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Why Do People Go To The ER For Primary Care Services?

Emergency departments are splitting at the seams, uninsured patients fill the waiting rooms, and Emergency Medicine physicians are crying “uncle” on a national level.  We assume that gaps in health insurance coverage force patients to seek treatment in the ED, but the reality is that many insured patients seek treatment there as well.  Why?  Because the ED is a crowded, but one-stop shop whose convenience cannot be denied.  PandaBearMD explains why one well-insured patient (who has a regular PCP) still chose to see him in the ED:

“As my patient related to me, in order to see his doctor he has to
make an appointment which is often weeks to months in the future. On
the day of his appointment, even if he shows up on time he will usually
have to wait an hour or two because the doctor is always running late.
Then he will spend a brief ten to fifteen minutes with his doctor who
will order a slew of tests and imaging studies, many of which will have
to be completed at a different location. He may, for example, have to
drive across town for a CT scan and it is usually scheduled for a
different day, often weeks in the future.

Then, as my patient explained, he must wait several weeks for his
next appointment where his physician will explain the results and
finally initiate either definitive treatment or, as is often the case,
referral to another specialist who will repeat the time consuming
process…

My patient also confided to me that even getting the results of studies
and imaging was not guaranteed. Although we are all quick to relay bad
news, apparently follow-up is not that pressing to many physicians if
the results are normal…

Consider now a visit to the Emergency Department. First, my patient did
not need an appointment. While it is true that he was triaged to a low
acuity and had to wait a while, at certain times of the day the waiting
times are not that much longer than the typical wait for his delayed
primary care physician. Second, the lab tests he needed were drawn on
the spot and the results reported within an hour even though he was a
low acuity patient. Our goal, you understand, is to discharge or admit
as fast as possible. Likewise his imaging studies were obtained, read,
and reported quickly. Finally, if anything serious has been discovered
he would have been admitted within hours. More importantly to my
patient, since everything was all right he knew fairly quickly instead
of biting his nails for a couple of months.”

This is a perfect illustration of how Americans value convenience over cost, and how health insurance can be an enabler for inappropriate ER use.  The solution here is in IT.  Primary Care Physicians need the tools to automate a lot of what they do, thus making care more convenient for their patients and themselves.  A common, secure PHR-EMR, synched with online scheduling, radiology suites and laboratories, health news alerts, care pages and vibrant community, chronic disease management tools, and comprehensive, credible, patient education will go a long way to keeping people out of the ER.  Revolution Health is working on such a system, and we have high hopes that the creation of America’s first integrated, digital medical home will improve the quality of life of patients and physicians alike. Achieving this goal will require cooperation and patience from all sectors in healthcare.  I hope we’ll find a way to work together as rapidly as possible or else the PCPs and ER docs are going to crack.  Hang in there, guys – help is on the way, though it might be a few years out…This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.


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4 Responses to “Why Do People Go To The ER For Primary Care Services?”

  1. Joe G says:

    Another culprit: asinine insurance plans.

    Under our old UHC plan, ER visits (if truly an emergency) were a $40 co-pay. Visits to Urgent Care facilities (even if it was a true emergency) were under the $1000 in-network and $2000 out-of-network deductible.

    Guess who got stuck with a $1,350 bill for tonsilitis (visit, lap work, follow-up visits) because he through he was doing the right thing by going to urgent care instead of the hospital.

    I dunno … maybe when I woke up at 4 in the morning with a 103-degree fever and agonizing pain in the middle of the night (turns out I had an abscessed tonsil and a very aggressive infection), I should have consulted the provider directory and read (or remembered) the fine print.

    But that sounds reminiscent of the “Sicko” anecdote where the unconscious woman was penalized because didn’t get her ambulance ride pre-approved.

    Needless to say, it’s 8 months later, and I, the doctor, UHC, my Connect Your Case HSA and RHG Member Services are still trying to figure out exactly what I owe and who should pay this doc.

    From now on, I go to the ER if it remotely resembles an emergency.

  2. Zagreus Ammon says:

    Dr. Val,

    This idea is not mine, but may have role in smaller communities where the lack of coordination of care is definitely inexcusable. The idea is a management intervention to create a service line connecting PCP’s, ER/urgent care and hospitalists. The physician group would have to be united, but would not include subspecialists and other consultants. It would be partly incentivized by productivity and partly by the overall performance of the group.

    Patients may like the old days when the same doc has the competencies requires to run an office, round in hospital, do surgery… At least this way, one group, one computer system and a singular interest to coordinate care…

  3. Dr. Scherger says:

    There is an old saying, patients want availability, affability and ability, IN THAT ORDER.  ERs offer availability guarenteed.  Also remember when patients could call their physicians directly, and if the problem wasn’t serious, “take two aspirin and call me in the morning”.  Ever try to call a physician “in the morning”!  Primary care must become readily available again, more available than the ER.  Online information and care is the most available service of all.  When Revolution Health connects with primary care physcians, the true revolution will happen.

  4. Number One Dinosaur says:

    You had me all the way up to “…the solution is IT.”

    No, it’s not; at least not any time soon.

    What we need is to improve the “available” part: I have open access. Call me for an appointment and I’ll see you today or tomorrow. The nearest hospital to me now does routine x-rays on a walk-in basis. If I were able to work in a group large enough to have an onsite lab that could provide the same kind of turnaround time as an ER, then we’d be in business. A customer-oriented, full-service outpatient facility could rake it in by providing Panda’s hypothetical patient with that instant availability he claims to want.

    With all due respect, EMR’s have nothing to do with it.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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