Of course much of the inpatient business would also not be there is the ED was not there as an entry point.
Which is not to say that individual EDs with particularly unfavorable payor mixes do not lose money. That is the case for some tertiary academic centers in poorer urban areas. Their profitable (privately insured) patients are coming in from feeder hospitals/referrals and from the pull of particular sub-specialty expertise … and their EDs feed in mostly Medicaid and the uninsured. Maximizing the former and minimizing the latter is required for them to survive.
Yikes! I hate to hear that stuff! Maybe the ED docs in your area are from a different generation and unwilling to change their practice. At the very least the PECARN rules for head injury are very clear on CT usage.
More consolidation of hospitals and services in general. But yes, those that are not making money shut down and those that are profitable expand.
Small urban hospitals have been closing in droves in general for many decades. Between 1990 and 2009 the number of hospitals overall has decreased overall by about 13%. The total number of beds are down by about the same amount and yet occupancy rate has still dropped. Smaller and mid-sized hospitals in urban areas that have not folded are not successfully competing in the ED space. The trend is not completely a bad thing: so long as there is still reasonable geographic access to Emergency Services a larger ED more fully backed up with specialty care as needed on that emergent basis will provide higher quality true emergency care and do it more efficiently. So yes some EDs have closed shop while others have expanded and redesigned. Having fewer EDs is not a bad thing so long as the community keeps up with the needs for ED capacity with fewer but larger high quality EDs efficiently operated.
I think one of the big drivers to close regional hospitals has been laproscopic surgery. That and a lot of other advances that have meant two things - reduced length bed stays, and a higher level of technology required for surgical in-patients. Seems most hospitals make their money on theatre fees and other technological services, and your typical in-patient recuperating is a loss maker. So things move to the point where you need a much higher capital investment but fewer actual beds. Here in Oz this is a particular problem as closure of a regional hospital can suddenly mean a many hundred mile journey to the next nearest. But the days of giving birth or having simple surgical procedures done in regional hospitals is gone. ER is going to be squeezed by these forces. Here in Oz we have long had the RFDS (Royal Flying Doctor Service - pronounced rufdus). They do emergency paramedic work, and a lot of non-emergency transport. The outback is a harsh place, and we do a lot of mining and drilling out there. It can be a hell of a long way for help to come.
My father was a radiologist, and even some decades ago was adamant that nobody with any form of suspected head trauma got way without a CT scan of the head. The modern upshot is that a modern hospital is designed with an x-ray suite next to ER that includes a CT scanner. It may take non-emergency patients as well, but it isn’t located with the hospitals main diagnostic imaging capability.
Costs here in Oz is not really seen by patients. The funding is baroque to say the least. Major hospitals are all state funded. This leads to the weirdness. The federal government pays for medical procedures performed by doctors via Medicare. But if they are done inside a state run hospital it is expected that the state funding cover them. This can lead to some odd things. But no-matter. An emergency patient won’t see the cost. (They will get billed for ambulance and paramedics, which is covered by private medical insurance.)
But some private hospitals provide ED services (not including major trauma and road accidents. We see essentially zero firearm injuries so they don’t figure in the equation, but if we did they wouldn’t take those either.) Typically there is an up-front non-refundable payment that private health insurance won’t cover of about $350. After that fees, tests and procedures are covered by a mix of government (Medicare) and private insurance.
Oh lots of factors are leading to the industry-wide consolidation.
Free-standing surgical and imaging centers take away lots of the profitable procedures. Changing payment structures have incentivized making hospital stays no longer than absolutely necessary. Improved care allows for more to be done out-patient. Free-standing urgent care centers can compete with the ED for large segments of the business. And the insurers are bigger: they can go to a smaller hospital and say “this is what we will pay take it out leave it” … the only hope for a hospital is to be part of a system large enough that it is difficult for the insurer to not at least negotiate, and large enough to eke out some efficiencies by making one hospital a “center of excellence” for one thing, another for another, closing the smaller elements of the system that do not add value to the whole from either the efficiency or the negotiation strength perspectives, and somehow being part of systems that include the outpatient side of things as well (which is why hospital systems are buying up physician practices as much as they can). A hospital not part of such a system equals not likely to continue to exist.
There are similar pressures in the UK NHS, where insurance companies aren’t involved and hospitals and doctors don’t have market forces to contend with. Partly it’s to do with advances in medicine, the acquisition of more expensive kit and more ambitious attempts to save more and more marginal emergency cases. There is a school of thought that says there should be more concentration of that sort of emergency medicine in fewer, larger, specialist centres. They’ve managed to do it by stealth for strokes in London, but if you try to do it more generally, people scream blue murder at the downgrading of their local hospital (and of course, as a state-funded service, politicians are drawn in, and it’s a much harder case for them to make that the sensible thing is to replace a smaller A&E unit with more distributed urgent care clinics or GP-led services for all the things that, with developments in medical science, can be delegated out from hospital specialists, or should never be taken to hospital in the first place).
Office use of CT did not increase five-fold with head injury leading the list, nor have office based practices increased their use of abdominal CT 8-fold in those time periods.
