Op-ed: Ease ER overload | KevinMD.com - My mom as case in point

Emblematic of soaring health care costs, which are projected to reach $3 trillion by 2011,is the nationwide crisis of emergency department overcrowding. More than $18 billion is wasted annually on unnecessary visits to the ER,with volume rising by 32% and wait times almost doubling to one hour during the past decade.Relieving this strain will be critical to any health care reform.

via www.kevinmd.com

My mom called me this morning. Yesterday she fell while walking and her right hand hurts at the base of the thumb.

We skyped this AM and it looks bruised and swollen. It hurts a lot and she's worried about long term complications if she delays treatment.

Today is Saturday. She lives in NYC.

I advised her to call her PCP. He called back promptly and recommended going to the emergency department. [I want to be very clear that this is an excellent doc operating in a system that does not support exemplary primary care. Exemplary primary care is punished by current payment policies.]

I checked out an orthopedics text and read up on 'fracture of the base of the thumb metacarpal' and found nothing her scenario that indicated the need of an emergency room visit.

Looking on line I find no orthopedist with weekend office hours.

I curbside consult an orthopedist who tells me that as long as my mom is not exhibiting certain specific signs (we go through a list & she has none of them) then the most the ED will do is put her in a splint and recommend she follow up with ortho on Monday.

I talked my mom through the splint, linked her to a video on Thumb Gutter Splint from Ottowa and gave her the signs of bad stuff.

This is basic primary care:

• Access when and how you need it
• Relationship (I know she's very capable and can build a splint and can recognize the bad signs)
• Comprehensiveness - willing to take on the bulk of people's needs and recognize the right time to call in specialists
• Care coordination - I can take the time and do what's right for her regardless of the fact that I'm in Seattle and she's in NYC.
  

This is how we decompress the emergency department. Fully functional primary care is an essential part of the solution.

Fund primary care so we are loosed from the fetters that bind us to a dysfunctional system.  If we shift 5% of the current funding pie to primary care we can fully fund exemplary primary care - the necessary technology, teams, expand the supply of primary care by making it a less repugnant career choice for medical students (and remember that this 5% funding shift is more than offset by 15-20% net savings).

Stop the stupid policies that equate only 'office visits' with meaningful care.

We in the profession have to get over our knee-jerk "go to ED" mentality and think instead: "What does this patient really need?"

Comments

[Raymond Zakhari, EdM, MS, NP-BC]

After having worked in various ERs, insurance companies, long term care, home care, and the battle field I have realized how much care can be done in the home and on a less costly out patient basis. I also realized how much time and money is wasted in the traditional health care system in bureaucracy.

In July 2009 I founded a web-based primary care medical house calls practice in Manhattan. I offer patients same or next day appointments with some holidays and weekends. Established patients can have email consultations and web-cam appointments as appropriate. I use e-prescriptions to pharmacies that deliver, and to home x-ray companies that can do EKGs, plain films and ultrasounds. I draw my own labs and use a house call lab service to draw labs that don't require a visit from me, and I use a PT company that makes house calls for part A and B medicare.

I also openly list my prices on my web site, and I still get patients that call asking if I take insurance. Upon finding out I don't they then tell me they are going to go to the ER for their sore throat, colds, and other ailments. (Because it only costs them $50 of a co-pay) and if they don't have insurance no payment is collected at the time of service so it's "free" one patient told me.

Another interesting thing I've observed is people have come to expect long wait times and endless forms, and are somewhat suspicious of hassle free care. All the "forms" are online.
The practice is called Metro Medical Direct.

[Jean Antonucci]

:)
Nice story.

1, Nuclear fire immediately says oh but specialists would be needed to be paid for curbsides .
And we say the PCP should be paid .For curbsides -I mean our work.
and we can end up at each others throats again
This is so wearying

2 Yeah it would have been nice if the PCP did what the son did but
then
really Dr Moore
with her right hand broken she watched a video using words like proximal and distal and wrapped herslef up in a splint??
Hmm. Get her to do the blogging, she must be incredible:)
Hope she is better.( will she get a new PCP? Is she on calcium and D ? what if she falls and can;t get up? Does she carry a cell phone? My PCP instincts takeover...I want to drown proof her)

[L Gordon Moore]

Excellent point Nuclear Fire, I agree completely.

In an overly simplistic scenario there are two stages of work that reduce use of unnecessary downstream services:
1: The PCP has the time, team tools to do more robust work for their patients. They can take the time to look things up, assess more deeply, treat more effectively.
2: The PCP works more collaboratively with specialists. Timely communication, timely access, and funding to support non-visit work in the PCP as well as specialty office can form the foundation of what have been called service agreements.
I suggest (and suspect you would agree) that both are important, both would reduce the chances of a patient receiving unnecessary interventions that may increase their risks and drive up costs without improving outcomes.
Gordon

[Nuclear Fire]

Your example would still require specialists you could curbside. One for a colleages mom is nothing, but enough of those and they'll eventually want to get paid for it.

[thuc]

great post gordon ! it made me step back and think of what more i could do in cases like that. hope i can be like that after residency.

[Gary Seto]

Gordon,
Hope your Mom recovers soon!