Tuesday, January 22, 2008

HealthCare Meltdown 101: The Emergency Room...

As we lingered after dinner with our dearest friends this weekend, we started talking about politics and health care. And, one of the first things spoken round the kitchen table was "We have great healthcare in America." And so began a converation about just some of the myths that Dr. LeBow debunks in his book: Health Care Meltdown: Confronting the Myths and Fixing our Failing System.

In the first chapter of the book, Dr. LeBow starts with these two quotes:
"America has the best health care system in the world." - Many American politicians


"The moon is made of green cheese." - Anonymous, 16th century, likely a dairyman

The first myth that Dr. LeBow tackles is one that I've heard even recently: "Everybody has access to care through the emergency room".

This myth was recently stated as fact by our own President, George W. Bush, a man whose home state ranks #1 in the number and percentage of uninsured, as noted by many sources including this review of US Census Bureau statistics. In a speech last July, the president made this bonehead statement:

“The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America. After all, you just go to an emergency room.”

There's a great commentary on this statement here.

This was the topic of a recent article in the Puget Sound Business Journal. In the article, one of my old partners in practice, Dr. Brian Wicks, appears to bemoan the fact that our government put in place laws that make it illegal for hospitals to turn away patients in the case of an emergency life-threatening condition or active labor, the EMTALA act. To quote Dr. Wicks:

"Anybody who walks into an emergency room will get taken care of, (and) that's part of the problem, because people use the emergency room instead of going to a primary care doctor."

So, what's wrong with this position? Well, there are a number of issues. The one that strikes me most squarely in the face is that (some) patients are not getting care when they present to the emergency department. They are, in fact, being turned away. Oh, not so that it would violate EMTALA. But, let me tell you a story, a true story.

A young man, while working at his construction job, injures his hand. His right hand; he's right-handed. He presents to the emergency department for care. (We'd all do the same thing, wouldn't we? Surely, this isn't the inappropriate access to which Dr. Wicks referred...) He is seen by the emergency department physician, and xrays are obtained. He has a comminuted fracture of the hand, a fracture that is thought to be beyond the scope of practice for a family physician, and would most commonly be treated with orthopedic surgery. Good thing we have a hand surgeon in our community, one might think. But, unfortuately, the hand surgeon is not on call today. So, the emergency department physician makes a referral to the orthopedic surgeon on call. (Our community hospital in fact keeps orthopedic surgeons "on retainer" by paying them to be available to take these sorts of cases. But, that's another topic.) The patient is given instructions to call their office the following day to schedule an appointment. So far, so good.

Well, when the patient calls the next day, he is told by the office staff that he cannot schedule an appointment. He sees one of my partners in our current practice, who hears the story and has our staff call on the patient's behalf. The answer remains the same, "Our practice doesn't take his insurance." (Oh, but I thought the hospital was paying you to be on call for the emergency department?...)

In this situation, which is not unique in our experience, the patient certainly runs the risk of deformity, chronic pain, and disability, because he didn't have the right "credentials" when he presented to the emergency room. He is not alone; the Kaiser Family Foundation reviews similar risk in the report entitled "Sicker and Poorer: The Consequences of Being Uninsured." And, the Institue of Medicine estimates that 18,000 adults die each year because of lack of insurance, in this report, despite this safety net of emergency department care.

So, while the emergency department didn't literally turn this patient away, the result was the same - the patient went without the care he needed. And, clearly this care is outside the scope of primary care. So, Mr. Bush, what would you have him do? So, Dr. Wicks, which of your partners in the community will see this man? And, if it were your brother, your father, your neighbor, what would you want for him?

I enjoy the benefit of close and caring friends. And, I think we came to the right conclusion at the end of our brief talk - the world has a hard heart toward others.

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