Shake that Money Maker

They say there is a crisis in the Emergency Rooms and while I certainly see a little of its effects at my own program, the crisis is not universal. Some Emergency Departments compete for patients, at least this is my understanding from the numerous billboards I saw the other day as I drove towards Detroit. Surely you’ve seen those billboards? You know, the ones with the pleasant looking ethnically ambiguous doctor, stethoscope carried jauntily around his neck, beaming down at a cherubic youngster whose boo-boo he has just fixed with the caption underneath promising a “New Vision of Health Care” with a guaranteed thirty-minute-or-less wait.

And no, they are not advertising for Urgent Care even though they are clearly angling for urgent care patients. The caption clearly indicates these clean, ultramodern medical establishments are Emergency Rooms. Naturally every Emergency Medicine resident must roll his eyes and curse at the idea of attracting even more ridiculoulsy trivial complaints to make his day even more hectic. On the other hand not every Emergency Department is over-crowded and packed with the indigent and uninsured. A nicely appointed ED in a good part of town can generate real income if it has a favorable payer mix. Even if emergency services themselves are not a money maker they can serve as a loss leader to bring paying customers into the hospital (and out of the specialty centers).

I am not against making money and I certainly realize that competition is ultimately good for the consumer in terms of better services and lower prices. On the other hand one can’t help notice that we are, with the exception of the small fraction of the uninsured who can’t bring themsleves to stiff the system, ridiculously over-doctored in the sense that large amounts of health care firepower, the physician’s time being one of the most important, are brought to bear on complaints that are either so trivial as to be laughable or so serious that they are impervious to our best ordinance.

Take, as one example, my patient of last night who the triage note said was a febrile, nauseous, anorexic, dehydrated infant. The nurse rolled her eyes when I picked up the chart which usually tells you all you need to know. Febrile was an axillary temperature of 99 measured at home and 98.7 in triage. Anorexic was a disinterest in feeding earlier in the day but breast feeding vigorously when I introduced myself. Dehydrated was an extremely wet diaper. Not exactly as billed on the triage note.

I have four kids. Every now and then a viral illness sweeps through all or most of them leading to a solid week of vomiting, diarrhea, and sleepless nights as one child after another succumbs and recovers. I have never taken my kids to the Emergency Department and we rarely take them to the doctor, especially for self-limiting things like that. They’re kids. They get sick. They usually recover. I understand that occasionally a “stomach flu” is meningitis so we are justifiably cautious with ill or toxic-looking children but come on now. EMTALA aside, what we really need is the ability to send people home from triage, as in, “Are you crazy? This is an Emergency Department and you ain’t sick.”

We don’t of course, and the large minority of patients for whom we can and should do nothing contribute to the excessive waiting time for patients who, while not exactly critically ill, never-the-less should be seen sooner than the what can amount to a ten hour or more wait in some departments.

On the other extreme, I see many incredibly old, incredibly sick, fantastically complicated patients who all present for some variation of being as old as dirt and sick as stink. Perhaps complicated is the wrong word. There’s nothing complicated about impending death. When you’re pushing 100 nothing is really standing between you and the Grim Reaper except he’s finishing his bagel and latte and he’ll get to you when he gets to you, dammit. We do what we can but we’re hard up against biology. The interesting thing about these patients is that they swim through the murky depths of American medicine accompanied by a small school of physicians who, like pilot fish, dart ineffectually around their decrepit shark picking off an occasional parasite. Between the cardiologist, the neurologist, the internist, the oncologist, the nephrologist, and the nice young girl in physical therapy who manipulates the fins every now and then these patients devour an incredible amount of medical resources.

My point? Nothing really except we get the health care system for which we pay. The current system can not help but be ridiculously expensive because of the way it is structured. Nothing wili ever change, no matter how or to whom you shift the costs because:

1.Patients are not encouraged or expected to take personal responsibility for their own health.

2. As every insurance scheme insulates the patient from the true cost of health care, there is no incentive for patients to make good economic decisions.

3. The legal environment makes it impossible for anyone in authority to exercise common sense. When I was younger, for example, drunks went to the drunk tank at the police station. Now they all come through the Emergency Department where they are expensive, space-occupying lesions. I understand that in our risk-averse society this is necessary to prevent the possibility of a habitual drunk aspirating his own vomit and dying without immeidate medical care. At the same time this kind of risk management isn’t cheap. If the public knew the cost they might be willing to live with slight chance of a drunk or two dying in police custody.

4. Futile care, which is in no way discouraged, sucks up a vast amount of medical care, everything from the physicians time to the cleaning lady mopping the floor of the ICU. Maybe by the time a patient is being fed through a tube, urinates through a tube, defecates through a tube, and breathes through a tube it’s time to let them go.

5. Doctors don’t know how to say “no” or admit defeat. The temptation, to which we easily succumb, is to shift responsibility by consulting specialists. I understand the need for specialists but by the time a patient accumulates a small platoon of them its time to examine, in terms of mortality versus cost, what all of the hired guns are really buying us.

The true crime is that the zealots believe a single-payer system or some other scheme of “We Swear It’s Not Socialized Medicine” is going to make health care less expensive. Unfortunately, until the structural problems are addressed, health care will just keep getting more expensive. To address them is, ironically, to preclude the need for anything other than consumer driven changes which are the only kind that will work.

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