I have worked in EDs in several states. In my experience, the use of CT in uncomplicated pediatric head injury is different from hospital to hospital. By far the worst, for overusing radiation was a for profit hospital in Dallas. For overusing everything. I had to change my practice at that hospital. I could no longer say to patients “this is what will happen and depending on those results, this is what will happen”. Because that hospital would admit anybody with insurance that they could possibly justify. Chest pain last night, negative EKG and enzymes, all of a sudden admitted with “intermittent chest pain”.
I read medical and ER records daily as part of my job. The one conclusion I’ve reached is that if you want to pile up a huge chart, go in complaining of chest pain. That seems to be the situation most frequently resulting in extensive testing - and just flat out lengthy records.
I guess what I would see as possible would be a more effective triage, and having non-critical cases either wait longer, or go elsewhere for their care. But I can imagine that it is extremely difficult to conduct limited yet effective triage. In a perfect world, the patient with bronchitis/sinusitis, the drugseeker, etc., could be ushered to a waiting room where staff would be able to minimally monitor/observe them to make sure they didn’t drop dead, and then either provide them minimal examination/treatment when the ER slowed down, or assist them in making their way to a non-urgent care facility. But the cost savings for the first thousand such patients would likely be offset by the liability for the one person whose diagnosis got missed, whose apparent bronchitis was instead highly contagious, etc.
And even if someone is a fuck-up - for example their diet, lack of exercise, substance abuse primarily responsible for their current situation, once their body reacts to their neglect/abuse, that does create an emergency situation. While I might be less sympathetic to those folk, I acknowledge simply letting them die is not an economically feasible solution.
Unfortunately, EMTALA does not allow us to do that. Also patient satisfaction scores are driving ER care to some extent now. The lowest acuity patients (the ones who get discharged) are the ones getting the surveys. So now we are expected to prioritize getting them in and out quickly (since wait times are the strongest predictor of poor survey scores). It’s a frankly ridiculous system that ostensibly is supposed to be focusing our resources on the sickest of the sick.
Actually, letting them die would be the MOST economical solution. It would not be a very moral solution but certainly less costly than admitting them to the hospital very week or two for complications of their untreated diseases.
So if I can slightly hijack for a moment–what are the economics of all of the new free-standing ERs that are popping up like weeds, at least in my area.
They are ERs, though some combine an urgent care facility that’s open part of the day, and an ER part that’s 24 hours, and I see the occasional cautionary news story of someone who thought they were going to urgent care and ended up with an ER bill.
Do they have the same requirements about taking in patients regardless of ability to pay? Or might they just be assuming that poor people will go to the hospital instead of a freestanding ER, so they can still charge the going insurance rates for ER treatment while not getting the same amounts of bill defaults?
There is a lot of variability depending on the state in which the facility is licensed, whether they are owned by a hospital or independent, whether they take Medicare/Medicaid and whether they advertise as Emergency Department.
Okay, let’s discuss only head CT use for head injuries.
I am thrilled that your personal implementation of the PECARN guideline (which for others reading, is the Pediatric Emergency Care Applied Research Network head injury clinical prediction rules) has allowed you to order fewer head CTs than you previously did. Your assuming that your rapid personal implementation has been the norm may however be a bit unfounded. Heck, even a major pediatric center, Boston Children’s Hospital, only achieved substantial decease in head CT utilization for pediatric head trauma with a significant focused quality control project being implemented:
(Sorry if the whole article is behind the paywall but I suspect you can get to it USCDiver.)
Note also figure 3, the data from the 35 other children’s hospitals that contributed data to the Pediatric Health Information System (PHIS). The rest of the system’s pediatric EDs started out higher, staying near 30% for two years after PECARN was published, and dropped less significantly than Boston Children’s drop in the following years sans the major QI initiative, ending still roughly three times higher than Boston Children’s rate was after the QI project.
And these are the pediatric specific departments in which the docs are reasonably expected to be most likely up to speed with the most recent guidelines.
It is also interesting to compare head CT rates in the U.S. to use in other countries. The Italian experience for example adapted PECARN ('[a]mnesia was introduced alongside the other original predictors.11–13 In the presence of isolated vomiting, CT was highly suggested if there was repetitive vomiting (more than 5 episodes) or persistent vomiting for more than 6 hours after head trauma …") and they on the one hand did not see a drop in head CT utilization, but OTOH their rate was already down at 7.3%.
Leaving pediatric care aside for a moment, I generally see two responses to industrial accidents. (1) The accident is immediately reported to the employer, and the employee is sent to an urgent care clinic. Unless there are objective neurological symptoms, the clinic is not going to do a CT scan or even an MRI of the brain, or refer the patient out for them at the first visit. They may take X-rays. (2) The accident is not reported to the employer, and the employee self-obtains medical care at the ER. In this case, even the mention of trauma to the head results in an MRI at the very least and most likely a CT.
I see this pattern repeated in work accidents daily, so it’s not confirmation bias and it’s a very large sample size (8 years now). Granted, it may be geographically biased (these are all Florida cases).
Regardless of the cause of the accident, it would be rare to get an MRI of the head W/O first obtaining a CT. CT is much faster and (relatively cheap) vs. an MRI. This is true in the case of trauma, not ongoing neurological complaints.
