Balancing public demand for high-quality, low-cost health care in the ED

Not a day goes by when emergency medicine is not in the news and not necessarily in a positive way. The mantra that the emergency department is expensive and, in fact, the “wrong” place to obtain care seldom gets challenged on the evening news and seemingly rarely by health care policy wonks.

Much of the care can be provided in a less-expensive setting. If only people would go somewhere, anywhere else for their care—primary care physician offices, urgent care centers, free clinics, after-hours clinics, clinics run by private enterprises, Walmart, Revco, settings staffed by physician extenders, shamans, telemedicine from third-world countries—all of society’s financial ills would be cured. Budgets could be balanced; taxes could be lowered; health care reform could proceed in a fair, impartial way without impacting negatively on any other aspect of our otherwise efficient and streamlined health care system. Our infrastructure could be rebuilt, the Cleveland Browns would win the Super Bowl, and Elvis would reappear.

Then I pass billboard signs on the interstate and elsewhere: “Come to St. Elsewhere right now. The wait to be seen in our emergency department is currently nine minutes.” Say what? Many people would be thrilled to be seen by their doctor within nine minutes of a scheduled office visit. I don’t see signs on the highway advertising that the wait to be seen by a teller at the local bank is nine minutes, nor for that matter at any fast food restaurant, supermarket checkout line, hairstylist, or muffler shop. Why us, especially when the cure for all of our health care system’s ills lies in keeping nonurgent visits out of our EDs?

By the way, there is no mention of board certification, skill set, or knowledge base on these billboards. Did the providers who will see you within nine minutes score over 90 percent on their boards? There is no mention of clinical acumen, only of time. We may or may not want filet mignon, but we definitely want Burger King speed.

There is no doubt that people who are having an ST elevation myocardial infarction should be evaluated quickly—in the single digits of minutes—and certainly for a 12-lead ECG. Many are on board with rapid evaluation for suspected strokes. No hospital in the country is going to have a patient who has just been shot in the chest or a child who was run over by a neighbor’s SUV wait around for more than 10 minutes to be seen by a provider. In fact, no matter how busy an ED is, that cyanotic, apneic patient getting wheeled down the hall gets seen rapidly.

So what is going on with the highway signs? Now they are inviting drivers to pull off  the road to have their cough examined or their earwax removed because it happens to be a convenient thing to do on the way to Grandma’s place. Clearly, no sane driver on I-95 is going to decide to get out of traffic to have crushing chest pain assessed only because of a billboard advertisement.

Now hospitals want to have un-sick patients modify their schedules to have nonpressing and nonurgent problems seen in their ED before they get to the beach. This is the P.T. Barnum theory of medicine: it is a crime to let suckers keep their money. Sshhh…we don’t really want patients to visit the ED, but come on down in your Beemer (but not your Chevette) because we can fit it into your busy schedule.

How can any of this be consistent? The short answer is, it isn’t. EM still represents the front door to the health care system. Whether it represents 2 percent, 4 percent, or even a high-single digit percentage of total U.S. health care expenditures depends, as with anything else in accounting, on how the numbers are allotted. To paraphrase Mark Twain, there are liars, damn liars, statisticians…and accountants.

While EM seems at times to be everyone’s whipping boy, these billboards represent a tacit acknowledgement of the field’s essential value to society and to the system as a whole. Yes, emergency bills look (and are) large to the general public, especially when they reflect a total cost including facility, lab tests, and imaging costs in the four digits for a visit to the ED. Yet this is a tacit admission that there is no other system within health care that can deliver what an ED provides on the desired timeline. Stay in the hospital for even one day and you can tack on another digit to those bills. An ICU stay or a week in the hospital becomes literally incomprehensible to the general public in terms of costs (tack on yet another digit or two). Very few middle-class or even upper-middle-class Americans can fathom writing a check for those sums. Is EM as a field that valuable to U.S. society that it is worth recruiting un-sick patients who cannot be seen quickly and conveniently in another setting? Make up your mind.

Perhaps we should be flattered that, despite the beating that it takes in the press and the enormous fees for which it is blamed, EM delivers whatever care the public wants efficiently and cost-effectively. Evidently, EM will do more, not less, of this in the future. The ED is the front line for virtually any type of public health catastrophe and might become an accessible portal for prevention as well. It will be interesting to see what the future holds—probably more billboards.