Misuse of Medical Services

The concept of misuse of medical services is being debated quite vigorously on a couple of the medical blogs that I like to read regularly. Look here and here. The question is simple: What constitutes proper use of the emergency department? The answer is unclear and the debate is hot. I thought I would weigh in. The post is somewhat lengthy...

I spent my last two years of medical school working in an urban ED in my "spare time." I have definitely seen my fair share of low acuity patients, and even spent some time trying to figure out why a nineteen-year-old mother of three would call 911 and bring herself and her children into the ED to be evaluated for a non-productive cough for less than 24 hours at 3AM. Of course, every patient who comes to the ED for tooth pain has talked to a dentist, but couldn't get in to be seen and every patient who ran out of their narcotic pain medications cannot get an appointment to see their "regular doctor" until 3 weeks from now.

Of course, there is that perception of what is and is not an emergency. Patients do not have the 1-5 triage system memorized and most of them lack advanced degrees in health care. EMTALA doesn't help. Although only a screening exam is "required," it's important to point out that most people that I have encountered believe that the mandate has become much greater than that. I believe that after their "screening medical exam," we should be able to point a patient towards a different venue of care, say back to their PCP or to a neighborhood clinic. I understand that, at times, real emergencies can present with non-threatening symptoms, and I would be interested to see how the number needed to treat comes out.

There is another issue here. Access to care is becoming much more complicated. Today, I read an article which said that the average wait to see a physician (in both primary care and sub-specialties) has increased by almost one week since 2004. This is especially true for patients who cannot afford private insurance. I'm not sure that I would be willing to wait 24 days to be evaluated for my fever and sore throat. If I had strep pharyngitis, I may already have rheumatic fever by the time I can be seen. Then, I'd have to sue my PCP for not being able to see me - and why not do my part to increase the cost of medical care in our country.

I'll tie it all back to education. We need to be explaining to our patients - in a respectful way - what is appropriate use of the ED and the cost associated. We need to make our patients aware of the fact that they are required to pay for our services. The orthopaedic surgeons in my area catch a lot of flack for requiring patients to pay before they are seen. I see both sides of this coin. I have been in school for 21 years and have 5 years of residency and one or two possible year(s) of fellowship ahead of me. It seems reasonable that I should be able to collect a fee for my services. I'm not sure I need to collect it right as the patient walks in the door, but I should be getting paid, and I'm not talking Medicaid rates either. No self-respectable lawyer (aka lawmaker) in this country would accecpt such an insult. Last I checked, members of congress were still giving themselves raises and doctors haven't gotten a raise for almost as long as I've been alive. I know, I know, we make enough money all ready, but the double standard seems a little insulting some times.

Maybe we could establish a system where, let's say level 1 and 2 patients are brought straight to a room without a discussion of costs. Every other patient will at least be advised of the necessity that they pay for their care and be given an option to instead follow with their primary doctor or perhaps go to the ED a the hospital where thre care is assigned (and medicaid - or its equivalent - will actually pay something for their visit). When a patient comes to the ED to request a UPT, the admitting clerk should be able to hand the patient a cup and show them the restroom. The patient should also be informed that they will be allowed to wait in the waiting area for their results, which will be provided after they remit a $50 fee.

I don't think that, in the end, I have a problem with patients using the ED for non-urgent care, but they need to be willing to pay for it. Similarly, I don't care if rich people fly on private air plans - but I don't expect to have to foot the bill...