Friday, September 22, 2017

Debating freestanding ERs

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.

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