The Amarillo Globe-News did a story on freestanding ERs and it has generated a lot of discussion on the AGN's Facebook page. I posted a response to it, and the CEO of ERNow responded. I parsed his response, but the AGN wouldn't let me post it. Here is is in total.
Sorry, but the elephants in the room are the public policy
and the ethical issues. No amount of PR spin is going to change the following:
• If the patient is dealing with a true medical emergency or
massive trauma, the freestanding ERs are an intermediate step that can delay
care in an inpatient setting; or, if less severe by requiring subsequent
inpatient care, would subject the patient and/or patient’s family to additional
and unnecessary cost.
• Freestanding ERs are an egregious duplication of capital and
other resources. Freestanding ERs not only compete for patients and staff,
contributing to increased costs across the board. By reducing patient volume at
each facility, the fixed overhead costs are spread over a smaller base, raising
overall facility and community costs. Competition for personnel can contribute
to staffing shortages as there may not be enough skilled clinical staff to
serve all the ERs.
• By taking patient volume away from the hospital ERs, the
freestanding facilities undercut the hospitals’ revenue and therefore hurt the
ability to reinvest in their facilities. The implications reducing hospitals’
ability to fund improvements should be clear.
• The argument that competition is good for patient outcomes
and as an economic paradigm in medical care reflects a misunderstanding of
health economics and clinical guidelines. Despite what some politicians and
others would have you believe, the health care industry is not a classic, free
market/supply-demand economic model. Anyone who has studied Econ 101 should be
able to understand this. As for patient outcomes, the basic paradigm being
undercut is that more volumes means more repetitions and better skill sets.
That’s why, as one example, the American Congress of Obstetricians and
Gynecologists has guidelines for patient volume for maintaining OB units in
hospitals. This model of repetition applies to any skill set, but in medicine,
it can have life or death implications.
• The assertion that the wait times at the hospital ERs are
long for true emergencies needs to be backed with evidence with independently
obtained data to have credibility. There is little doubt that the clearly
non-urgent cases may have longer wait times, but that’s the purpose of triage.
That people can only get care for anything in an ER speaks volumes about the
failure of public policy in health care.
• In many communities, freestanding ERs are neither clear in
differentiating themselves from urgent care centers (which CMS and other
insurers recognize) nor forthcoming about the insurance coverages if one uses
the freestanding ER.
In short, health care is degraded by using a business model
instead of a charitable health care model.
Gerad Troutman
Gerad Troutman I love healthcare economics (have an MBA from
WTAMU) and healthcare policy questions (leaving DC now after meeting with DHHS,
would love to consider serving our community in Austin someday). I'll try to
respond to each of your points, and I like your points and believe you make
good ones.
[Maybe if I had a theatre, music or
ag degree from WT, I’d brag. And MBA, not so much from any school and
especially from WT.]
By this accord, [What accord?] all
hospitals should close down aside from those who have Level 1 Trauma centers
(which doesn't exist in Amarillo), top level Stroke Centers, etc. There is
misinformation by the public that all hospitals can automatically handle
everything.
[Please show me how you concluded I implied
this about hospitals. Because, I never said anything of the sort. The
misinformed public is the result of the kind of spin and propaganda coming from
those not interest in a rational health care system. In short, the above
sentences are a red herring.]
That is simply not the case and most every healthcare
facility has a limitation at some point. At ER Now we have transferred dozens
of patients to Lubbock (our local hospitals couldn't handle their final needs)
and even some to Dallas. We provided the same life saving Emergency Care that
any local hospital based ER would have, but we did it quick all the time, and
always by a residency trained, board certified Emergency Physician.
[First, it would be rational to base
your assertion on data, or at least back it up with examples. But you overlook
that if the patient needs the inpatient that Northwest Texas Healthcare System
or Baptist St. Anthony's Health System can provide, an ambulance trip from your
facility to these hospitals is an extra cost. The hospital here don’t charge patients
for wheeling them from the ER to the ICU, cath lab or elsewhere.
Second, you overlook that the local hospitals
have triage and that a patient presenting with signs and symptoms of an
emergent nature; or, arriving by ambulance from the field, will be handled
quickly and properly. Since you’re asserting otherwise, can you provide unbiased
evidence that FEC’s handle these crises faster?
Yes, come cases, after
stabilization, might be better handled elsewhere. Lubbock has a burn center,
for example, and would be a clear case of an appropriate transfer. But what
magic does an FEC provide in this case?
Finally, it’s all well and good you
have boarded ER docs. But in making your case as you did, you’re implying the hospitals
don’t have properly qualified physicians. Credentials committees, in my
experience, don’t take their responsibilities lightly. You’re making a serious charge.]
I disagree with adding costs to inpatient needs, and
actually globally, I believe FECs decrease those costs.
[Part of this makes no sense. It’s
nice to “believe” FEC’s decrease system costs. But, can you reasonably demonstrate
it? Further, with Medicare, Medicaid and some other private insurers disallowing
your fees, the costs fall hard on the patient. Go to ABC7 Amarillo’s website
for a story last year on this very issue.]
We send patients straight to inpatient beds, ICUs, surgical
suites, cath labs. We have an opportunity to spend more time with patients, and
can often avoid admissions if not truly warranted. [I
addressed some of this above, but, again, you’re asserting something you haven’t
backed up. Unwarranted admissions at hospitals? What percentage of patients
does that really apply to?]
