
It is not news that crowded conditions and long waits are staples of most emergency rooms in the United States. Many hospitals have been forced to send incoming ambulances elsewhere because of crowding. So it's clear that an influx of patients seeking help for non-emergencies -- a sprained ankle or seasonal allergies -- could further impair the ability to care for the critically ill or injured.
This appears to be what occurred after universal coverage was enacted in 2006 in Massachusetts, where ER visits increased by 7 percent, with costs rising 17 percent. It could be that the newly insured were accustomed to going to emergency rooms for treatment.
Adding patients to the ER in this way is simply not cost-effective. ER doctors rarely have relationships with the patients we see, and we don't have time for a lengthy dialogue about their ailments. So we often order expensive tests that add to a hospital's already-high fixed costs. As a result non-emergency care delivered in the ER costs almost five times more than in a doctor's office or clinic.
There are four ways we can steer minor emergencies away from the ER.
First, establish more offices and clinics that are not based in hospitals (and do not carry hospital overhead). The recent trend toward low-cost, retail- and pharmacy-based clinics has been a relative success for what these facilities offer: quick evaluation and treatment for simple problems. They have been found to cost less than one-fifth of what an ER costs for the same complaint.
Second, invest in allied professionals and paraprofessionals such as nurse practitioners, physician assistants and medical technicians to deliver much of this basic care. Training more primary-care physicians will not be enough.
Third, improve systems related to the delivery of health care. Every well-run company knows its supply and delivery chain in detail, so why don't health systems? Managed health-care systems such as Kaiser Permanente and the Mayo Clinic are ahead of the curve in this
respect.
Every municipality or county should have a detailed understanding of where needs are and a plan to address them. For example, by knowing the exact numbers of diabetics, smokers, and people with kidney disease and high blood pressure in our communities, we can predict how many CT scanners or, say, vascular surgeons are needed. Gaining this knowledge will require cooperation and information-sharing among all health-care entities: insurers, hospital systems (both public and private) and managed-care systems.
Finally, we need to employ the new ideas and technologies that have emerged from the Internet and social networking revolution to link patients with informed advice about their conditions. In a fully realized online system, simple medical questions can be answered by health advisers in real time. Patients can be directed to walk-in clinics, urgent-care centers or even emergency rooms when necessary.
This ER doc from San Francisco writes a good article on the need to keep routine care out of the ER's. This condition was made prevalent in the days when a lot of people (estimates of 30 million are on the low side) didnt have healthcare. Their only outlet for care was ER's as most states make it illegal to turn away patients in the ER. As we move into the new era of near universal healthcare, this behavior will persist unless we are proactive about it. In fact, as Massachusetts was the pioneer, they say their visits to the ER increased by 7 percent. I assume this is because now that everyone has healthcare, they are emboldened to use it. However, their behavior is still to go to the ER.
The physician in the article comes up with very good points on how to keep patients who require routine care out of the ER: more "Minute-Clinics" like clinics; more nurse practitioners and the like; improving the dynamics of larger health systems to be more integrated an efficient; and using the internet to have patients better understand their conditions. I applaud Dr. Brokaw for thinking about the issue and putting forth viable solutions. All of these should be sought.
However, humbly, I believe there are simpler methods to reduce patients going to the ER for routine care. These will not solve the problem 100%, but I believe they will help tremendously.
First, we must have an effective communication campaign to the public to go to see their primary care physician for routine care. The reason patients are going to go to the ER for routine care even with insurance is because it is a learned behavior from the previous days. In the US, these millions of new people are not used to seeing a PCP before going to the ER.
Second, as part of this communication plan, we must communicate when it is appropriate to go to the ER. From childhood, we are taught when it is appropriate to call 9-1-1 compared to calling the local police department. However, there is no similar communication campaign for when it is appropriate to go to the ER. My wife is a physician, and my family and friends (fortunately or unfortunately!) is full of physicians. I remember a specific instance when I went to the ER because I could barely talk or swallow out of my sore throat. In discussing with these physicians, they all looked at me cross eyed (you readers may also!) and couldnt believe I wasted previous ER time with this. An effective communication plan, much like the plan around effective use of 9-1-1, would alleviate much of the problem.
Lastly, we must create nudges to start to get all these new uninsured (and people like me who have had insurance) to begin to get into routine care with their PCP. I am now doing my annual physicals, but rarely did before the last 24 months. One big nudge would be for the PCP offices to take a dentist like culture when it comes to appointments - when I leave the dentist, they insist on setting up my next routine 6 month appointment. On the other hand, at my last annual physical, (a) I had to ask to set it up and (b) the scheduler said their schedule doesn't go out far enough yet!
I believe in simple solutions. People previously were going to the ER because they had no choice. With health insurance, people do have a choice, but will go to the ER because (a) that is what they are used to doing; and (b) they (including me!) dont know better. We need to change their pattern of behavior through communication and simple nudges. This is cheap and easy to implement.
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