Monday, February 13, 2012

Emergency Room: Use and Misuse and Cost

     Not enough people realize how expensive it is to society when a sick patient uses the Emergency Room rather than going to his/her private physician, or even a local UrgiCare Center (otherwise known as " Doc-in-a-Box"). There was an article a few months ago in "Archives of Internal Medicine" that demonstrated the cost of a visit to the ER by a patient complaining of dizziness: $20,000 for all the tests and consults. But if you called your family doctor and saw him/her with the same complaint, the cost would be much, much less.

     The problem is that to the ER doctor and staff, you are an unknown person with an unknown medical history both recent and remote. And they will not quite trust either your memory or the computer history (EMR). If the record indicates that an echocardiogram showed mitral regurgitation, then they will want to repeat it to inspect the results themselves.  They also have to ask themselves, in addition to diagnosing and treating you, what tests they can do to avoid being sued in case you turn out to be a "zebra".

     Let me explain the above terms and concepts. First of all, unlike your family doctor, they cannot tell you to call them tomorrow or go to the ER if you are not feeling better. Secondly, although common diseases occur commonly, they can present with weird symptoms. (For instance, a female in her 20's with malaise, a diffuse maculopapular rash and wrist arthralgias has Hepatitis B until proven otherwise.) We tell our medical students "If you hear hoofbeats in Central Park (in NYC) don't look for a zebra". But if you die from a zebra, and it is within the differential diagnosis of your complaint(s), then the ER, the doctors and the hospital will all be sued, even if Osler himself would have not made the diagnosis.

     Insofar as Xrays are concerned, I know which of my referral radiology groups overread or underread xrays and CT scans and MRI's because I always review the radiological studies with the radiologist before I go home or see the patient in the hospital. The ER doctors have no way of knowing if the report was written by an over-reader or an under-reader. Now that we have color-Doppler echocardiograms, EVERYone's echocardiogram shows at least trace mitral regurgitation, delimited by a backwards color jet, but this is a simple matter of fluid dynamics because everyone's mitral valve takes a finite time to close and some blood has to back-flow. So how much backflow do you need before the "trace' becomes "minimal and therefore clinically significant?5%, 10%? Pick a number? Or do you have to hear the flow as well? But then women with less chest muscle than men would have an increased "incidence" of mitral regurgitation because they would have less distance across the chest wall between their mitral valves and the stethoscope.

     The ER has to function (a) to ask themselves what disease or process you could have that could kill you if they do not make the diagnosis, (b) what tests and consults they need to order to avoid a possible malpractice suit, and (c) how can they best ensure your compliance with whatever follow-ups they suggest and prescriptions they order, also realizing that they can be sued (successfully) if you do not follow their suggestions and something happens to you. I should add that (a) is what I tell my medical housestaff when I am ward attending, viz: if the patient is alive when I arrive at 8AM to start my morning rounds, they have done their job.

     Part of the ER's problem in dealing with uninsured patients (for which the state is supposed to reimburse them but that is another story) is that it is very difficult to arrange for an outpatient follow-up if the patient has no insurance. No doctor  will agree to see such a patient, and very few clinics will. Teaching hospitals generally have a medical clinic where indigents and uninsured patients will get the proper follow-up and care, but teaching hospitals are re-imbursed at a higher rate by both the federal and state governments than are smaller regional hospitals.

     I guess I am led to the conclusion that some sort of nationwide health care system where everyone within our borders has a family physician  would DEcrease the annual cost of health care. I still remember when I was a JAR (junior resident) in the ER. Part of our duties was to help the medical intern manage and treat DKA, diabetic ketoacidosis, a serious condition that often affects insulin-dependent diabetics, and can be fatal. My fellow resident had gone to medical school and interned at McGill University, a fine institution. But she had NEVER seen a case of DKA in the ER. We later mutually realized that since Canada has nationwide medical insurance run by the provinces, and each Canadian has a family physician, no diabetic ever gets so far out of control that he/she "crashes" in the ER with DKA. The flip side, as I have mentioned in an earlier blog, is that the number of surgeries in a given hospital is rationed: e.g. a given hospital may be allotted 100 open heart surgeries, 300 gall bladder removals and 200 hip replacements per month. If your doctor admits to that hospital, you go on the waiting list. Last I heard, the wait for elective hip replacement in England was over two years (!) So Canada spends more than we do per capita on primary care and less on surgery.

     So all countries ration medical care by time, or by money or by availability. For instance if Columbia-Presbyterian Medical Center wants to install another echocardiogram machine, they need permission from NY State. The reason given is that some Medicaid patients may end up being examined by that machine, and the state pays a certain % of every bill to Medicaid, so the fewer echocardiogram machines that a hospital has, the less the state has to pay annually for echocardiograms.

     "Whatever they are talking about, they are always talking about money."


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