eds

A physician's perspective on why the ED model is stuck

Fri, 06 Jun 2008 06:59:59 -0400

As some you will recall, in a recent column I looked at the issue of how EDs handle patients with non-critical but acute illnesses. (I'd suggested that some form of step-down care, probably in the form of an on-site urgent care clinic, would make a lot of sense.)

However, when I ran my argument past a veteran emergency physician with decades of experience in California EDs, he told me a different story, one that made me sit back and think about whether my suggestion was practical, given the culture of the ED as it stands.

'Why,' I asked him, 'should acutely but not critically ill patients be booted to the curb, rather than cared for via a different track (as happens in some re-worked emergency departments)?'

Here's his reasons why you're not likely to integrate urgent care with ED care anytime soon:

* Culture: Emergency physicians choose the specialty and do the residencies to deal with emergencies.

* Process design: EDs, by and large, are not designed for anything but emergency evaluations.

* Health system stresses: The failure of primary and specialty care to meet demand; having that demand forced into the ED limits how flexible ED staffers can be.

* External pressures: The fact that most EDs and emergency physicians are pressured to produce at greater than 2-3 patients per hour makes it unlikely that that they could adjust to a partially urgent-care-based model. ("You can't do semi-elective workups with that degree of pressure," he notes.)

* Financial credential concerns: "We are profiled by insurers, and do not want to be the outlier" by investing extra resources in patients who aren't in serious trouble, he says.

* Managed care standards: "Length-of-stay and other ED metrics are driving the industry now--and a protracted workup in the ED skews the LOS and may make you an outlier," he says.

* Reimbursement models: Investing more resources in the less-critical patient can be particularly difficult if health plan incentives discourage it. "Where I'm at, with 95 percent capitation," there would be tremendous resistance to have "workups" occur in different cost silos," he notes.

It sounds to me as if integrating critical care and urgent care in the ED setting would be one hell of a challenge, at best. Still, with some hospitals managing to create separate tracks for the critically and acutely ill, it must be possible.

What do you think would need to happen to turn your emergency room into a system that had distinct workflows (other than basic triage) for sick patients versus mortally ill patients? Do you think it would even be a good idea to try and make this happen? Tell me what you think! - Anne

Why EDs need urgent care services

Fri, 30 May 2008 06:59:59 -0400

Today, EDs are crowded at levels they've never been before, and there's few if any signs the problem can be made better. Sure, smart hospitals can improve patient flow by investing in IT that tracks them efficiently. And there's always ways to make better use of time when patients are waiting--for example, I've heard of some that take blood samples and do an EKG while patients was boarding in the hallway.

But I'd argue that the answer isn't necessarily getting them in and through the system as quickly as possible--out the door or into beds--isn't necessarily the best way to think about dealing with this flood of patients.

After all, just because a patient isn't dying (and doesn't need to be admitted at that moment) doesn't mean that they're a) not just a bit too acute to be lightly sent home to bed, b) might benefit from palliative meds to tide them over until specialists can see them, or c) in need of more information to better self-manage their condition than the more or less useless handouts EDs typically provide. And that argues strongly for establishing at least some kind of primary/urgent stepdown presence in the ED for patients who still need help once it's been determined that they're not in immediate danger.

For one thing, a primary care-minded staff member such as a nurse practitioner can do much to help coordinate care between the ED and on-call staff at primary care practices. He or she can also ask a few probing questions of the primary care physician to see if there's tests or issues the patient might not have mentioned, something that ED physicians seldom has time to do.

What's more, an NP can help develop a slightly more robust care plan for moving forward than "here's a referral," which all many non-critical patients get. Such help not only improves outcomes overall, it also builds relationships with patients who may have a need to return to your ED someday.

On top of everything else, if hospitals place an urgent care person within the ED, that could serve as a funnel to future relationships with the patient and his or her family which could include ambulatory surgery referrals, relationships with affiliated primary care practices, physical therapy and more. In other words, while health systems may not get an admission out of that visit, but they could develop a longer-term relationship that proves fruitful for both sides.

