Sunday, May 25, 2014

Are Emergency Rooms Admitting Too Many Patients?

This blog has discussed conflicts of interests.  Indeed, every player in the medical arena has found itself challenged by conflicts where one’s self-interest competes can skew what should be pure advice.   This issue is not restricted to the medical universe.  Every one of us has to navigate through similar circumstances throughout the journey of life.  If an attorney, for example, is paid by the hour, then there is an incentive for the legal task to take longer than it might if the client were paying a flat fee.  The fee-for-service (FFS) payment system that had been the standard reimbursement model in medicine has been challenged and is being dismantled because of obvious conflicts that were present.  (This is not the only reason that FFS is under attack, but it is the principal reason offered by FFS antagonists.)  Physicians who were paid for each procedure they performed , performed more procedures.   This has been well documented.  Of course many other professions and trades still operate under a FFS system, but they are left unmolested.   Consider dentists, auto mechanics and plumbers and contractors. 

FFS is not inherently evil.  But, it depends upon a high level of personal integrity which, admittedly, is not always present.   In my own life, I often hope and pray that the individual who is offering me goods or services is thinking of my interests exclusively.  Am I living in fantasy land?

The Rand Corporation released a study in May 2013 that demonstrated that emergency rooms accounted for about 50% of hospital admissions during the study period from 2003-2009.  When I have posted on Emergency Medicine in the past, it has stimulated a high volume of responses, some good, some bad and some ugly.  

I think it is inarguable that emergency room (ER) care wastes health care dollars by performing unnecessary medical care.  As a gastroenterologist, I affirm that the threshold for obtaining a CAT scan of the abdomen in the ER is much lower than it should be.   And, so it is with other radiology tests, labs, cardiac testing, etc.
I understand why this is happening.  If I were an ER physician, I would behave similarly facing the same pressures that they do.  They face huge legal risks.   They are in a culture of overtreatment and overtesting because they feel more than other physicians that they cannot miss anything.  They argue that they have only one chance to get it right, unlike internists and others who can see their patients again in a follow-up visit.  If an ER physician holds back on a CAT scan of the abdomen on a patient who has a stomach ache, and directs the patient to see his doctor in 48 hours, what is the ER physician’s legal exposure if the patient skips this appointment and ends up having appendicitis?

Keep in mind that we should expect that ERs to have higher hospitalization rates of their patients, since their patients are much more likely to be acutely ill.  

Is the Emergency Room a Revolving Door?

But even accounting for the sick patients in the ER, I think there is a significant percentage of ER patients who should be sent home and are sent upstairs instead. This would be an easy study to perform.  Compare the intensity of testing between the emergency room and a primary care office with regard to common medical conditions.  I would wager handsomely that the ER testing intensity and admission rate would be several fold higher than compared to doctors’ offices.  Want to challenge me on this point?

Even though I understand why ER docs do what they do, it is a bleeding point in the health care system that needs a tourniquet.  

It is clear that ER physicians are incentivized to admit their patients to the hospital.  Of course, they might be ‘encouraged’ to do this by their hospitals who stand to gain financially when the house is full.  Leaving the financial conflict aside, when an ER physician admits a patient, he is completely free of the risk of sending a patient home who may have a serious medical issue. I am not referring here to patients who clearly should be admitted, but to the large group of patients who most likely have a benign medical complaint, but the ER physician advises hospitalization ‘just to be on the safe side’.  These same patients if seen in their own doctors’ offices would never be sent to the hospital to be admitted. 

Where’s the foul here?  Here are some of the side-effects on unnecessary hospitalizations.
  • Wastes gazillions of dollars
  • Loss of productivity by confining folks who should be working.
  • Departure from sound medical practice which diminished the profession.
  • Emotional costs to the individuals and their families.
  • Unnecessary exposure to the risks of hospital life.
How can this runaway train be brought under control?   First, let’s try a little tort reform.   Second, pay a flat rate for an ER visit.  Under this model, if the ER physician orders an MRI on a patient with a back strain, the hospital swallows the cost.  Finally, when hospitals are penalized financially for hospitalizing folks who should have been sent home, we will witness the miracle of a runaway train performing a U-turn on the tracks.

While the Rand Corporation's results are not earth shaking on its face, my intuition, insider's knowledge and a tincture of cynicism all converge on the conclusion that for too many patients the ER has become a portal of entry in the hospital.  Is the greater good served if the ER is a revolving door or barricade?


  1. Speaking only as a former home health care nurse, the ER was indeed THE (as opposed to 'a') portal of entry in the hospital as dictated by employers, physicians and providers. Choice was not an option. Will be interesting to see if PCMH will have impactful change this.

  2. Many are admitted because their insurance company would not pay for emergency care unless they were. Case in point: A patient suffering from anaphylactic shock from fire ant bites comes in with a swollen, protruding tongue, eyes swollen shut, hugely swollen lips and gasping for air. The accompanying family member says that the patient's insurance will only pay for care if they admit the patient, and treatment begins. It took quite some time to relieve the symptoms, and the ER doc says he doesn't feel comfortable discharging the patient and gets her admitted for an overnight stay. She does require a treatment from respiratory therapy during the night. Fair or not? Who's at fault? The ER doc, the patient, or the insurance company? It was a real emergency and treatment was absolutely necessary to save the patient. Admitting her was later admitted to be a choice of the physician in order to get the hospital paid and was really unnecessary for the patient's survival. The right answer, of course, is to stop making admission a requirement before the insurance company will pay for the ER visit. Government could do everyone a big favor with proper legislation, but it went to ridiculous, gross extremes with O'care.

