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The Seeds of a Solution to the Problems of Emergency Medicine



January 3rd, 2014
by Mona Sarfaty

As one of the principal authors of the original Emergency Medical Treatment and Active Labor Act (EMTALA), I want to make clear that our efforts as the advisors to Senator Kennedy’s Committee in 1985 were squarely focused on the responsibility of hospital emergency departments (EDs) to provide access to emergency care within their communities. Representative Stark in the House of Representatives agreed unequivocally with Senator Kennedy about this point and together they helped enact the “anti-dumping” bill with bipartisan support. Nevertheless, it took years of additional work before EMTALA began to make a real impact. Access problems may have changed since EMTALA barred “dumping,” but inadequate access to care remains a problem.

The intent of EMTALA was never to make EDs a major provider of outpatient care. However, as documented in the December issue of Health Affairs, EDs now provide a significant percentage of all acute care visits for the uninsured. Many of the people who rely on EDs as a source of outpatient care lack access to the bedrock foundation of a rational health system—a primary care home. Some have no regular source of care, some do not know where to go for a medication refill, and some feel they have no other way to find reassurance or safety when panicked about their wellbeing. In particular, finding urgent mental healthcare remains a significant challenge for many. But, thirty years after the passage of EMTALA, the nation is slowly moving to address the access problem. The seeds of a solution are scattered around the country. They must grow and spread if they are to coalesce into a full-blown remedy.

What follows are some key elements necessary to continue improving access to primary healthcare while assuring that investments in emergency care are appropriately utilized.

Patient-centered medical homes. The enhanced version of primary care that is offered by health teams working in patient-centered medical homes (PCMHs) is one part of the solution. PCMHs provide access to care on a 24/7 basis with the following special features:

  • Open access: allows people to see their primary care provider on the day they call or the next day
  • Care manager: nursing staff who help people manage chronic conditions thereby reducing ED visits
  • Transition care: helps reduce hospital readmissions, which typically include ED visits, by encouraging discharged hospital patients to follow up with their primary physician in the next few days

Health reform. By supporting an increase in the number of community health centers, and establishing more widespread coverage by health insurance, health reform is expanding access to outpatient care. Community health centers have been shown to decrease ED use in their communities. Hospitals that have worked to establish ongoing relationships between primary care physicians and ED patients have also decreased ED use.

Health Information Exchanges (HIE). The HIE in Delaware permits hospital EDs and other medical providers throughout the state to save time and money by sharing patient data stored on “back-end” servers that secure and hold patient medical information, and reduce the need to repeat costly diagnostic imaging and lab testing. They provide emergency clinicians and other providers with quick summaries of patient diagnoses, tests, and prescribed medications. The efficiencies from HIEs are real; reports on cost savings are not yet verified.

Analyses of emergency room usage. Data leads to clarity about the nature of the problem, and helps shape solutions. Careful analysis can lead to groundbreaking cost saving innovations like in Camden, NJ, where analysis led to the discovery of “super utilizers” with hundreds of ED visits per year. Many such individuals had mental illness or homelessness as well as chronic disease. Their needs were addressed by accessible and appropriate care such as nurse practitioners or physician assistants placed at convenient access locations closer to home like apartment buildings or shelters. Such appropriate care reduced ED use and essentially paid for itself with the money that was saved through diminishing ED misuse.

Taken together, these approaches could solve many of the problems of urban EDs. One more piece of the puzzle is still missing though: this is strategic collaboration between providers, public health departments, and local or state governments – all of which have a stake in repairing the overloaded and inefficient emergency care system. This collaboration should be based on transparent data and joint accountability. Public and private financial incentives or stimuli could help. Federal demonstration funding has supported the formation of HIEs.

Increased support for analyses of ED data in the context of collaborative and transparent work by multiple stakeholders with planning grants could push the agenda further. This cooperation between stakeholders in the same “medical neighborhood” will allow these solutions to disseminate and build toward rational systems that care for the patient with the right clinician in the right place at the right time.

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1 Trackback for “The Seeds of a Solution to the Problems of Emergency Medicine”

  1. January 7, 2014
    January 7th, 2014 at 4:25 pm

8 Responses to “The Seeds of a Solution to the Problems of Emergency Medicine”

  1. Mona Sarfaty, MD MPH Says:

    I am not sure what a negative incentive approach would mean or look like. Other approaches have been constructing evidence bases. Any approach deployed should have an evidence base before it is exported beyond one site or system. The super-utilizer problem is being explored and addressed in the Camden-Philadelphia area. Individuals with 100′s of visits to ER’s are being identified. Many have mental issues or problems related to homelessness. Novel approaches are being tried and found effective. These approaches have placed CRNP’s in very accessible locations close to the super utilizers. These clinicians can then become the safety spot, saving the ED’s from this burden. It is not known at this time whether this approach is generalizable but more evidence may be on the way. Clearly the ED problem has many aspects to it. But the super-utilizer problem is one costly and burdensome piece of it.

    Care managers may be able to offer similar response and safety to private patients who are inappropriately using the ED. The care management function is supported by many medical homes and/or health systems because it can more precisely address those patients and is less costly.

