THE ER: Will It Be There When You Need It?

Myles Riner, MD

Sooner or later, you will need the ER. I don’t care how healthy you are, how much you hate going to the hospital for care, how much you dis trust doctors or modern medicine, how rich you are or how deep in the woods you live. The odds are almost 100% that in your lifetime you will end up in the ER. You may get lucky, and find yourself in a hospital that is staffed by highly quali fied emergency physicians, backed up by a full roster of highly trained specialists and a bevy of great nurses, technicians, and the latest in diagnostic equipment and sophisticated operating rooms and ICUs and cardiac cath labs and all the rest. But don’t count on it. The odds are pretty good that in the very near future this is not what you will find. In fact, in many areas of the country, you may not be able to find this right now. Why is that?

Emergency Departments (ERs) and the folks who provide care in these facilities are generally devoted to meet ing a mission, actually, several missions. Providing care to everyone, 24 hours a day, 365 days a year, regardless of insur ance status or ability to pay for this care is one such mission, perhaps the most important one.

Another is providing surge capacity (the ability to gear up and staff up to meet sudden, unexpected surges in demand) in response to disasters, multiple casualty incidents, terrorist attacks, epidemics and pandemics, and the everyday situation where serious illness or injury strikes lots of different individuals in a community in a very short time span.

A third mission involves serving as a safety net for unfortunate members of the community who have no place else to turn for help—no readily available family, no outpatient psychiatric service, no safe place to shelter, no protection from abuse.

Another mission of the ER is to serve as the urgent diagnostic referral center for the entire medical system, allowing officebased physicians (and sometimes even hospital inpatient services) to send patients in for evaluation and stabili zation without having to disrupt their office practice and abandon patients who have been waiting for their scheduled appointment. Surprisingly, one of the missions of the ER is to keep patients out of the hospital by providing observation care and stabilizing treatment that often avoids the need for more expensive inpatient care. Patient edu cation, coordination of postdischarge care and followup, surveillance monitoring for contagious disease, even preventative care: all are part of the mission of the ER.

With so many roles to play, so great a need for flexibility and prepared ness, and so wide a range of services and skills that must be mastered and dis pensed, is it any wonder that visits to the ER continue to grow year after year, or that the number of hospitals able to meet all these missions has shrunk by the hundreds over the last decade?

You might wonder why a facility like the ER that is so critical in so many ways to our communities is disappearing at such a rate, and why excellence in fulfill ing these various roles is getting harder to find, or rely on. There are many reasons for this, but the underlying fundamental reason is that no one wants to pay to ensure that these missions are met.

Health plans don’t feel responsible for helping hospitals and emergency care providers to meet these missions. Legisla tors don’t want to put their reelection at risk by mandating funding or payment for these services. Insurance regulators aren’t willing to require health plans to fund these services lest they lose the chance to work in the future for the insurance companies they currently regulate. Consumer advocates and advocates for the poor want these services for free, or at the lowest possible cost, ignoring the fact that their constituents often rely on the ER as the only place they can reliably get the care they need. Many hospitals are living with such small margins that they just can’t afford to subsidize the ER to meet all these missions.

In this world, we get what we pay for, and if we aren’t willing to pay, we may not get anything. No one wants to pay anything more than the bare minimum for the actual care they receive in order to help the hospital and the ER staff meet all these missions: not the health plans, or the employers, or the consumers, or the government. Yet the government mandates that all these missions be met, particularly the first and most important, but in fact all the others, too. Talk about being caught between a rock and a hard place.

Maybe some of these missions can be met at lower cost—through greater efficiency, through sacrifice, through higher quality and fewer mistakes, through pension reform and union busting, through better technology and computer-driven information systems and volunteerism and telemedicine and all sorts of cost-effective care policies. We should try and currently are trying many of these approaches (though I would definitely not support all of them), and in fact many emergency physicians and nurses have worked very hard to implement cost effectiveness in the ER. However, it isn’t nearly enough to make up for the way third-party payers are ratcheting down reimbursement for ER care. As a result, this care will suffer, and already has.

If you need ER care—and you will— or if, heaven forbid, disaster or terrorism strikes and we really, really need our ERs to rise to the occasion (as seems to happen nearly every week), don’t be surprised if your local underfunded, understaffed, undersupported, underprepared and regularly overwhelmed ER fails you. And don’t blame emergency care providers. They are pedaling as fast as they can, and they warned you.

---

Dr. Riner, of Mill Valley, is a retired emergency physician who worked at Marin General Hospital. This article first appeared on his blog, The Fickle Finger (www.ficklefinger. net/blog) in May 2016.
Email: mriner@comcast.net