Will reform make things even worse for EDs?
ACEP polls indicate EDs seeing increase in patients
With Congress seriously considering several pieces of health care reform legislation, two studies conducted in Massachusetts by the American College of Emergency Physicians (ACEP) have some observers worried that reform will mean even worse crowding conditions for the nation's already overburdened EDs. According to the polls, nearly two-thirds of Massachusetts emergency physicians report more patients are seeking emergency care as a result of state health care reforms, and nearly two-thirds of Massachusetts residents say their ED wait times have increased or remained the same.
In an ACEP Internet poll of 138 Massachusetts emergency physicians conducted in September 2009, more than 20% of physicians report higher acuity levels, and more than 27% report lower acuity levels since the Massachusetts mandate went into effect. Fifty-one percent of the respondents said patient acuity levels have remained the same. In addition, 62% of emergency physicians said boarding admitted patients in EDs has increased or stayed the same since the Massachusetts mandate.
"I think what happened in Massachusetts is they really tried to pass something to set a precedent, and really rushed it though . . . generating increased demand for care without the infrastructure to handle it," says Don Lombino, MD, medical director of the ED at Stamford (CT) Hospital. "The upshot is you get longer wait times because you can't just create more doctors to treat those patients overnight."
Lombino is concerned that he hasn't heard any discussion on Capitol Hill about subspecialists and call panels. "In the current system, they are not interested in covering right now," he notes. "I can't imagine what will happen [under reform]. There could be a compromise in the care received."
You need to examine these statistics carefully, advises Stephen Epstein, MD, MPP, an emergency physician at Beth Israel Medical Center in Boston and a spokesman for ACEP. "There's a difference between crowding and the number of patients who come to EDs, he notes. "We've had more patients come, so if the expectation of policy-makers was that reform would reduce those numbers, they are mistaken."
The prospect of seeing more patients just means the issue needs to be faced realistically, Epstein says. "The state has done a number of things to alleviate crowding, including banning ambulance diversion throughout the state," he says. "This has really addressed the numbers of patients coming to EDs since they passed reform."
David John, MD, director of emergency services at Caritas Carney Hospital in Dorchester, MA, doesn't see the increase in patients as a bad thing at all. "We've had a 10% increase in patients, although I do not know if this had anything to do with universal insurance," he says. "But from our standpoint, it's a great thing. We receive these patients anyway; so even if we get 10 cents on the dollar [of what we think we should receive], that's money we otherwise would not get."
ED managers have 'anti-crowding' tools While two recent surveys in Massachusetts sponsored by the American College of Emergency Physicians (ACEP) indicate that universal health care could make a bad ED overcrowding situation even worse, experts say that ED managers are equipped with many strategies to help offset these pressures. "I don't think we're totally helpless here," says Don Lombino, MD, medical director of the ED at Stamford (CT) Hospital. "We have certain control over what we can do on a daily basis to accommodate increases — for example, having a physician in triage is a more efficient way of seeing patients and perhaps disposition before they even get to the ED proper. We can look at every operational issue and maximize the efficiencies to try and avoid boarding and excess waiting times." He concedes, however, that each of these strategies can reach a point of maximum efficiency, "and there does come a time when you require more staffing." This is not an issue ED managers should be addressing for the first time, says Stephen Epstein, MD, MPP, an emergency physician at Beth Israel Medical Center in Boston, and a spokesman for ACEP. "People need to do what they should be doing already to streamline operations for hospital flow," he says. "Crowding in the ED is merely a symptom of a much larger problem involving the entire health care infrastructure." Epstein notes that several years ago, the Robert Wood Johnson Foundation sponsored the Urgent Matters initiative to test theories and best practices in patient flow. "They found that you could adjust surgical schedules by having surgeons operate on weekends, or consider discharges before noontime, which would require primary care providers to change their schedules," he says. |
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