So, folks, what do you think? Am I on base here? Is there something I'm missing? Write to me and tell me what you think. -Anne

SPOTLIGHT: Hospital EDs not ready for mass casualties

Tue, 06 May 2008 06:59:52 -0400

While they may be managing to deal with overcrowding right now, there's no way that the nation's hospital EDs will be ready for mass casualty events such as a natural disaster or terrorist attacks using conventional explosives. That's the verdict of the House Committee on Oversight and Government Reform, which says that current Medicaid regulations have only made things worse. Article

Trend: More free-standing EDs opening

Fri, 25 Apr 2008 06:59:56 -0400

In recent years, the number of freestanding emergency departments has grown dramatically, climbing 23 percent from 2005 to 2006, according to the American Hospital Association. These EDs treat many of the minor conditions typically addressed by urgent care centers, but unlike urgent care centers, are open 24/7. With 179 already in existence, and a dozen or more in the planning stages across the U.S., these independent EDs are an increasingly popular alternative to crowded EDs.

The question, critics say, is whether they're good for the health system as a whole. For one thing, they skim off such patients from medical practices and urgent care, both of which typically charge less. This could raise health system costs overall, analysts say. Also, patients who need additional help--such as surgery or cardiac procedures--still need to be rushed to traditional EDs, a delay which could prove to be harmful, some emergency care providers suggest.

To learn more about this trend:
- read this USA Today article

Related Articles:
Congress takes on ED overcrowding.
Case study: AZ hospital posts ED wait times on website.
EDs seeing more affluent patients, less uninsured.
Hospitals charge fee for non-emergency ED visits.

SPOTLIGHT: CA faces specialist flight from EDs

Fri, 25 Apr 2008 06:59:52 -0400

Specialists are becoming an increasingly precious commodity in emergency departments across the U.S. But even by national standards, things are particularly bad in California, whose Medi-Cal program has some of the lowest retention rates in the country. These low rates, combined with other forces giving specialists the ability to refuse on-call schedules, are creating a crisis in the state's EDs. Article

U.S. Reps give boost to physician-owned hospitals

Fri, 11 Apr 2008 06:59:57 -0400

In recent times, physician-owned hospitals have taken a lot of fire in Congress--but at least two U.S. Representatives say that some of the criticism is out of line. In a recent letter, sent by Reps. Sam Johnson (R-TX) and Ruben Hinojosa (D-TX) to their Congressional colleagues, the two contended that information provided by a trio of hospital groups on the subject was inaccurate. They're saying that in its recent recommendations arguing for new limits on such facilities, HHS inappropriately relied, in part, on faulty information provided by the American Hospital Association, Federation of American Hospitals and Coalition of Full Service Community Hospitals. These groups, which feel extremely threatened by the growth of physician-owned specialty hospitals, simply misstated some key facts, the Congressmen say.

Their contention is backed up by Deputy Inspector General Stuart Wright, who says the groups' document includes several statements that misrepresent the IG's findings in a recent report on self-referral. For example, the IG's report, Prohibit Physician Self-Referral, found that 55 percent of physician-owned specialty hospitals have emergency departments, while the groups said "more than half" of such facilities lack such full service EDs.

To learn more about the controversy:
- read this Modern Healthcare piece (reg. req.)

Related Articles:
Congress considers specialty hospital regulation
Physician-owned hospitals: A conflict of interests?
Texas specialty hospitals do lucrative business
Partnership building 10 doctor-owned hospitals

Study: Crowding may increase hosp. stay for some children

Thu, 10 Apr 2008 06:59:54 -0400

A new study suggests that if the hospital is crowded on the day a child is admitted, that child may be in for a longer stay if he or she has a less-complicated illness that requires ongoing monitoring. While crowding doesn't affect lengths of stay for children with serious, complex conditions--like bacterial meningitis--children with respiratory conditions may see an impact, according to researchers with The Children's Hospital of Philadelphia. And this has a big impact, since respiratory conditions are the most common reason for pediatric hospitalizations, the authors said.

To draw this conclusion, researchers looked at all children admitted to 323 hospitals in Pennsylvania and New York between April 1996 and June 1998 with one of 19 common pediatric conditions. Researchers found that for children admitted with diseases like viral and bacterial pneumonia, asthma and bronchitis, admission day occupancy above 60 percent resulted in a 25-day increase in the average length of stay per 100 patients. This is a concern, given that the average occupancy for hospitals studied was 75 percent.

Researchers theorize that the need for frequent monitoring can strain the resources of hospitals already near-capacity, and with caregivers stressed, children's care isn't as efficient.

