Hell if I should know

A Daily Dish reader describes a quandary.

How do we decongest our overcrowded and dangerous emergency departments?

I am a pediatric emergency room physician. The vast majority (statistics say about 75%) of our patients do not need to be in the emergency room. Ask anyone who does the job--we routinely see children for colds, for diaper rashes, even for pimples. I once treated a 6 year old girl for gum stuck in her hair, and last week I treated a teenager with a sore throat who had an appointment in 30 minutes with her doctor but couldn't wait that long.


The problem is easily identified, but the solution is not. If we stop accepting everyone, chances increase that someone with a real emergency will be turned away by a secretary, a nurse, or by EMS personnel. As it stands, chances are increased that someone with a real emergency will be forced to wait too long to be seen as their condition worsens or that mistakes will be made because of the increasingly chaotic environment. Despite President Bush's statement 2 years ago that “people have access to health care in America, after all, you just go to an emergency room,” the system is completely overwhelmed.
The problem is due, in part to this: "The law (known as EMTALA) states that we must see everyone who presents to the department, regardless of the frivolousness of the complaint." The doc goes on the describe the merits of the law, but laments some of the consequences.

As a primary care physician, I have seen the tendency for patients to over-access the ED many, many times. I saw it in Manhattan, and I see it in Maine. I often see patients on follow-up from ED visits who went in for reasons that were clearly non-emergent, and I will talk with parents at night who are unwilling to wait until the next morning for an appointment. The ED is always open, and what's the down-side if you're not paying for the visit anyway?

As I have mentioned before, the tendency to over-access care is not limited to ED visits. I have patients whose parents bring them in for things that clearly do not need medical attention, or who aren't improving from their colds rapidly enough to suit them. ED visits are particularly costly, in part because (and this may be an unfair generalization, but it has been my experience) of a tendency by ED physicians to over-treat and over-test. Having to cough up some kind of payment tends to disincline people to access care they don't need, and I am moving more and more toward supporting a single-payer system that requires some kind of affordable co-pay (the cost of a pack of cigarettes seems reasonable). As draconian as that may seem, our current system is unsustainable.

1 comment:

  1. The demand for a free good can easily be infinite. We simply must charge something for medical care, or we'll find far less plesant ways to ration it, like making people jump through hoops and sit around waiting for weeks to be seen.

    I've heard France offers what is essentially catastrophic coverage to everyone, paying 100% after a threshold of several thousand dollars. Up till that threshold, the citizen pays about half of the cost. Private insurance is cheap, since the large risks are covered by the government. The bill for the first few thousand helps keep people from abusing the system. How about something along those lines for the US?

    I'll tell you, if everything is covered from dollar one, I'll use the hell out of the system. Why not? I've paid for it, and it is a bennie of citizenship. If I must pony up a reasonable amount ($5 isn't going to make me think twice) then I'll be far more careful in my use of the medical system. I don't think I'm unusual.