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Friday, June 13, 2014

Are emergency rooms admitting too many patients?

This blog has discussed conflicts of interests. Indeed, every player in the medical arena has found itself challenged by conflicts where one’s self-interest competes can skew what should be pure advice. This issue is not restricted to the medical universe. Every one of us has to navigate through similar circumstances throughout the journey of life. If an attorney, for example, is paid by the hour, then there is an incentive for the legal task to take longer than it might if the client were paying a flat fee.

The fee-for-service (FFS) payment system that had been the standard reimbursement model in medicine has been challenged and is being dismantled because of obvious conflicts that were present. (This is not the only reason that FFS is under attack, but it is the principal reason offered by FFS antagonists.) Physicians who were paid for each procedure they performed , performed more procedures. This has been well documented. Of course many other professions and trades still operate under a FFS system, but they are left unmolested. Consider dentists, auto mechanics and plumbers and contractors.

FFS is not inherently evil. But, it depends upon a high level of personal integrity which, admittedly, is not always present. In my own life, I often hope and pray that the individual who is offering me goods or services is thinking of my interests exclusively. Am I living in fantasy land?

The Rand Corporation released a study in May 2013 that demonstrated that emergency rooms accounted for about 50% of hospital admissions during the study period from 2003-2009. When I have posted on Emergency Medicine in the past, it has stimulated a high volume of responses, some good, some bad and some ugly.

I think it is inarguable that emergency room (ER) care wastes health care dollars by performing unnecessary medical care. As a gastroenterologist, I affirm that the threshold for obtaining a CAT scan of the abdomen in the ER is much lower than it should be. And, so it is with other radiology tests, labs, cardiac testing, etc.

I understand why this is happening. If I were an ER physician, I would behave similarly facing the same pressures that they do. They face huge legal risks. They are in a culture of overtreatment and overtesting because they feel more than other physicians that they cannot miss anything. They argue that they have only one chance to get it right, unlike internists and others who can see their patients again in a follow-up visit. If an ER physician holds back on a CAT scan of the abdomen on a patient who has a stomach ache, and directs the patient to see his doctor in 48 hours, what is the ER physician’s legal exposure if the patient skips this appointment and ends up having appendicitis?

Keep in mind that we should expect that ERs to have higher hospitalization rates of their patients, since their patients are much more likely to be acutely ill.

But even accounting for the sick patients in the ER, I think there is a significant percentage of ER patients who should be sent home and are sent upstairs instead. This would be an easy study to perform. Compare the intensity of testing between the emergency room and a primary care office with regard to common medical conditions. I would wager handsomely that the ER testing intensity and admission rate would be several-fold higher than compared to doctors’ offices. Want to challenge me on this point?

Even though I understand why ER docs do what they do, it is a bleeding point in the health care system that needs a tourniquet.

It is clear that ER physicians are incentivized to admit their patients to the hospital. Of course, they might be ‘encouraged’ to do this by their hospitals who stand to gain financially when the house is full. Leaving the financial conflict aside, when an ER physician admits a patient, he is completely free of the risk of sending a patient home who may have a serious medical issue. I am not referring here to patients who clearly should be admitted, but to the large group of patients who most likely have a benign medical complaint, but the ER physician advises hospitalization ‘just to be on the safe side’. These same patients if seen in their own doctors’ offices would never be sent to the hospital to be admitted.

Where’s the foul here? Here are some of the side-effects on unnecessary hospitalizations.
• wastes gazillions of dollars,
• loss of productivity by confining folks who should be working,
• departure from sound medical practice which diminished the profession,
• emotional costs to the individuals and their families, and
• unnecessary exposure to the risks of hospital life.

How can this runaway train be brought under control? First, let’s try a little tort reform. Second, pay a flat rate for an ER visit. Under this model, if the ER physician orders an MRI on a patient with a back strain, the hospital swallows the cost. Finally, when hospitals are penalized financially for hospitalizing folks who should have been sent home, we will witness the miracle of a runaway train performing a U-turn on the tracks.

While the Rand Corporation’s results are not earth shaking on its face, my intuition, insider’s knowledge and a tincture of cynicism all converge on the conclusion that for too many patients the ER has become a portal of entry in the hospital. Is the greater good served if the ER is a revolving door or barricade?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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