In 1986, when Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA), hospitals and ambulance services were mandated by law to stabilize anyone needing emergency healthcare services regardless of citizenship, legal status, and/or insurance status.
This was instituted at the time to prevent the prevalent practice of “dumping” — refusing to treat patients because of insufficient insurance or transferring or discharging patients on the basis of anticipating high diagnosis and treatment costs. While the implications of this law are indeed very noble in providing undifferentiated care to all patients based solely on healthcare needs and not financial status, it has unfortunately led to many patients presenting to the emergency department (ED) for primary care issues.
The misconception is that the care in the ED is similar if not better (because of increased access to consult services and imaging) and quicker than waiting to see your primary care physician (PCP). A 2010 study published in Health Affairs found that 14 percent to 27 percent of visits to hospital EDs are nonemergent, such as minor infections, strains, fractures, and lacerations. The study found that all of these cases could have been appropriately triaged in urgent care centers or retails clinics.
England has a model that may be a potential solution. The healthcare goal of the National Health Services (NHS) is to “treat the right patients in the right place at the right time.” The NHS employs nurses and paramedics to handle 999 (their equivalent of our 911) triage calls with more appropriate triaging of patients based on acuity.
Despite my research interest in cost effectiveness of healthcare solutions, I am a strong believer that you cannot put a price tag on quality patient care. However, I do believe that cost savings achieved with efficient provision of healthcare translates into monies that we can spend to advance other healthcare initiatives. In the same 2010 Health Affairs study, it was found that hospital EDs could save $4.4 billion annually if more visits took place at alternative, more appropriate care sites. This is $4.4 billion dollars that could be used to institute electronic medical records (EMRs) in EDs or to buy ultrasound machines for use with patients who have difficult access to such diagnostics, for example.
By triaging patients to the appropriate provider (primary versus emergent), we utilize our healthcare resources more efficiently and effectively. We are already bursting at the seams when it comes to ED volume. Every day when I walk into a shift and scan the waiting room, inevitably there will be those patients who need a medication refill, have dental pain, and/or want their blood pressure checked. Many of these patients unfortunately don’t have access to a primary care physician who can address these chronic issues. The ED is not an ideal place for continuity of care for patients, but if the same patient keeps presenting to the ED frequently enough, the likelihood he or she will see the same doctor are high.
Despite concerns with the new healthcare reform, there is also significant opportunity to impact the delivery of healthcare in making sure our patients get appropriate care based on their chief complaint with the appropriate follow-up care that sometimes is best achieved with a primary care physician as opposed to an emergency medicine physician.
In my residency training I have started educating my patients that the best way to ensure continuity of care is with their PCP, and I try my best — on days when the trauma bay is not full of extremely-sick patients and my waiting room is not overflowing — to call the patient’s PCP to update him or her on our plan and of the discussion we had about how to get the most appropriate care in a timely fashion. I think if we all work together, regardless of specialty, to educate our patients on the importance of primary care and its ideal location, we can impact the triaging of care one patient at a time, which will have a domino effect on the healthcare system at large.