Everyone knows that one of the key factors of cost containment is getting a handle on over-utilization of resources. The Dartmouth Atlas project made this point, and though the study had its problems we know deep down that a lot of waste comes straight from the ED. Let’s start by talking about consults, the problem of getting a “specialist for every body part.” Is a major player in the problem of cost escalation?
Greg Henry: 75% to 80% of all expenditures in the health care system require the authorization or ordering by a physician. The great Pogo line is “We have met the enemy and he is us.” He IS us. And it starts with the ethos of the training going on in medical schools. Virtually all of us have been trained at one of the 127 major medical centers in the United States, where you get an expert on the left testicle to look at the left testicle and an expert on the right testicle to look at the right testicle and nobody ever has to make any real decisions. Secondly, if it is of no cost to you as the doctor, why the hell wouldn’t you do it? The problem is that you’ve been given a blank check so you just go ahead and order. Because to not order puts you at some risk, while ordering puts you at no jeopardy. We’ve set up a system to fail and the ordering of consults, as far as I’m concerned, is a small part of what is a much bigger question.
Ricardo Martinez: There are two issues here. There’s variation in the emergency department and there’s consulting once they get to the floor. In terms of practice variation, I’m glad to see a greater focus on agreed-upon clinical pathways. I really don’t need to call five different cardiologists to get five different answers at 2 o’clock in the morning. It’s much more cost effective and efficient to have a pre-ordained way to do things. Plus, this gives you a system, and I can improve a system. What I can’t improve is the fact that everyone does things differently.
Regarding consults, I would point to the fact that you often get multiple consults before the patient is admitted, all to find out which particular one person is going to admit that patient. You see it a lot with abdominal pain in females. You get an OB, general practitioner and a surgeon all looking at your patient before you can make a decision. A couple years ago my wife went through the hospital and I was amazed that no one seemed to be in charge. There were so many different physicians involved that if I wanted to get an answer I practically had to call a convention.
This ordering of excessive consults is part of our established practice pattern and it’s driven a lot by the financial and the medico-legal forces in the system. However, I think some of the new pay-for-performance and some of the new cost sharing programs that are coming up may change those patterns dramatically.
GH: Unfortunately, the pay-for-performance that they’ve suggested doesn’t really pay for performance. It’s past focused.
MLP: So we know that there is over-consultation. What role do we play in changing this culture?
RM: There is over utilization and there is under utilization, and sometimes you’re damned if you do and damned if you don’t. I think that it’s appropriate to get a consult on a patient when you know the patient will require follow-up. Or when you need that procedural or cognitive intervention. I think we’ve all run across emergency physicians who practice defensively by consulting a tremendous number of physicians rather than use clinical acumen. I think that that is a killer to patient flow and to cost, and quite frankly, it’s poor quality care. I’m concerned because I’m finding that more and more docs coming out of emergency medicine training programs are reluctant to leave the big city because they have been trained to believe that consultations are ubiquitous. They’re used to calling anybody and everybody. I think that will change going forward, but right now it’s a real barrier to getting docs to go out into the community.
GH: You can always tell the intelligence of a physician by the way he/she has written a consult. If it states a specific question, asks about a particular disease possibility, then you know the person has thought about the case, knows their limitation and now needs someone with a higher level of expertise to be involved. The truth of the matter is that I don’t need a consult on most low back pain. I’m the expert in that. I need surgical intervention when I check the patient and they’re febrile and are losing control of their urine. I understand what I need at that moment in time. I need a guy who does an MRI and probably a surgeon. But there aren’t a lot of other issues on the table. I think that the guy who orders too many consults is obviously not thinking about what the question is.
RM: That applies to consults, lab tests and imaging tests. What is the question I need to have answered in order to provide good patient care? Whether the patient has a headache or low back pain, they may not need a specialist right away. They may do very well to have someone take care of them as a whole person rather than as a particular complaint.
MLP: So there are multiple reasons to over consult, from ignorance to laziness to actually padding your friends’ pockets. Do you support the idea of a medical home, a quarterback who is given the money and doles it out as he feels necessary, someone who pays, or benefits, based on the level of utilization of resources?
RM: I certainly support the idea of a medical home. Having someone in charge who sees the whole person and can manage their care is better than having a patient bounce around between unrelated providers. Having said that, we’re pretty homeless right now. A lot of patients come in because they can’t get access to care, and that looks like an issue that will exist for the foreseeable future. I actually believe that the emergency physicians should be paid the part of the money that’s being set aside for medical homes for collaboration and integration. That’s what we do, and we do a great job at it. A lot of what we do is to take care of a patient and then try to find continuing care for them or integrate them with their medical practitioner. Somehow we’ve been excluded from that integration process when it’s actually a crucial piece of what we do.
On the hand, I am against having a medical home incentivized to minimize acute care. There’s chronic care and there’s acute care. The majority of the health care costs right now are for chronic care and a lot of those patients could be managed better if they were maintained by a central physician. But the acute care aspect will never go away – people will always have heart attacks and get in accidents – so emergency care will always be essential to the health of the communities. The health care debate has not focused on acute care; it has only focused on chronic care. When I was in California, we ended up with a capitated environment, and we started to see some perverse behavior. I had a woman in a car crash with neck pain and the primary care physician refused to authorize care. He wanted us to send her over to the office, which just wasn’t feasible. And this was a guy that I knew and respected. But financially it wasn’t in alignment with his bailiwick. So I think we need to make sure that we keep a very strong firewall between chronic care and acute care so that the ERs can remain a safety net for society.
GH: I have a much more cynical view of this. I think that the chance there’s going to be a medical home for most people is slim to none. Why? Because of the ethos of the current generation of physicians who want to work 9-5, Monday through Friday. Three-quarters of the week, they don’t want to be there. That means we’re there, picking up the slack. I remember as a kid that my family doc wouldn’t leave the office until the last patient had been seen. They took care of people!
Washington has sprung this medical home idea on us like it’s some kind of new concept. Heck, this goes back to Hippocrates! I have no idea how they think this is going to work since come 6 o’clock in the evening, I’m going to be their medical home, because no one is going to see them when they have a problem. I think that we’ve turned out feckless physicians who don’t step forward to do what they’re supposed to do. But I’m just one guy giving an opinion.
RM: I do see some hope on the horizon. I think that we have a tremendous number of patients who are transferred from smaller facilities to larger facilities just to be seen by a specialist. Not for procedures necessarily, but just to be seen and get the cognitive reasoning aspect of it. That is incredibly inefficient and it’s not very good patient care. With advancements in technology, however, I think we’re going to see an increased ability to extend the care and the reach of specialists. You’re going to see more and more electronic collaboration so that patients can be taken care of locally. I think that if we do things right (I emphasize right) I think you’re going to see that we can build an infrastructure that allows better access to specialty resources through the internet. We do that already for X-rays, and we use the phone to extend the reach of poison control, but we’re going to need to see that in a variety of other specialty areas.