  3. On the one hand I have heard of many people avoiding getting help for serious, even life-threatening illness because they can't afford to pay for an emergency visit - this is just wrong.

    On the other hand, I'm keenly aware via facebook of quite a few people who most likely have factitious disorders or munchausens, abusing the system. A lady I have been watching has had dozens of emergency admissions, some for longer stays - going around several hospitals - in the last few months she's been to George Washington University hospital, Howard University hospital, Providence hospital, Johns Hopkins Hospital, Sentara Northern Virginia Medical Center, Mary Washington hospital, Inova loudoun hospital..... surely that's not right? And she posts photos of her medications, several a week, all of which have different prescribing doctors names on the labels (no she's not that smart I gather). Doctor/hospital shopping, isn't it?

    So my question is - people who do this are not rare. They are out there in quite large numbers. I gather they don't usually post it so blatantly on facebook, but even so you hear about people getting busted for this sort of behaviour all the time and worse, using it to defraud people out of gifts etc. Why aren't hospitals trained to spot this better? And if they do spot it, why don't they have people trained to address it? These people aren't all 'bad', what they are doing is also a sickness, but they are looking in all the wrong places for help. They do need help - but going through the ER all the time is wasting money - theirs and whatever funding goes towards people who are not able to pay their own way (the majority of them are on disability of some kind, although I have no idea how they manage to pay for so many visits).

    I'm in Australia - here people abuse the system too, but it's harder to hospital-shop because you can only use the public hospital in your area - and it's all one computer system. I know people who have gone private so they can continue that behaviour or gone to lengths like changing their names!

    I bring this up because these people obviously add a huge strain to the system with unneeded medical treatment and time and resources, and also, they are infuriating to watch (and worrying since some of them manage to have interventions done to them that are not even medically warranted), infuriating because many watching them can't afford to get care for their own REAL issues and to see someone who actually hasn't anything medically wrong getting so much help is a bit of a slap in the face for them.

  4. Pleases to receive comments. Shout out to the Aussie! The issues with respect to ER is same as with respect to health care overall. When you're spending someone else's money, you spend much more than is necessary. When the ER department is penalized for unnecessary care, we will see more efficient services being delivered there. When patients bear some of the $ risk, they won't insist on an MRI for a back ache. Reimbursement will dictate behavior as no other forces seem able to modify our current pattern of overdiagnosis and overtreatment.

  5. Rosemary B here
    Tort reform.
    I still cannot figure out how Obamacare is going to help their slave doctors when there are lawsuits for bad government health care, oops I mean, mistakes.

  6. A couple comments:
    1) I am an EP- emergency physician, not an ER physician
    2) I work in an emergency department (ED) not a emergency room (ER)
    3) Most of the FFS do not go to EP/ED's. If the data from CMS is true, most of the money goes to specialists/consultants.
    4) I often send patients home with come back to the ED for a repeat abdominal exam (if the history and physical support that plan)
    5) Most insurance will pay for ED care- but will not wave the copay unless the patient is admitted
    6) I am interested in your thoughts on how many unnecessary scope's preformed by GI?
    7) Perhaps if the country invested in a combo of tort reform and EHR's that can communicate with each other. How do I know the patient was just discharged from hospital A with a neg stress but comes into hops B c/o chest pain with assoc ACS like symptoms?

  7. Here is a response from an Emergency Physician:

  8. Will, thanks for contributing your thoughts. Let's leave aside my outdated terminology for your specialty and the venue you work in. I cannot recall an ED physician asking a pt to return for a repeat abdominal exam, beyond the typical and appropriate recommendation, "if your pain gets worse or persists, please return to us."

    Your point about our disjointed EMR systems is spot on. I'm sure you see patients who have had multiple CAT scans all over town, or at your own institution, often for the same indication, which is usually abdominal pain.

    Do GI physicians perform too many scopes? Yes, we are part of the problem, which I have confessed to repeatedly on this blog.

  9. I have left 'White Coat's comment (submitted under Anonymous) as submitted. Despite its vitriol and personal attack on me, I felt there were elements of his rant that merited publication. Readers and physicians can read my post and his response and make their own judgment.

  10. I have read your post, White Coat's response, and made my judgment: this was an ill considered and poorly informed piece that you wrote.

  11. Agree with 884. Your piece was poorly informed and was out of touch. BTW, you're being eviscerated on KevinMD....perhaps responding may douse the fires a bit?

  12. This comment has been removed by a blog administrator.

  13. william reichert,MDJune 10, 2014 at 4:26 PM

    At my hospital the EP does not admit. The admitting physician admits. In this case that would be you.
    Obviously your wisdom in your opinion is needed in the ER.
    You should put down your colonoscope and go see the patient yourself. Maybe you can teach the EP's your wisdom.
    Recently I admitted ( I am a hospitalist ) an active Gi bleeder. The GI was called but had to do a few more routine colonoscopies before he was free to show up. When he did, hours later, the patient was dead.