What is an ER?
ERP and I had a discussion yesterday that raised some interesting questions which I believe warrant further consideration. His post was about the frustration with the unpaid mandate of EMTALA and the related lawsuit by some California physicians seeking increased reimbursement for their treatment of Medicaid patients.
He complained that since ER docs are legally required to see these patients, it isn't fair that we aren't reimbursed adequately for our services. I reminded him that a new model of emergency medicine is emerging, the freestanding ERs, some of which do not accept Medicare or Medicaid and therefore are not legally required to follow EMTALA. His position is that such facilities are not really ERs at all, that it is our duty as emergency physicians to see every patient that presents for care whether they have the inclination or ability to pay us or not, and if we do not treat all comers then we are not practicing Emergency Medicine.
Perhaps he is right, but one could make the same moral argument for all physicians regardless of specialty. Shouldn't all physicians have the quality of beneficence? Yet only emergency physicians and those specialists taking ER call for a Medicare-participating facility are legally required to provide unreimbursed care. When we try to define the essence of the practice of Emergency Medicine, are we talking about the legal requirement or a moral requirement?
The legal requirement is undefined. A facility may provide emergency medical services without being open 24 hours a day or 7 days a week. There is no legal requirement that an ER must be physically attached to a hospital, affiliated with a hospital, certified by JCAHO, or even staffed by trained or experienced emergency physicians. Board certification is certainly not required, whether in EM or by any other specialty. And, perhaps most importantly, there is no legal requirement (yet) that any ER, physician, or medical facility accept Medicare or Medicaid.
Some rural ERs are reportedly staffed by a single unsupervised physician assistant, according to one of my commenters. Others are not supported by adequate hospital facilities to manage complex injuries or illnesses, so the sickest or most injured patients must be transferred elsewhere. Most hospital-based ERs without comprehensive specialty backup must at least occasionally transfer neurosurgical injuries, ophthalmic injuries, penetrating trauma, pediatric cases, or a variety of other conditions based upon the expertise of their medical staff or the whims of their call schedule. Others must transfer patients when there are no available inpatient beds. Is such a facility more of a "real ER" than a for-profit freestanding ER with similar staff, more sophisticated equipment, and superior specialty backup? Of course not.
What of the case of the University of Chicago ER, who technically followed EMTALA when they medically screened, stabilized, and discharged the boy whose lip was bitten off by a pit bull? They certainly met the legal definition of an ER that night. In some cases, EMTALA causes us to provide worse care than if that law didn't exist. When an ER whose hospital has no trauma surgeon on staff receives a walk-in patient with a gun shot wound, they often waste precious time "stabilizing" the patient and trying to find an appropriate accepting hospital when the patient might be better served by simply calling 911 from the lobby and sending him immediately to the nearest trauma center. When a patient who has been sexually assaulted presents to an emergency facility without the properly trained staff to collect forensic evidence, she doesn't need to wait 2 hours for a receiving hospital to send the transfer paperwork, she needs to be directed to the proper facility without causing her any more discomfort and delay than necessary.
Following natural disasters, I've worked in emergency departments (yes, pleural) without power, using a headlight to find my way down the hallway. We had no X-ray or laboratory facilities whatsoever, so for those weekends we were essentially practicing 19th century emergency medicine. And yet we were still an ER, both by my definition and ERP's, because we turned no patient away. All you really need in an ER is a good doctor, a good nurse, some basic equipment, and good sense. Increased assets make some ERs more capable than others, but the underlying job is still the same: diagnose, stabilize, and make a proper disposition.
I don't think that emergency physicians should be held to a higher moral standard than physicians of any other specialty, and I believe that all physicians who choose not to work for the government should have the right to refuse to treat any patient. Of course we can and will continue to provide charity care, but we will do so because we are compassionate physicians, not because the practice of Emergency Medicine specifically requires it of us. By refusing government subsidies and freeing ourselves from the requirements of EMTALA, we will be empowered to control the frequency and volume of our charity like other citizens.
He complained that since ER docs are legally required to see these patients, it isn't fair that we aren't reimbursed adequately for our services. I reminded him that a new model of emergency medicine is emerging, the freestanding ERs, some of which do not accept Medicare or Medicaid and therefore are not legally required to follow EMTALA. His position is that such facilities are not really ERs at all, that it is our duty as emergency physicians to see every patient that presents for care whether they have the inclination or ability to pay us or not, and if we do not treat all comers then we are not practicing Emergency Medicine.
Perhaps he is right, but one could make the same moral argument for all physicians regardless of specialty. Shouldn't all physicians have the quality of beneficence? Yet only emergency physicians and those specialists taking ER call for a Medicare-participating facility are legally required to provide unreimbursed care. When we try to define the essence of the practice of Emergency Medicine, are we talking about the legal requirement or a moral requirement?
