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Breaking News: Urgent or Not? Who Decides May Spell Future of EDs

SoRelle, Ruth MPH

doi: 10.1097/01.EEM.0000421863.35257.f1
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Washington Gov. Christine Gregoire in March suspended implementation of a law that would have denied payment for many of the “nonurgent” visits made to the state's emergency departments by Medicaid patients. Like similar proposals around the nation, Washington's legislation was seen as a way to lower the cost of health care.

Governor Gregoire acted at the urging of many in her state who felt the policy would set up patients for disastrous health consequences while placing physicians and hospitals at risk of lawsuit. Washington emergency physicians instead proposed a “best practices” policy designed to reduce the number of nonurgent visits to the emergency department without placing patients or their physicians at risk.

The Washington State chapter of the American College of Emergency Physicians argued that patients often do not know when a visit is urgent, and that term's definition is the fundamental issue, said Jesse Pines, MD, the director of the Center for Health Quality and an associate professor of emergency medicine and health policy at George Washington University Medical Center in Washington, D.C. “If you ask someone [in the ED] if their symptoms are urgent, they will say, ‘Yes, that's why I came here,’” he said.

Yet looking at when patients came to the emergency department and their diagnosis can make determining urgency difficult. Determining what is truly urgent is beyond the ken of most patients. The two most common symptoms that push patients to seek emergency care are chest pain and abdominal pain, which can signal true emergencies like a heart attack and appendicitis, though in most cases they do not. The emergency department rules out deadly conditions, and provides pain relief and answers where possible and reassurance where not.

“All the ways we measure urgency — triage levels, time it takes to see a primary care doctor — are not meaningful to people who judge their own urgency and make their own decisions,” said Dr. Pines. “Say you have a low-acuity complaint, something you want advice about. It's not going to kill you, but it's worrisome. Where do you best handle those visits?”

Some may say your doctor's office or a retail clinic, but the answer really depends on how accessible that service is, and that accessibility is often determined by the insurance you have, the responsiveness of the physicians, and the availability of a physician. “It may be determined by the local health care microcosm,” he said. “Are the patients near an emergency department or an urgent care center? Do they know one exists or that they could go to different sites? What are the out-of-pocket costs? How long do they have to wait? Often, people who go to the emergency department make a perfectly rational decision based on their circumstances, alternatives, and costs.”

Policies like the one in Washington State are shortsighted, said Dr. Pines and his colleague Zachary F. Meisel, MD, a Robert Wood Johnson Foundation clinical scholar and an emergency physician at the University of Pennsylvania, in Time magazine last April. (See FastLinks.) “Policymakers think that ED use, in aggregate, is a costly problem and a major driver of unnecessary health care costs in the U.S. ACEP claims that rather than delivering unnecessary care, EDs treat many patients who have no alternative when they need comprehensive medical care in a timely manner; that is, EDs deliver altogether necessary care,” they wrote.

One way to reduce nonurgent care in the emergency department might be to offer alternatives. “Some people have no other place to go,” said John Moskop, PhD, a biomedical ethicist and a professor of internal medicine at the Wake Forest University School of Medicine in Winston-Salem, NC. “That is true for people who have no primary care physicians because they are uninsured or cannot find someone who takes Medicaid. Others include people who are unable or unwilling to take time off work to go to the primary care office when it's open. Many have to go after hours when the emergency department is open and others places are not,” he said.

Dr. Moskop said many patients are unsure whether their complaint needs immediate attention. Their sore wrist might be a fracture or just a sprain, but they are unable to determine that themselves. “They go to the emergency department and the emergency physician evaluates it, and says, ‘Your wrist is just sore.’ That gets counted as a nonurgent visit,” he said.

Implementation of the Patient Protection and Affordable Care Act will compound the problems of emergency departments, Dr. Moskop said, providing many people with insurance for the first time. Eight million will receive Medicaid, and others will get private insurance, but many on Medicaid will not be able to find a physician and may still end up going to the emergency department, he said. “While the act also includes increased payments to train physicians and set up community health clinics, they have a long lead time — a seven-year pipeline to train primary, less for physician assistants and nurse practitioners — but it will also take a while for the health care system to gear up and practice delivery systems to change.”

The nation faces a dual need — increasing access to care while decreasing costs, but focusing on emergency department costs is unlikely to yield all the savings needed, said Dr. Moskop. “In the near future and foreseeable middle future, a significant number of people will need access to the emergency department for their care. For example, undocumented immigrants who have no coverage under health reform will go to the emergency department when they absolutely need it.

He said nonurgent care will remain in the emergency department for the short term, but primary care physicians, as more are trained, can take on the burden of these insured people. “But it will take years for those providers to come online,” said Dr. Moskop. “In the meantime, we need to continue to support the provision of care in the emergency department. It might be a little more expensive, but I'm inclined to think it is good quality care,” he said.

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