June 20, 2018
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Will be hard to woo Americans away from the ER

Erik Steele
By Dr. Erik Steele

If God ran a hospital department, it would be the ER. It’s a place where miracles can happen, the sick of heart and spirit are welcome, and how high you rank depends on how sick you are. His head nurse would be your mom, gladly taking you in no matter what the problem and whether you can pay, doors and arms open 24/7, but with an IV needle and sterile gloves.

It’s no wonder then that Americans have a love affair with our ERs, visiting them more than 125 million times each year. Like many love affairs, it’s expensive; an average charge of $1,200 per visit, costing Americans about $120 billion a year by some estimates. Perhaps half of those patients could have been treated somewhere else less expensively — urgent care clinic, primary care office, (my favorite — your home woodworking shop) etc., saving us up to $35 billion a year.

Efforts to get us all to break off this affair are growing. Health insurance companies, employers, and many state Medicaid programs for the poor and disabled are trying to woo us away with progressively aggressive efforts. Politicians are getting into the effort in a big way. Even some hospitals and their ERs are trying to reduce avoidable ER use, something almost never seen in the past.

Many of those efforts will be dead on arrival, however, just as previous ones have been. If the new efforts are to avoid that fate, those seeking to help Americans fall in love with another place for acute care will have to deal with some realities:

— Myths and misconceptions, the sometimes unscientific experience of ER staffs, and public biases often drive legislative and other debates about who uses ERs frequently and why, rather than real studies of ER use. This leads to interventions designed to address perceived, rather than real, ER use drivers.

— Patients often use of the ER is not because of what they feel for symptoms, but because of what they fear is the cause of their symptoms. Is it gas or a heart attack? Is it a headache or a cerebral hemorrhage? The difficulty patients have figuring this out is not surprising, since we sometimes have trouble figuring this out in the ER.

— With rare exception, no other site of care allows patients to have access to the care they need whenever they think they need to get it. While many of us are happy to judge patients for coming into the ER when they could have gone to their own physicians for the problem, few of the judges have answers for the child care issues, tough transportation issues, burden of chronic disease including mental illness, lack of another reliable adult to watch the kids when a sibling needs care for an ear infection, or lack of another reliable source of care that often drive ER use. These issues often make the ER feel like the only site for care whose hours of operation match hours of patient need.

— No other site of care can bring almost every diagnostic and treatment resource to bear on a patient the way the ER can, and the resources it does not have it can usually get in a few heartbeats. That means it can rapidly figure out and solve most acute problems the way few other sites of care can.

— Treatment without regard to ability to pay, and of all comers, is part of the ER culture. A recent study of poor patients found they trusted hospital care more than care from other sites, found it easier to access and less costly to them, and the ER was more likely than other sites of care to be able to meet more of their immediate needs. The reasons 342,000 Americans visit ERs each day are some of the same reasons a million American visit a Walmart every day.

America needs to be weaned from its love affair with the ER, and to get less expensive and more coordinated care from other sites. Those other suitors who fail to understand the needs of the patient seeking acute care, and the appeal of the ER competition, will be alone at the prom.

Erik Steele is the former chief medical officer of Eastern Maine Healthcare Systems. He recently accepted a new job at Summa Health System in Akron, Ohio.


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