The legal requirement is undefined. A facility may provide emergency medical services without being open 24 hours a day or 7 days a week. There is no legal requirement that an ER must be physically attached to a hospital, affiliated with a hospital, certified by JCAHO, or even staffed by trained or experienced emergency physicians. Board certification is certainly not required, whether in EM or by any other specialty. And, perhaps most importantly, there is no legal requirement (yet) that any ER, physician, or medical facility accept Medicare or Medicaid.
Some rural ERs are reportedly staffed by a single unsupervised physician assistant, according to one of my commenters. Others are not supported by adequate hospital facilities to manage complex injuries or illnesses, so the sickest or most injured patients must be transferred elsewhere. Most hospital-based ERs without comprehensive specialty backup must at least occasionally transfer neurosurgical injuries, ophthalmic injuries, penetrating trauma, pediatric cases, or a variety of other conditions based upon the expertise of their medical staff or the whims of their call schedule. Others must transfer patients when there are no available inpatient beds. Is such a facility more of a "real ER" than a for-profit freestanding ER with similar staff, more sophisticated equipment, and superior specialty backup? Of course not.
What of the case of the University of Chicago ER, who technically followed EMTALA when they medically screened, stabilized, and discharged the boy whose lip was bitten off by a pit bull? They certainly met the legal definition of an ER that night. In some cases, EMTALA causes us to provide worse care than if that law didn't exist. When an ER whose hospital has no trauma surgeon on staff receives a walk-in patient with a gun shot wound, they often waste precious time "stabilizing" the patient and trying to find an appropriate accepting hospital when the patient might be better served by simply calling 911 from the lobby and sending him immediately to the nearest trauma center. When a patient who has been sexually assaulted presents to an emergency facility without the properly trained staff to collect forensic evidence, she doesn't need to wait 2 hours for a receiving hospital to send the transfer paperwork, she needs to be directed to the proper facility without causing her any more discomfort and delay than necessary.
Following natural disasters, I've worked in emergency departments (yes, pleural) without power, using a headlight to find my way down the hallway. We had no X-ray or laboratory facilities whatsoever, so for those weekends we were essentially practicing 19th century emergency medicine. And yet we were still an ER, both by my definition and ERP's, because we turned no patient away. All you really need in an ER is a good doctor, a good nurse, some basic equipment, and good sense. Increased assets make some ERs more capable than others, but the underlying job is still the same: diagnose, stabilize, and make a proper disposition.
I don't think that emergency physicians should be held to a higher moral standard than physicians of any other specialty, and I believe that all physicians who choose not to work for the government should have the right to refuse to treat any patient. Of course we can and will continue to provide charity care, but we will do so because we are compassionate physicians, not because the practice of Emergency Medicine specifically requires it of us. By refusing government subsidies and freeing ourselves from the requirements of EMTALA, we will be empowered to control the frequency and volume of our charity like other citizens.
Labels: ER, health care crisis, rants
posted by scalpel at 2:42 PM
19 Comments:
How will your facility arrange for a hospital admission? I think it's icky if all you do is send them to a "real" ER despite the patient having a diagnosis and work-up complete. Huge pet peeve. I think to be legit, there has to be a really obvious partnership with some receiving hospital/hospitalist group where patients can be admitted w/o needing to stop in another ER.
A freestanding ER can transfer or arrange a direct admit to any hospital the patient chooses. Remember, all (or most) of these patients are insured, so it's no trouble finding an accepting hospital, and there is no reason to require a specific partnership with any particular hospital.
An agreement could be beneficial to guarantee acceptance of the rare uninsured patient, but it is unnecessary.
I don't know enough to say what an ER "should" be, but to give special moral requirements to ER physicians doesn't make a lick of sense.
It was a good discussion - however, the main point to my post was to illustrate the lawsuit filed by 5 ER doc groups in California against the state for underfunded but mandated care for medicaid patients. (see my post on my site for the reference) The arguement they gave is that by definition of their job (ie Emergecny medicine), if they are to work where their training intended (a "real" ER that has to follow EMTALA), they are treated differently than any other physicians in that they are forced to accept low medicaid payments for the mandated EMTALA care. This apparently violates the California constitution - so I guess for the sake of this arguement, one would have to argue that practising "Emergency Medicine" is defined as working in a "real" ER that sees everyone, accepts 911 calls, and falls under EMTALA. Since no other physicians are forced by definition of their training to follow EMTALA (they can chose to solely work in an office and or not take ER call), ER docs are singled out unfairly under the law. At least that is the lawsuit's allegation. We shall see how it plays out.
Defining our specialty by the restrictions of a bad law does not seem to be in our best interests.
Is a "pleural" ER one that only sees pulmonary patients?
Heh. Missed that one.
