Taking the high road to the emergency room

When does Atul Gawande sleep? In addition to serving as a general surgeon on the staff of Brigham & Women's Hospital, he is also the premier healthcare business reporter in the nation.

Gawande began his writing career for The New Yorker in the late 1990s, initially focusing on specific patients and the progression of his own medical career. But in recent years, his work has focused on the medical business and how the bleeding--of money--could stop. He's written about the simple checklist of Dr. Peter Pronovost that virtually eliminates ICU central line infections, and of how the good doctors of McAllen, Texas provide care that's twice as expensive as the nationwide average. Both stories have set the medical community and consumers abuzz.

Gawande's narratives perchance to dream about a more perfect form of healthcare delivery. But they always include a flip side, the suggestion that implementing worthwhile changes requires a supernatural effort. The checklist really only works if nurses are empowered to goad physicians into following the instructions for installing a central line to the letter--upending a time-honored relationship. The heart surgeon he followed in McAllen has performed more than 8,000 bypass procedures. Gawande confides to the reader that just thinking of such a feat is tiring. But he doesn't mention something that no doubt energizes this doctor: He's probably netted north of $30 million for such work. Who's going to make him surrender such income for the sake of financial propriety?

Gawande's most recent article focused on a clinician on the polar opposite of the spectrum. Jeffrey Brenner's practice in Camden, N.J., targets the city's sickest 1 percent of its citizens, just 1,000 people in all. Brenner had extensively mapped the city, these patients and their visits to the hospital ER. They visit so often that they represent a third of the medical costs for Camden's hospitals.

That's primarily because nothing is done in the ER to improve the overall health conditions of these patients, most of whom suffer from chronic conditions such as diabetes, hypertension or morbid obesity. Preventive care and hyper-observation is the key, which Brenner delivers through a team of nurses and social workers.

There's more emotional tension in this article than any Gawande has written: It begins with Brenner futilely trying to get past police to treat a young man bleeding to death on the sidewalk from a gunshot wound. Near the end, Gawande touches on a patient who's racked up $52,000 in charges for treatments of her migraines in the ER, and a group of well-insured patients in Atlantic City whose costs have been reduced by 25 percent but are regularly ambushed by their former doctors to get them back in the fold. "As the saying goes, one man's cost is another man's income," Gawande observed.

How else do you explain InQuickER, pure antimatter to the situation as described by Gawande? It's a system that allows patients, for a fee, to make a reservation to visit their local emergency room at an appointed time and avoid hours of waiting. The Georgia-based company is small, with just 23 hospital clients in eight states. But as the Los Angeles Times recently reported, it's beginning to make significant inroads into my stomping grounds of Southern California. Five hospitals owned by for-profit operator Tenet Healthcare have the system in place in the region.

Read Gawande's article and it is easy to conclude the ER is a place you should only visit when you're seriously injured. On the surface, many hospitals and hospital organizations echo this party line. They're squeezed by the combination of the EMTALA mandate to treat all ER patients and the number who come through their doors without insurance.

However, most states don't permit hospitals high enough levels of reimbursement to justify operating an urgent care center. So again, they turn to their ER as a source of revenue to make up for their uncompensated cases.

If you're healthy enough to make an appointment for your ER visit, should you really be going there? The Dr. Brenners of the world say no. But as his colleague scribe remarked rather sadly, "outsiders tend to be the first to recognize the inadequacies of our social institutions. But, precisely because they are outsiders, they are usually in a poor position to fix them." Therein lies the rub.

The question of what to do is now being contemplated by all those policymakers and policyholders trying to figure out how to pay for our incredibly growing healthcare bill. They no doubt will experience many, many more nights where they remain wide awake. - Ron