You know what? I’m tired of being the poster boy for the high cost of health care. It seems like any time I’m in a group of non-physicians and somebody wants to complain about skyrocketing insurance premiums and deductibles, they all start looking at me in a not-so-subtle way. “Hey guys, I didn’t do this!” I want to say. But of course I rarely get the chance.
First, the truth is that emergency care, though expensive, is only a small fraction of the nation’s total health care bill. The numbers vary depending on who you talk to, but by best estimates the nation’s EDs account for about 3% of the total. Three percent. The truth is that the patient who comes in by ambulance could pay almost as much for the ride in as the care rendered by the emergency staff. And that’s just looking at the total bill. Let’s say the patient is charged $1500 or more for their emergency visit. My portion is only 10-20% of that, yet I’m the one who is the face that everyone sees.
When the patient gets an ED bill that isn’t covered by their deductible – and increasingly it is not –
I’m the one they want to find fault with. Even the hospital wants to put me in the cross hairs of the cost conundrum. If a patient with a chronic disorder bounces back after being treated in the ED, which so many of them do, somehow that’s my fault. My lack of ability to make them do what I told them to do is somehow my failure. So when the hospital gets penalized for readmissions, who’s to blame. Me? How’s that? They were fine when I sent them home or I wouldn’t have done it. In “the old days” it was easy. We just admitted anybody and everybody. I remember an administrator bringing me into his office once and telling me that since our group took over admissions from the ED had fallen 20%. I was expecting a compliment on the quality of care. Instead he simply told me if the admissions didn’t rise back to “normal” we’d all be fired.
Hey, I was everyone’s favorite doctor after that. But as Nick Cage said in one of my favorite cult classics, Raising Arizona, “That ain’t me no more.”
Part of the problem is the faceless way we interact with so many people. Try as we may to bond with every patient – and I work very hard at it – the truth is that I have very limited time to create a human connection with my patients. There’s a line of patients right behind them, and I have tremendous pressure to move them down the continuum of care. I need to either treat ‘em and street ‘em or make the diagnosis and admit them to the right service. I don’t have months or even years of contact with the patient, on which the patient bases a value for my care.
For example, many years ago, when I had just gotten out of law school, I was approached by a family who wanted to sue their caregivers for the results of a catastrophic birth injury. The problem arose when their young, inexperienced family doctor – who the family knew and loved – decided that he wanted to attempt vaginal delivery of their twins…just for the experience. They trusted their doctor until, you guessed it, the second twin got into trouble. Then they needed the anesthesiologist and obstetrician in a mighty hurry. The resultant injury was placed entirely at the feet of the OB, not the family doctor. In fact they didn’t even want to name the family doctor in the suit, despite the fact that his actions had lead to the disaster.
While this situation is about perceptions of liability, it is also about perceptions of value. They didn’t know the OB, so he was an easy target. I don’t begrudge a surgeon for taking a patient to the OR for a procedure we do in the ER everyday… even when they charge five times as much as we would for the same procedure. Patients often see more value in the procedure if it is done in the hallowed halls of the operating suite. But I do wish I had the time to do the victory lap that coming out the OR to see the family provides to surgeons. This personal moment seems to solidify the value of the intervention in the mind of the family. The value proposition for said intervention might be better in the ED, but patients lack the personal connection to their “healer” and are thus more likely to complain.
And “value” isn’t about actually saving lives, either. We all know that if you make a mistake that costs someone their life, you will pay millions. But make the diagnosis and do the procedure that saves someone’s life and you will often receive a few hundred bucks.
But I didn’t write this piece just to whine. It is my firm belief that when all eyes are on you, even for the wrong reason, it is an opportunity to step up and take the lead. And that is just what some are doing. The next generation of emergency physicians are looking at our specialty with new eyes. They have picked up the baton to reshape medicine starting at the entry point for most patients, the ED. EPs are embracing new technologies for telemedicine that are springing up each year. This will allow medicine to come to the patient in ways previously not thought possible. I firmly believe that in a few short years the habit of sorting through countless patients to find the truly sick ones will be a thing of the past. Emergency physicians will spend more time with – and do more for –
the sickest of the sick instead of simply triaging them elsewhere. The not-so-sick will be triaged out before they even reach the ED.
As medicine shifts in coming years towards a paradigm of paying for value, the judgment of the emergency physician will become worth even more. Why? Because the ability to manage patients before they come to the ED will become of paramount importance. And we are the ones who have been specializing in that for decades.
And most importantly, emergency physicians are beginning to take their years of experience and apply them to the problems of the larger healthcare system. I couldn’t be more proud of Steve Stack and his ascension to the head of the AMA. He’s the associations youngest leader in 100 years for a reason. It’s folks like him – and even you and me – who have an opportunity to take a leading role in medicine’s next great evolution.
When I first reported to my emergency medicine residency in 1979, I saw a little poster that I have never forgotten. It said, “When you are up to your neck in alligators it is hard to remember that your original intention was to drain the swamp.” It can feel like we’re up to our necks when we see our faces on the posters highlighting the runaway cost of healthcare. But I want to challenge you to step up and take on the challenge, and embrace the position that we have been given. Let’s reinvent the system. Let’s drain the swamp.
