“Go to the ER or call 911”

I’m getting up there in years.  Maybe not as old as some of my friends and mentors, but I’m getting there.  I don’t necessarily look back on the past as the “good ol’ days,” but I do recognize that things have changed — including medicine.  At the most fundamental level, our American system of healthcare, based largely on third party payment of insurance claims, has changed as well.

Years ago, if you got sick, you’d call your general practitioner and he’d make a house call.  As Medicare and Medicaid changed the reimbursement model (and private insurance adopted many of these standards), the house call became antiquated, so your doctor would meet you at their office, even after hours, to deal with an urgent matter.  As this model changed — and emergency medicine advanced — your doctor would meet you at the hospital ER.  Now, if you call your doctor after hours, you’re most likely to hear a recorded statement that says, “If this is an emergency, hang up and call 911 or go to the nearest emergency room.”

The result of this is that emergency rooms are crowded and EMS call volume continues to climb. The response from the emergency medicine world isn’t exactly inspiring.  Numerous individual EMS providers bemoan “911 abuse” for matters that aren’t “real emergencies.”  And now a noted emergency medicine physician-blogger has opined on “the go to the ER mentality of American medicine.”

Economics says that people are fundamentally rational. So, let’s take that approach.  If you have a medical problem and “do what you’re supposed to do,” you call your primary care physician.  With any luck, you’ll be able to get an appointment for an office visit in the next few days. If the matter is VERY simple and resolves quickly, you’re just out the copay for an office visit, assuming you have insurance.  If the matter is beyond the ability of what “evidence-based medicine guidelines” (AKA protocols for primary care medicine) allow for a primary care physician, you can expect multiple follow-up visits, referrals to specialists, and referrals out for lab work and imaging, all with their own separate copays and co-insurance.  Meanwhile, you’ve also lost time from work and your regular life as well because all of these visits have to happen between 8 AM and 5 PM on weekdays. Tell me how agreeing to “play by the rules” of American medicine is rational?

However, if you go to an emergency room, you’ll be seen by a physician trained in emergency medicine, which covers a wide spectrum of medical care.  You’ll also have access to lab studies, imaging, and, if warranted, consultation with specialists.  While the copay and coinsurance will be significantly higher, you are paying for access to a one-stop solution — and one that doesn’t require an appointment and is available 24/7. And if you call 911, you get a literal house call from a group of trained mid-level providers who show up with diagnostic equipment and medications that most primary care physicians don’t have in their offices — along with a ride to the above referenced emergency room where the majority of your medical needs can begin to be addressed.

Is emergency medicine, both in-hospital and prehospital, over utilized?  Absolutely?  What’s the solution?  I honestly don’t know.  I do know what doesn’t work — and that’s emergency medicine providers complaining about overutilization of emergency services.  In all likelihood, there’s probably no one solution. From the standpoint of business and economics, I’ve never known a successful business model based on telling people they don’t need your services and turning them away. Emergency medicine, both EMS and emergency departments, need to embrace their role as providers of unscheduled medicine to the masses.  Likewise, primary care, in order to remain relevant, needs to understand that not every patient’s needs can be scheduled two weeks from next Thursday and only during regular office hours. The problem is not an unequal or even inefficient model of healthcare delivery.  The problem is and remains a healthcare delivery system that is not meeting the schedule and demands of modern society.