As the economy sputters along, we in medicine (especially emergency medicine) are often accused of being too expensive. Frankly, sometimes I agree. Our federal compulsion to see all patients regardless of ability to pay has resulted, quite naturally, in costs being shifted to the paying customers. Simple sutures and sprains, therefore, result in exorbitant charges; more complex issues can be fiscally inconceivable. After all, paying patients cover nonpaying ones in a kind of federally selective socialized care. My son's appendectomy, with a single night in the hospital, was $25,000. I rationalized it by telling myself I was paying for his surgery and probably for the surgeries of three other kids who had no insurance.
But that's not the point. If people of influence want to cut costs, they should talk with those of us who actually take care of patients. Actually, most honest practitioners from any specialty could give remarkably astute suggestions that do not require congressional committees or PhD economists — and that would therefore be roundly ignored.
Still, I have to throw some ideas out there. From the position of the emergency department, a vantage point that lets us see wasteful, costly actions from many perspectives, I can identify some simple moves that would result in serious cost savings for America. I know, I know. I'm not a manager or administrator, not a federal official, not an expensive consultant (at least not in this area). As a mere mortal practicing medicine on human beings for a living, I may not have much credibility to those who actually make the decisions. But I'll make my suggestions anyway. Maybe then I can become an overpriced consultant!
The first thing that comes to mind is the requirement to do a review of systems to be paid for higher levels of care. Really? The government wants me to apply an internal medicine paradigm to every significant ED patient? I suspect that positively oodles of money are wasted when, while asking the patient about his fever, chills, and diarrhea, a compulsive doc asks, “And do you have any chest pain?” How many patients, even with ankle sprains, answer, “Come to think of it, I have!” It's a fishing expedition, and we seldom reel in anything worthwhile. We should be seeing the patients for their complaints, not searching for others, which will invariably result in expensive and fruitless workups.
Of course, to cut costs we also have to deal with our consultants. I hear over and over how emergency physicians order too many x-rays and labs. In fact, we'd order at least half fewer tests if the admitting physicians and consultants didn't compel us to do so! It's so difficult to admit an abdominal pain without a CT (before the surgeon even touches the patient). So tough to admit an elderly patient with weakness without liver function tests! The list goes on and on. If we could all come together on what is really essential, and if our consultants would see patients without every test known to mankind, we'd save dollars! And if the federal government (the nastiest consultant of all) would not ask us to do things like blood cultures for pneumonia, which have no proven benefit, to document “quality care.”
I understand, some of it is driven by perceptions of malpractice concerns. But that's another thing we must address. When hospitals are compelled by federal law to see all patients under EMTALA without compensation, it is simply criminal and degrading, to continue to expose them (and us) to the same risk of malpractice. We should be excused from liability for gratis care, but if not, then the government should pick up the tab as if we were (for those patients) working in a federal facility where malpractice litigation is severely restricted.
Another radical idea: How about making narcotics over-the-counter? On the whole, I think it's a bad idea but not entirely irrational. How many of our extensive, expensive workups initiated for confusing but worrisome complaints are really only subterfuges to obtain narcotics? Fine, buy them at Walgreens, and save the world the money. And keep me out of the middle! Yes, some bad things will happen. But we sell alcohol over the counter with tens of thousands of alcohol-related deaths each year. The difference, please? Imagine if you needed a prescription for alcohol!
If you really want to save some more money, especially for Medicare, ask nursing homes to stop sending every poor little demented gentleman and lady to the ED for the slightest issue. “Her blood pressure was up,” “She has a skin tear,” “I think she has a UTI,” “She fell but got up and doesn't want to go. But the rules say she has to be checked out.”
Much of this could be averted if doctors with nursing home contracts would step up, and establish more rigorous rules … or go see the folks themselves. I know, it's easier to push the “go to the ER” button, but it results in great cost and little benefit for patients who are often old and sick, and just want to be left in peace. And whose families don't even want them transported, often as not! This, of course, circles back to litigation.
Another? Recently we were told that our neurologists would not accept referrals from emergency physicians, that patients had to have a primary care physician to make the referral. How stupid! Many patients, particularly younger ones, don't need a primary care physician. To be honest, I'm 46, and almost never go to my physician. It's a kind of treasured myth that everyone needs one. How often do we discharge patients by saying, “Follow up with your primary care physician,” when it just doesn't matter for many of them? It's wonderful to have a family physician, but is one necessary for everyone? Having a primary physician is a cost-savings if you have illnesses or problems. But if you don't, those regular checkups and screenings may not be of great benefit compared with episodic visits to urgent cares centers or EDs based on complaints.
Speaking of cost-savings and complaints, when I was at the ACEP Scientific Assembly last year, I informally surveyed folks about EMR. “How's it going with EMR?” I cleverly asked. “Killing us,” was the standard answer. EMR has slowed productivity to a key-clicking, mouse-sliding halt. Want to save money? If we MUST have EMR, then someone needs to streamline it, cut out about half of those “necessary” fields, and reduce the forests of paper being produced by paperless systems.
I would also suggest that money would be saved by simply giving physicians of every specialty a tax deduction for uncompensated care. Pay them the Medicare value of the care they provide to those with no insurance. This would potentially keep folks off the rolls of assistance programs and actually encourage docs to see the indigent. The Holy Grail of paying no income tax for a year, state or federal, would be a strong incentive. And it would avoid all of the administrative costs of state and federal assistance.
Finally, let's stop using emergency physicians as lifelong residents. How many times have I heard this: “Hey, I'm admitting Mrs. Hanson for pneumonia. She can go upstairs, but I need you to look her over, too.” What? We have become the portal for admission; too many patients, even coming from their own physicians' offices, are expected to stop for our evaluation. Even the hospitalists want us to do that when outside patients come to them. I understand that it's because they may not be able to see the patient as fast as they should, or distrust the outside doctor's evaluation, but it's a terrible and costly redundancy even if it's easy money for you and me.
I know there are untold more ideas for cost savings. Send them to me via my blog. Maybe we can collectively compile a document that can be ignored and cast aside by the powers that be as they find more ways to spend our tax dollars without improving quality care.
Read all of Dr. Leap's past columns in the EM-News.com archive.