    My colleagues point out, as you did, that some physicians are sending their patients to the ED because they are too overloaded to address the problems in the middle of the night (or day for that matter). This is another aspect that needs addressing. A pooled coverage resource staffed by alert nurses who can capably interact with patients would be helpful. In Maryland, Children’s National Medical Center established suburban sites that are able to receive patients 24-7 in a non-ED setting. At Kaisers, there are staff nurses who stand ready to interact with patients at all times.

    Multi-faceted problems need multi-faceted solutions. These solutions may vary in different geographic areas, but greater knowledge of the array of approaches currently in use may help communities around the country develop the mechanisms they need.

  2. Mona Sarfaty, MD MPH Says:

    Dear Dr. Lindeman,
    The pool that covers ED care for the uninsured in Massachusetts is an approach that does not currently exist in many other areas. But, the incentive to use care based elsewhere (not the ED) could be a positive one, namely a dependable and reasonably prompt response to the patient’s concern from a known source.

  3. Rob Lindeman Says:

    The plain meaning of “substantially more” suggests something less than “full price” (although if hospital services were sold as any other service was sold, without the intervention of a third party, I suspect the price would be substantially less, but this is a digression)

    With respect, I do not know what community Dr. Sarfaty serves, but in my community (Framingham, MA), nobody is billed for hospital services. Those without Medicaid, Medicare or commercial insurance have their hospital services paid for via the free care pool. Nobody defaults, least of all the hospital.

    “In the current system, those without insurance are billed at a higher rate than those with insurance.” Let us stipulate that this questionable assertion is true. Can an individual not negotiate with the hospital to settle a bill?

    People respond to incentives, positive and negative. When there is no incentive to seek care from a doctor as opposed to an emergency department, people choose the ED. It makes no intuitive sense, but it is the case. Provide adequate disincentives and ED’s will revert to performing the function for which they were originally intended, stabilizing and treating the emergently ill.

  4. Rob Lindeman Says:

    “Mr. Lindeman’s solution is to make all those people that use the ER pay the cost of the services they use.”

    Forgive me, Dr. Sarfaty, it’s DOCTOR Lindeman.

    I said nothing of the sort. Here’s what I DID say (I’m cutting and pasting):

    “Make them pay substantially more and they will stop coming.” That is the plain meaning of the expression “substantially more”.

  5. Mona Sarfaty Says:

    BTW, I am a Fellow of the AAFP for nearly 35 years.

  6. Mona Sarfaty Says:

    Dr. Antonucci’s perspective is shared by many hard working primary care physicians around the country. The central idea of the medical home is to provide better financial support to primary care practices so they can provide the care that they are already struggling to provide–and with an expanded staff team that they can actually afford. This is what the principles articulate. If local systems are not adhering to this central tenet, they will not get the primary care backbone that is needed.

    Mr. Lindeman’s solution is to make all those people that use the ER pay the cost of the services they use. This raises many issues, but suffice to say that all those people ARE billed for the services they use. In the current system, those without insurance are billed at a higher rate than those with insurance. This is the result of negotiations between insurers and hospitals. Those without insurance often default–collection systems recover very little.

  7. JEAN ANTONUCCI MD Says:

    Written by someone who does not take care of patients, with a salary and benefits and little touch it seems with the real world. I am a primary care doctor, who was on call 24/7/365 for 8 yrs before “they” invented the cute PCMH term; I knew what it was. EMTALA was another well intended mandate with unintended consequences.”Patient centered medical homes” certified by a non publicly accountable body and analyses will not fix the problem. Oh goodie let’s fund more studies. In every high functioning highly industrialized country, except this one, the system is based on primary care PCPs who do not have to beg for money or be accused of whining as they endlessly point out the mess, nor do they hope maybe they can make up to wow 30% of what the dermatologist who goes home at 5-and whose answering machine says if you have a problem call your PCP makes. To those of us who work it is not a big mystery what needs to happen Ask us And health reform? Sure One is exempt from the penalty if insurance cannot be purchased for under r 8% of income. I already, as a physician pay 9.3%. It is going up to seriously unaffordable as we shift uninsured status to the barely hanging on middle class. When will Washington learn? We need to change the payment for primary care tomorrow and get those funds from specialists and hospitals and the rest of the waste. I practice with low cost and high quality but I am subjected to the tyranny of NCQA and passwords that expire and systems that do not work. For pete sake Many of us know what needs to be done. Washington will not do it.

  8. Robert Lindeman Says:

    This is a stunningly myopic piece.

    EMTALA, as you must know, threw open the doors of emergency rooms via the “prudent layperson standard.” For a generation now, a person may receive emergency level of care if he wants it, regardless of the severity of his/her illness. You solved the dumping problem and the transfer problem, and replaced it with an enormity that has changed the face of medicine, perhaps irreversibly.

    There are currently two foci in the culture of over-treatment, and one of them is the emergency department. EDs as a matter of course routinely over-test, over-diagnose, and over-refer, and over-medicate, precisely because EDs were not designed to deliver primary care.

    The solution is not more distribution of resources into creating new providers and spaces to provide care – as if these things could be created out of thin air! The solution is to replace and give people more skin in the game. Make them pay substantially more and they will stop coming.

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