To learn more about this study:
- read this press release

Related Articles:
Study: Sticking to one MD helps pediatric patients. Pediatric report
Pediatric specialist MDs in short supply. Pediatric report
Hospitals invest in pediatric EDs. Pediatric report
Pilot program to monitor pediatric health. Pediatric report

EDs seeing more affluent patients, less uninsured

Wed, 09 Apr 2008 06:59:58 -0400

Here's a study that flies in the face of what we've been reading elsewhere. According to new research published in the Annals of Emergency Medicine, emergency departments are actually seeing a growing percentage of affluent patients, while the number of uninsured patients is falling. Researchers found that uninsured patients accounted for 15.5 percent of visits in 1996-97, but only 14.5 percent of visits in 2003-04. Meanwhile, the number of visits by higher-earning people with incomes of more than 400 percent of the poverty level grew from 21.9 percent to 29 percent during the comparable period. Wow. That is a stunning reversal from the conventional wisdom. So, if the uninsured aren't the biggest cash drain on EDs, what's really going on?

To learn more from the study:
- read this Modern Healthcare piece (reg. req.)

Related Articles:
CDC report backs emergency department overcrowding charges. ED report
Case study: California hospitals help emergency department "frequent fliers." ED report
Hospitals charge fee for non-emergency ED visits. ED report
CMS faces ED overcrowding scrutiny. ED report

Study: MDs refer profitable patients to their ASCs

Wed, 19 Mar 2008 07:59:57 -0400

This isn't too surprising, but it's not something policymakers will like, either. A new study of referral patterns in the Philadelphia and Pittsburgh metros suggests that physicians who are high-admitters to physician-owned ASCs send far more privately insured patients to those facilities, while sending Medicaid enrollees to hospital outpatient departments, in many cases. The study, published in Health Affairs and completed through the University of Chicago, looks at whether having a stake in an ASC affects the types of patients a physician would refer to a facility. Research found that for the top 50 percent of physician referrals to ASCs, 45 percent of Medicaid patients were sent to hospital outpatient departments, while 92 percent of privately insured patients were sent to physician-owned ASCs.

Folks, these numbers seem to pretty much clinch the argument that ASCs keep the best-paying patients for themselves, while blocking the poor from getting whatever benefits the specialized ASC services might offer. Looks like this could kick off some heated discussions on Capitol Hill.

To get more information on the study:
- read the Health Affairs report
- read this Modern Healthcare article (reg. req.)

Related Articles:
NY accuses ASCs of collecting overpayments. Reports
Number of PA ASCs keeps growing, but profits level off. Report
CMS updating rules for ASC Medicare participation. Report
Doctors sue HealthSouth over surgery centers sale. Report
Profits way up for Penn ASCs. Report
Georgia physicians battle for looser ASC regs. Report
Ohio bill would force hospitals to have 24x7 EDs. Report

Trend: Hospitals spending to care for obese

Mon, 10 Mar 2008 07:59:57 -0400

Here's another story bringing home an issue which we've covered in the past here in FierceHealthcare. With growing numbers of Americans--15 million at last count--now carrying at least 100 extra pounds, hospitals are finding that they need to acquire special equipment to accommodate these patients. The accommodations begin in waiting rooms, and have expanded to the point where hospitals utilize everything from special chairs designed to fit a morbidly obese frame to special stretchers carrying up to 750 pounds and lifts helping nurses move patients up to 1,000 pounds. Hospitals are buying MRI machines big enough to hold 550 pounds, and replacing wall-mounted toilets good only up to 325 pounds. They're also getting bigger beds and walkers for such patients. Small wonder that medical supply maker Stryker estimates that the U.S. bariatric market is already $100 million a year, with 20 percent annual growth.

These accommodations are expensive, unfortunately. For example, bariatric furniture can cost 20 percent to 50 percent extra, boosting the cost of a hospital bed from $6,000 to $8,000, to more like $10,000 to $12,000. Stretchers that hold 700 pounds cost more than $3,000, where others cost more like $2,400. And overhead lifts can cost $12,000. Meanwhile, insurance companies don't pay extra when hospitals care for bariatric patients.

To learn more about this trend:
- read this Philadelphia Inquirer piece

Related Articles:
Medicare will pay for bariatric surgery. Report
Bariatric surgery to increase bottom line? Report
Trend: Hospitals investing in patient lifting devices. Report
Volume of child obesity surgeries growing. Report
Study: Obesity has impact on EDs. Report