If hospital based ERs largely were sitting around empty,
without waits, I would agree with you. Fact is, many/most have waits and even
have times when they have EMS diversion.
[As I noted above, the triaging
moves true cases in very quickly. I’ve seen it done. You’re conflating uninsured,
poor or otherwise disadvantaged people with non-emergent problems with the role
of the ER in theory. And conflating the lack of primary care resources with
true emergency care. I hate to say it, but you’re being disingenuous. Further,
those EMS diversions are rare and generally occur when inpatient beds are full.
Hospital are not going to divert a true emergency case (e.g., an acute MI)
because they can hold the patient in a post-op area after treatment. FECs offer
nothing better.]
Competition for staff can increase salaries, which one may
argue is not good for the healthcare economics but is good for our countries
economics. So which do we balance? We created over 50 FTEs in our community
(mostly licensed jobs) and created a large property tax base for our community.
These things help our community grow.
[I am not sure you understand some
of these economic issues. At least you seem to understand that staff competition’s
raising salaries isn’t a “good” thing for health care economics. It creates
inflationary pressure on the whole system. I don’t see how it’s good for our “countries”
(sic) economics when, as with the oil boom, the bubble will burst. Those FTEs you
claim to “create”: from where did those people come? Other facilities? That’s
not job creation. Fresh out of school? How does that match your argument for
experience? As for creating a “large property tax base,” the tax base is
already here. That’s the meaning of the term. If you say you contributed largely
to the tax base, I’d ask you how large?]
Many hospitals are private, for profit, and all in our
community are. What about the ability for the FEC to reinvest, grew, perhaps
expand to other communities? I have issue when we think it's bad for the FEC
but is ok for the hospital. Both of these facilities provided needed services
to communities.
[I’d like to suggest you look at the
history of health care in the United States. You were born in 1980, according
to the Texas Medical Board website. That was at the height of the Great Society’s
programs to rationalize health care in a good way. PL 89-239 launched a huge research
imitative to combat heart disease, cancer and stroke. PL 89-249 established
community health planning, which sought to eliminate unneeded duplication of facilities
and other irrational practices. Two years later, Ronald Reagan and the Republicans
came along and dismantled these programs, based on their notion that the “free
market” would allocate health care resources more efficiently. The GOP
continues to visit that fraud on us today.]
I agree to a point that volume helps skill, but I would say
to you there is a limit to human proficiency. I have seen literally thousands
of patients with 'chest pain' in my short career. I think my clinical acumen
changes little if I see 5 patients with CP this month of 50. Procedurally, I
have done hundred to thousand of intubations (breathing machine) and readily
have backup plans for an accepted failed intubation (there is an accepted
rate). I think performing multiple hour long surgical cases is a very different
compassion to the life saving procedures and clinical acumen we obtain in
Emergency Medicine.
[I can’t and won’t make a judgment of
clinical skills. I just subscribe to the notion that reps builds any skill in
any field.]
So how do you define non-emergent? I would agree to you that
hospital ERs generally do a great job as the sickest of the sick on getting
those patients right back and stabilized. The issue are those abdominal pains
that ended up being a heart attack, or an impending ruptured aorta (large blood
vessel) that had normal vitals, or mild mind confusion that ended up being a
stroke. These are all also time sensitive emergencies and these are missed
everyday due to long wait times.
[First,
by writing, “I would agree to (sic) you that hospital ERs generally do a great
job as (sic) the sickest of the sick on getting those patients right back and
stabilized,” but it strikes me as a contradiction to your main arguments above.
Further, again, the implications of your assertion about those missed diagnoses
is troubling — essentially saying that hospitals are missing cases due to wait
times. I think you need to back that up with data and compare it to missed diagnoses
in other clinical settings. Is it more or less?]
I like to think there are not bad actors out there, but I
acknowledge there is always that possibility, just like there are hospitals
that have been convicted of fraud. I think the vast majority of FECs want their
communities to know they are a real ER and we should be visited for the same
reasons you'd go to a hospital based ER, expect you will get more personalized,
immediate care in a FEC. We have been purposeful in our advertising and used ER
in our name and Emergency is printed multiple times outside.
[I guess your key argument is we’re
more touchy feely and you won’t wait long if you think you’re really sick and you’re
not. And if you’re really emergent, we’ll be nice and stabilize you and you’ll
go to the hospital anyway.]
There are issues with a purely charitable healthcare model
when we think about advancement in medicine. [Please
tell me what they are.] There can also be issues with for profit
healthcare models (which many hospitals are becoming, and those in our
community already are). Profit ability is what provides for innovation and
drives people to do it bigger, better, faster, and cheaper than the guy down
the street.
[This is (I am sorry) breathtakingly
ignorant. This is complete misunderstanding of the difference between excess of
revenue over expenses and profit when looking at non-profit vs for-profit hospitals.
Read Herbert Klarman’s “The Economics of Health,” please.
Thank you for the comments and I always enjoy seeing different
perspectives. I believe we are a value add to healthcare and that ER Now has
become an important piece of Emergency Care in the Texas Panhandle. FECs on the
Texas coast filled a huge void during Harvey and are continuing to do so.
[Harvey is a “this is not a drill”
disaster and everybody is pitching in on the Gulf Coast. I know. I live there
now. FECs aren’t special in this.]
Because of the importance of this topic, I have responded in
detail so as to continue this discussion. My responses are in brackets and in
Word are in red.