I tend to think it's a hard to make an argument that you're a "real" ER if you don't accept ambulances nor elderly patients (at least those on Medicare which is most). Doesn't mean you can't make money doing it (ie charging $700 for strep instead of $200 or whatever a clinic would charge for the same service) or that it's not an appropriate choice for minor emergencies, but it's still not what I would call an ER.
Regardless, every ER doc in California (and everywhere else) shouldn't be expected to abandon working for a hospital to start their own freestanding ER or work in an urgent care if they want to be free of the laws that prohibit them from getting paid for their services. That's just obviously silly.
There is an urgent care clinic up here that is open 24 hours and had lab, XR available. They had the big, red "EMERGENCY" sign and people in the area came there with the usual urgent care stuff, but many came with heart attacks, etc, thinking it was a "real" emergency room due to the sign. They could do the ASA, nitro, and IV, etc and would ship them to us for admit. All the docs and nurses are ACLS/PALS-trained. They do not accept ambulances.
They were told by the city and state to remove their emergency sign because they were not an emergency facility and people were being misled by this. It sounds quite similar to what you were proposing.
It was billed as an office visit/urgent care visit, not an ER visit.
What is the difference between this urgent care and your place?
1) We do accept ambulances. We don't get many.
2) We do treat heart attacks and strokes and anything else that a hospital-based ER treats. We admit patients directly without shipping them to another ER.
3) We bill as an ER visit, not an office visit or urgent care visit.
4) We're not in a lame-ass yankee state.
Wow Scalpel, you are calling K a Yankee??!? Them's fightin' words in TX I imagine.....
Not sure what an ER is or is not, but I guess I know where I'm working if/when I go back to college...Wow, paid homework AND blogging time (you better not firewall my blog, Jerk).
dear sabra, please define for me the 'special requirements of ER physicians' and from whence you gleaned this 'special requirement'.
communism is on the march.
Couple of points:
1: "We're not in a lame-ass yankee state."
I believe those lame-ass yankee states kicked your state's ass when they tried to secede? Correct?
2: Though I think there is a valid argument here, I do want to point out one thing that is slightly off topic. I have NEVER EVER met an ER doc in danger of going under. Though medicare and medicaid under-bills (certainly no argument there). Payment structure is such that I have always found ER docs when the day is over bring home a reasonable salary for all their hard work. You can quibble about whether it should be more, point taken. I can't say the same for general internist's and FP's (I am not one). Medicare/medicaid has these poor sods so far under the screws that they lose money unless they are seeing patients every 10-15 minutes. They lose money everytime they give out a needed vaccine. Primary care is cheaper than going to the ER we all know that. But why scalpel do you see so much primary care which you aren't really trained in doing? The system is broken. The answer I see bantied around is to pay everyone LESS (oh yeah maybe giving the PCP an extra 5%...BFD.). The powers that be don't get it.
Excellent article. Interesting comments. You all have a special place in my heart. Keep up the good work!
1) The Union was unsuccessful in every single attempt to invade Texas, and generally got their asses kicked every time they tried.
2) A "reasonable salary" is not necessarily a desirable salary, but I would agree with you that the system is broken. That's why I'm trying to leave the system.
3) I am trained in primary care, but I choose to practice emergency medicine instead.
Counterpoint
1: Winning a battle (actually skirmish)is not winning a war.
2: I too was "trained" in primary care internal medicine. I then subspecialized. I am not so arrogent to think that my training well over a decade ago, makes me competent to walk into a primary care medicine clinic today. It is a fallacy perpetuated by those who think any ole NP or PA can walk out of school and be a "primary care provider". Or any doc from another field can just do primary care on the side. It just ain't so.
While I agree somewhat, I would submit that the subset of "primary care" complaints that present to an ER (or a fast track area) are generally of the acute variety rather than the preventive medicine cookbook variety. We really don't get many prescription refill requests, we don't attempt to follow or manage chronic problems, and we are hesitant to change medication regimens, for example. An acute exacerbation of a chronic condition is not an unreasonable cause for an ER visit.
So I consider the argument that we see a lot of primary care in the ER to be misinformed. Could a primary care doc handle some of it? Certainly. That doesn't make it primary care. Our specialty not only involves treating emergencies but also determining when a patient has (or just as importantly, doesn't have) an emergent condition.
"So I consider the argument that we see a lot of primary care in the ER to be misinformed. Could a primary care doc handle some of it? Certainly. That doesn't make it primary care. Our specialty not only involves treating emergencies but also determining when a patient has (or just as importantly, doesn't have) an emergent condition.".
I agree with most of this statement. However, we do get requests to do SOME primary care stuff- like med refills, requests for physicals or "allowed to return to work" notes, BP checks, etc. However, we can chose NOT to intervene in these depts since after screening for an emergent (or urgent) condition, we have fulfilled our obligation as ER docs and can politely tell the patient that we do not practise routine primary care and send them on their way.
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