Your article, “Intensity of Care, not Boarding, May Be Clogging EDs,” mentions legislation, rules, incentives, teeth, efficiency, pay-for-performance, penalties, and education. (EMN 2013;35:1; http://bit.ly/Uo6o2b.) It posits that “there are a lot of solutions out there,” lacking only, it seems, the motivation to implement them.
Personally, I think that not a bit of what is discussed would solve our problems, for they go far deeper than how efficiently we can get widgets to work. The article's tired remedies involve nothing more than behavior modification techniques, mostly involving negative feedback loops to medical providers.
One of the techniques, education of the public, is laughable on its face. Let's acknowledge this: the vast majority of the public has very little in the way of medical knowledge by which to judge the severity of their own complaints. If anyone is to be provided with negative behavioral incentives for overutilization of resources, it has to be the public. America simply cannot afford infinite provision of resources with no “skin in the game” for the beneficiaries thereof.
I say that the problem goes far deeper, and it is this basically: the source or fountain of all material well-being is the human mind, which for many if not most Americans is very poor. The value in the world marketplace of goods and services created by many American minds does not come close to the cost of providing the owners of those minds with the very expensive medical resources theoretically available for the let-no-expense-be-spared mindset with which people approach the medical world when it is their own or their loved ones' health at stake. In other words, our country is not rich enough to pay for any and every conceivable low-yield procedure or medication invented by the bright minds that gave us such wondrous advances as MRI.
The problem, as I see it, will solve itself only when the expense of technology comes down. We as a society need to innovate even more to provide more at lower cost to everyone. I think there will be a sort of inflection point in the future similar to what happened in the computer business; new undreamed of technologies will begin to appear, making the medical equivalent of cellphones and computers available to everyone, even people with little to no resources.
For now, the problems might yield a bit if we could think of a financial disincentive to those who so freely access the system at little or no cost to themselves at the present. A bank account with, for example, only $1,000 in it, to be cashed by the beneficiaries on Dec. 1 of every calendar year if they have lost weight, stopped smoking, been in no car wrecks, made all their well visits; and stayed away from the ED. For every ED visit, a progressive series of charges would be made: $50 for the first, $100 for the second, $150 for the third, and so forth. For people who are in poor health, well, sorry; just count the blessing that you have medical care at all! And do not dare complain that you don't get $1,000 like everyone else; at least you are here on Earth to enjoy whatever life you have, thanks to medicine.
John G. Boulet, MD Huntsville, AL