ER docs order tests to avoid lawsuits first, help patients second and Emergency care, but not at a hospital

CAL/AAEM News Service at
Mon Jun 20 12:19:26 PDT 2011


May 26, 2011
ER docs order tests to avoid lawsuits first, help patients second

Fierce Healthcare
By Alicia Caramenico
A patient's best interests may not be motivating emergency room doctors to order tests as much as self-protection from medical liability lawsuits, a new survey from the American College of Emergency Physicians finds. More than 50 percent of roughly 1,800 ER doctors said the main reason they order the number of tests they do is fear of being sued.

Until such fear is alleviated, overtesting is likely to continue to cost big bucks to patients, as well as the overall healthcare industry. Almost 49 percent of ERs docs said diagnostic testing accounts for the biggest expense on a patient's ER bill.

Moreover, such defensive medicine can cost anywhere from $60 billion to $151 billion a year, according to ACEP President Sandra Schneider. "That dwarfs total expenditures on emergency care, which at $47.3 billion in 2008 represented just 2 percent of all healthcare spending," she said in a statement.

In order for hospitals to trim expenses, they must address medical liability issues, as 44 percent of ER docs consider fear of lawsuits the biggest challenge to cutting ER costs.

While defensive test ordering is boosting costs, it also--more alarmingly--is endangering patients' health. Recent studies have shown that the use of CT exams in emergency departments has significantly increased, along with the exposure to high-dose ionizing radiation.

ACEP suggests that hospitals look to tort reform enacted in Texas, which capped non-economic damages and saw a drop in healthcare costs and an improvement in patient safety.

Dr. Arlo Weltge, a Texas-based physician, agrees, saying the state's reform changed how he practices medicine. "Now if a young patient comes in with what is essentially a bonked head, I feel like I can have a reasonable discussion with the parents without feeling pressured to order a test," he told the Huffington Post.

May 31, 2011
Emergency Care, But Not At A Hospital

Kaiser Health News
By Michelle Andrews

Emergency departments are struggling to keep up with demand, serving a growing number of people at the same time that their numbers are shrinking. One increasingly popular option to improve access to services is the freestanding emergency department, a facility that, as its name suggests, isn’t physically located with a hospital.

Services at these facilities get high marks, but questions remain about whether they’re the best choice for some serious medical problems, such as heart attacks. And some policy experts say the facilities may not be serving the people who need them most.

Since 1990, the number of hospital-based emergency departments has declined by 27 percent, according to a study published in the Journal of the American Medical Association in May. Meanwhile, the number of visits to hospital emergency departments has been on the rise, increasing 30 percent — to 123 million — between 1998 and 2008 alone, the study found.

Freestanding emergency departments originally emerged to serve people in rural areas where access to emergency care was scarce. But in recent years, freestanding EDs have often been cropping up in fast-growing suburban areas where the need isn’t always as clear.

"It seems that now they’re being aimed at populations that do have a fair amount of access to health care already," says Emily Carrier, a senior health researcher at the Center for Studying Health System Change, who is also an emergency physician.

Experts say that, in an effort to muscle in on a competing hospital's ED and siphon off some of its patients, health care systems sometimes build freestanding EDs even if there are already adequate emergency services nearby.

Whatever the reason, they’re on the rise: In 2009, there were 241 freestanding emergency departments, 65 percent more than there were just five years ago, when there were 146 such facilities, according to the American Hospital Association. They’re located in at least 16 states, according to a study for the California Healthcare Foundation.

Care That's Close By

One Saturday evening when Phil Dyer was puttering around the garden of his home in Issaquah, a Seattle suburb, he felt his heart begin to race, and his throat constricted so much that he could barely breathe. His wife drove him to the emergency department, a freestanding facility two miles away that’s operated by Swedish Medical Center, a health care system with four acute care hospitals and three freestanding EDs.

Whisked directly into an exam room, the doctor checked him over and determined he was probably having an allergic reaction to a bug bite. He gave Dyer, 58, a shot of epinephrine and sent him home. The whole process took less than an hour. Before the Issaquah ED was built a few years ago, the nearest emergency department was at a hospital about 12 miles away, says Dyer. Having emergency care so close is "reassuring," he says. "It was always disconcerting that we had to go so far [before]."

Unlike urgent care centers, which are limited in their hours and services, freestanding EDs are generally open 24/7 and are capable of handling most emergencies, say experts. Generally operated by larger health care systems, they’re staffed by emergency physicians and nurses, and typically have lab and radiology services on site. They can stabilize and provide initial treatment to patients with a wide range of emergent problems.

They often have arrangements with local emergency medical services personnel to deliver patients elsewhere who need services not available at the facility. "If they diagnose you as having a heart attack, they’re going to bypass our freestanding ER and go straight to the cath lab at the hospital," says Dr. John Milne, vice president for medical affairs at Swedish Health System, referring to a catheterization lab, where hospital personnel can insert a cardiac catheter to diagnose and treat heart problems.

While it's certainly important to know where the nearest emergency department is, there’s no easy way for consumers to know what specific services are available there. If someone is facing a true emergency, let the pros sort out where you need to go, say experts. "If you're having chest pain, you really ought to call 911," says Dr. Sandra Schneider, president of the American College of Emergency Physicians.

Many times, however, the situation is not so dire. A third of patients who visit the emergency department have problems that are considered non-urgent or semi-urgent, according to the Centers for Disease Control and Prevention (confirming). In those instances, patients would be better off visiting an urgent care center or their primary care provider, if they could get an appointment (a big if, in many cases). That would likely save patients a pricey copayment for an ED visit and would also be a more cost-effective use of health care resources overall, since insurers pay a lot more for emergency department care than they do for a visit to an urgent care center or a primary care provider.

Hospitals, meanwhile, market their freestanding EDs for their convenience and short wait times. And indeed, since acutely ill patients are often diverted to hospital-based emergency departments for care, it’s not surprising that waits are generally much shorter at freestanding facilities, where door-to-discharge times may be 90 minutes or less, compared with 180 minutes for hospital EDs. Whether a shorter wait results in actual health benefits isn’t always clear, however, say experts.

"There are some data showing that long wait times are a problem for some medical conditions," says HSC’s Carrier. "But it’s not necessarily clear that consumers will see improved health if they don't have to drive an extra five minutes.".

Anna Parks &
Brian Potts MD, MBA
Managing Editors, CAL/AAEM News Service

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