A letter to Gruntdoc on ER admission

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Category : Medical Rants

Our lack of a health care system drives admissions that one could avoid. We spend major dollars performing an outpatient evaluation with the patient in the hospital. We do this for our convenience and the patient’s convenience.

We should all recognize that such admissions contribute to our high costs. These admissions represent a convenience, not a necessity.

I remember 30 years ago admitting patients to a hotel like facility to perform such evaluations. Perhaps we should develop lower cost methods to do these evaluations.

I have internist colleagues who keep patients too long – just to get the workup complete. I see emergency physicians admit patients who do not really meet admission criteria to ease the evaluation.

Our payment system fails us in so many ways. Our liability system fails us in so many ways.

I understand the plight of the emergency physician. They are the only group that must see everyone. I want universal coverage to help patients, emergency rooms and hopefully expand primary care.

Dear Gruntdoc,

This is not a critique of emergency medicine. This is a critique of the choices you have.

db

Comments (8)

[…] Read the original post: A letter to Gruntdoc on ER admission […]

I respect ER physicians for the difficult job that they do well, but I don’t admire ER practice style. I’ll take heat for my current blog post at http://www.MDWhistleblower.blogspot.com where I criticize the ER’s culture of medical excess. I’ve heard the arguments from my ER friends, but I’m not persuaded. As a GI, it seems that a CAT scan of the abd/pelvis is on the routine ER admit orders. My GI and primary care colleagues have similar observations.

42 percent, of the 120 million visits made in 2006 to U.S. hospital emergency departments were billed to the Medicaid and Medicare programs

Of the 24.2 million emergency department visits billed to Medicare, 38.3 percent ended with the patients being admitted, compared with 11.2 percent of the 41.5 million visits billed to private insurers, 9.5 percent of the 26 million visits billed to Medicaid, and 6.8 percent of the 21.2 million visits by the uninsured.
• Uninsured patients were the most frequent users of hospital emergency departments. Their rate of 452 visits per 1,000 people was 1.2 times greater than the rate of 367 per 1,000 people among patients with public or private insurance.
• The “treat-and-release” rate for uninsured patients was 421 visits per 1,000 people, compared with 301 visits per 1,000 for those with insurance. This is a possible indication that people without insurance use hospital emergency departments as their usual source of care.

The study is based on an analysis of data from the 2006 Nationwide Emergency Department Sample, which contains records of emergency department visits from about 1,000 community hospitals nationwide. The hospitals account for 20 percent of all U.S. hospital emergency departments.

At some point, physicians have to blame themselves for their payment system.

[…] GruntDoc, another EP blogger, fires back across the bow that Dr. Centor hates EPs, and Dr. Centor writes back, bringing up an interesting point: why are we paying so much for social admissions? Shouldn’t […]

In general, Medicare sets relative prices in the US. The results are the fault of the government run portion of the US medical system. These relative prices historically have meant more specialists and fewer primary care docs through plain old pricing incentives which have distorted the market to a non-optimal place. This means that there aren’t enough primary care docs available to do outpatient workups for everybody. This lack of capacity is why you have insufficient people accepting medicaid/medicare and excess ER admissions.

The common sense fix is to figure out how to price without distorting the incentives in favor of primary care or specialization. But that’s not on the table in Washington and it doesn’t seem to be on the table here.

What’s the solution advocated here? Why let’s give even more power and influence to the people who have been making the same error for decades, overpayment of specialists and underpayment of primary care. Yeah, that’s the ticket. It’s economic analysis genius!

I am not using my name to protect my institution. I am currently a PGY-1 in Internal Medicine at a top 10 academic medical center. As a resident, I will work at several different hospitals. One is a “county” hospital, staffed completely by academic physicians, the other is the true university hospital. At the university hospital we discharge patients quickly and have outpatient follow-ups. At the county hospital, we discharge patients later, and still lose them to follow-up, only to catch them a year later, and a year too late. I had to give Stage 4 lung cancer diagnoses several times last month. In looking back at previous imaging, all were called “suspicious” a year before, and all required repeat imaging to follow the lesion. What do we do for these patients? More inpatient workup? Better followup? I don’t know yet, but I hated giving those people a diagnosis that I knew we would not even try to cure, when a year prior we could have offered a chance at a cure.

Un-named – I’ve learned from my internist wife that the uninsured sometimes have an unrealistic idea of how much testing costs. You would do your patients a favor to find out what independent labs are out there that offer bargain priced imaging. They exist and more of your uninsured patients would likely get those follow-up tests if they only knew how to get them cheaper. Americans have been conditioned not to price shop for health services and this conditioning costs lives.

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