Does Your ER Deliver?

Nationwide, we're turning our hospitals, which were previously focused on providing high-quality medical care, into service-oriented hotels with the focus on "customer satisfaction", complete with valet parking, concierge service and lobbies that rival the Hyatt in aesthetics.

While this is not necessarily a bad thing in and of itself, the impact of the culture shift from seeing the people we treat as patients and turning them into customers is a difficult transition to make at best and dangerous at worst. When the focus shifts from treating the patient in the best manner possible to making sure the atrium is well-lit and there are no glitches in getting a "customer's" bags to a room, the cost of health care only goes up. Can quality still be emphasized simultaneously?

Now, that hotel-style trend is going to the emergency room.

ERs across the country are now offering various forms of financial remuneration for extended wait times. Tickets to sporting events, movie passes, meal vouchers, along with written apologies, are being offered to patients and their families who do not receive treatment in under thirty minutes.

In a country in which the average door-to-door time is 240 minutes, or 4 hours, receiving treatment in 30 minutes is really just a marketing ploy. Your ER physician can see you in 30 minutes, but that does not mean that your lab tests, X-rays or any other ancillary testing will be done any sooner than if you had waited in the lobby during that time.

Regardless of when the physician sees you and orders testing or therapies, there are still just as many people ahead of you in line as there was when you checked in, assuming the same triage level. Moreover, there will still be people coming in after you that will be treated ahead of you due to their acuity.

The final kicker, however, is the cost of the remuneration. Yes, those meal tickets or movie passes are included in the price of your admission to the E.R. And, with the rising number of ER visits per year, the opportunity to "earn" your movie passes is more and more likely.

According to the recent Press Ganey survey of ER wait times, Patient Perspectives on American Health Care, patients (and I use that term intentionally) tend to be more satisfied in emergency rooms who see fewer people. The more patients an ER sees, the less satisfied those patients are. The same survey also states that patients tend to be less satisfied with the care they receive during the 3:00-11:00 pm shift, being most satisfied with care provided between 7:00 am and 3:00 pm. Everybody knows that the evening shift is the busiest in the emergency department, so the satisfaction level goes down with the surge in patients.

When the Emergency Medical Treatment and Active Labor Act (EMTALA) was passed in 1986, hospitals that had been turning away patients based on inability to pay were no longer able to do so. The result has been disastrous for ER's. I am not saying that people should be turned away from the ER if they don't have insurance, but I am saying that there was no provision in EMTALA for reimbursing ER's for the care they provided.

Between the fact that Medicare and Medicaid do not reimburse hospitals enough to break even on medical services provided and the fact that the underinsured and uninsured often fail to even set up even minimal monthly payment schedules for services rendered, emergency departments are operating at a deficit to start with. Currently, private insurers are denying emergency room visit claims for a variety of reasons, including omission of notification of the insurance provider prior to ER admission, inappropriate use of the ER (for a variety of listed conditions for which the insured should be making an appointment with a primary physician such as a sore throat or cough) and so on. It is not uncommon for hospitals to lose $140,000 and up annually just in providing emergency services to the community.

As a result of EMTALA, from 1995 through 2005, emergency department visits went up 20%, the bulk of these visits in the non-urgent to urgent (need to be seen in the next 24 hours) categories. During that same time frame as a result of no-pays and under-reimbursement, 38% of the nation's emergency departments closed permanently, leaving their neighbors to shoulder their share of the increased patient load.

Also, the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) inadvertently affected ER wait times. HIPAA set standards for patient privacy and once the act was in place, many hospitals did away with semi-private rooms in order to be HIPAA compliant. Fewer inpatient beds are available. When the inpatient beds are full, patients are held in the ER longer, in some cases 24 hours or longer.

In a nutshell, we're doing more work with less remuneration which results in less staff and fewer resources. You get meal vouchers and movie tickets that wouldn't be necessary if we were reimbursed for the care we provided in the first place, had fewer people abusing the emergency room and were able to move patients to appropriate inpatient settings.

Do you want to help fix the problem and be happier with your treatment? Here are some strategies and tips for your next minor illness or injury.

1. Ask yourself, "Do I really need to go to the emergency room? Or should I make a clinic appointment?" Call your primary provider and ask for his or her advice. All doctor offices have a physician on call for the group 24 hours a day. Use them. That's what they're there for.

2. If you don't have a primary physician, get one. Establish a relationship with a regular physician who knows you and your health history. By using the emergency room as your primary health care source, your health history is divided into bits and pieces that make it tremendously difficult for us to treat you in a real emergency. By having a primary physician that you see on a regular basis, it makes it much easier to figure out how to help you. The average clinic visit costs $85, the average ER visit $450. Which bill would you rather pay?

3. Utilize your region's Ask-A-Nurse hotline. The Nurse Hotline in Des Moines, Iowa is currently fielding over 3,000 calls a month, helping people choose the most appropriate care for themselves and their families.

4. Be familiar with your insurance and its requirements. If there is a hotline number to call to notify the carrier that you're arriving at the ER, use it. Generally, we will only contact your carrier if you are admitted to the hospital.

5. Do not come to the emergency room during peak times. If you cannot get into your doctor's office that day, don't wait until 5:00 pm to come in. Get to the ER during the day. Your wait time will be shorter and you'll be happier with your service.

6. Don't choose the busiest ER in town to visit unless it's the closest hospital and yours is truly an emergency. If it is, you should be calling 911. If it is something that should be seen in the next few hours and you have the ability, use another, smaller ER elsewhere in your city.

7. Go to an emergency room at a hospital with which your doctor is affiliated and has admission privileges. Understand that your care will be delayed if your doctor is not affiliated with our hospital, especially if you have to be admitted, because we cannot have your regular doctor participate in your care.

8. Remember that we want to help you. We don't mind that you come in with a condition that's not emergent. Non-urgent and urgent conditions are our bread and butter. It's how we stay employed and pay for our kids' soccer cleats. Most of us really do care and we want to be able to spend more time with you, so if you have any questions about the care you're receiving, stop us and ask!

9. Bring a list of your medications and dosages and your allergies. Know your own health history and be able to tell us when you've had surgery and what for. This is the most basic vital information we need in developing a treatment plan for you and your care can be delayed when your pharmacy is closed and we have no way of finding out what medications you take. Medications interact with each other differently and we won't easily be able to prescribe anything for you safely without knowing what you've already taken today.

10. If you're seen in the emergency room and don't have insurance and aren't sure whether or not you'll be able to pay, let us know. We'll be happy to refer you to people that can help. All hospitals have a business office or finance office that is in charge of making financial arrangements. Most hospitals have a social worker or financial advisor on staff that can discuss options with you while you're still in the ER. Some hospitals have a foundation set up from which funds can be drawn so your bill can be discounted or forgiven completely.

We're doing everything we can to make you feel as though you have received the highest-quality care you could've gotten. But some of the responsibility of your own satisfaction falls on your shoulders. We are the health care safety net. We are the last resort.

Our administrators would do well to remember that as well. Thirty minute guarantees are for pizzas.

So, will that be thin crust or deep dish?