American ER Doc Gone Walkabout Episode 019b
I’d like to step way out of character, and be serious for a moment:Many thanks to ACEP and the media relations folks. They provided me with press credentials that gave me a bunch of freedom to wander in and out of sessions, and around the convention (despite being at the conference for a limited amount of time since I was working shifts). One of the conditions that we agreed, in order for me to wear the press hat (as LITFL’s one and only correspondent), was that I “not learn anything.” That both allowed me and forced me to step out of my usual role, and observe the process and context of the meetings, rather than the content of the lectures. It was an interesting project and made possible by the generosity and helpfulness of ACEP and their staff.
Thanks a giant bunch, ACEP and media relations.
So, on to a few thoughts from days 2 and 3:
I thought that, as LITFL’s roving reporter, I ought to go to the press conference. There we (the press – I love how that rolls off the tongue) learned what ERP’s “know” even if we can’t recite the numbers: Frequent Flyers (by a more socially acceptable terminology) often have chronic illness, or drug and alcohol issues, or psychiatric problems, and are often homeless. They are either relatively frequent visitors, or pretty rare – depending on whether you believe that the glass is 1/4 full, or 3/4 empty. We may not have been aware that they frequently drop from sight after a year or two of frequent visits.
ACEP emphasized that ERP’s are the only ones there to help them when they have a crisis, and that the crises are often pretty bad – 50% get admitted. (They didn’t point out the possibility that some admissions may be of the nature: “Oh, him again, I don’t have the time or energy to spend 8 hours playing with meds and drips to get him out – and by getting him out the door, removing my potential to bill for critical care, since no one critically ill could possibly go home after even the most expert care. I will get paid the same, and have far less brain damage, if I spend 30 minutes plus a phone call to the admitting team rather than spending 8 hours of ED treatment.)
(A note to my Aussie and UK friends: those of us in the advanced, market driven medical economy of the US may not think of such things explicitly, but I would be profoundly surprised if a functional MRI scan done during the care of many patients, did not “light up” in the shape of a dollar sign. I am so sorry that you guys don’t have the opportunity to have your medical care affected by such considerations. Keep reading for more economic jaw droppers, my upside down friends.)
There may have been more than just science here. Medicare (often followed shortly by all insurance) has proposed financial penalties for any patient readmitted within 30 days – the presumption being that superb medical care would prevent such readmits. Ignoring the role played by inability of the patient to buy his discharge medications after the initial supply runs out, inability to see a doctor in outpatient followup, inability to afford healthy low salt foods, and inability to find somewhere to stay.
A variety of sessions dealt with issues of management, efficiency, and coding/billing. Chaos management seemed to be a common topic, with that popular subtopic: boarding. Nobody but a true cynic would believe that there’s a plan to the shortages (just like nobody believed that Enron would intentionally cause electrical shortages in California), and I’m not that cynical, but a true cynic might believe something like:the best way to assure high bed occupancy (and therefore, better net income) is to have a queue of ready bed occupants waiting in the ER waiting room. So, to be sure of a good bottom line you should under-build and under-staff. But then, to improve net a bit more, write a contract with your ED physician group that provides bonuses or penalties based on patient satisfaction scores. But, of course, if people have to wait in the waiting room, live on hallway stretchers, wait for days to go to the floor, when they get that survey – they’ll take it out on the Doc, who will then lose his bonus. Bingo! Couple birds with one stone: save capital costs by underbuilding, save staff costs by understaffing, improve occupancy rates and thus net, and finally save money when the “planned fail” kicks in costing the ERP’s a bonus for patient satisfaction.
Naw, that couldn’t happen – only a cynical conspiracy theorist could believe that.
More later, mates.
Next time: The Final News from #ACEP12
American ER doc