Cost cutting in EDs can be misguided

To the Editor:

Every year, Rhode Island emergency departments are hard at work seeing more than 350,000 Rhode Islanders in need of immediate health care, 24 hours a day, 7 days a week, 365 days a year. And like clockwork, every year we open our newspapers to headlines such as “Report: Nearly 60% of ER visits in R.I. in 2014 could have been prevented,” as published on Feb. 10, 2016, in PBN.com.

These stories about most ED visits being preventable all subscribe to the same narrative. Take a look at all the ED visits in the state, and after the visit decide that they were unnecessary. Sadly, the average Rhode Islander is in no position to do the same with their health care.

In Rhode Island, as in the rest of the country, we have a prudent layperson standard. In other words, what would the average person do when faced with a potential emergency? For example, if your family member had chest pain, which according to HealthFacts RI is one of the most common “preventable” visits, would you want them to stay home, or be seen by a physician? How would you know whether their visit is “preventable” or actually a heart attack without being seen?

- Advertisement -

This “Monday morning quarterback” approach is common in the discussion of ED visits both in Rhode Island and the rest of the United States. The HealthFacts RI data assumes that if a patient was seen and discharged, that their visit was preventable. While well meaning, as we would all like to have cheaper health care, it is a risky proposition. Both harmless and deadly conditions often have the same presentations, much to the consternation of patients and their physicians. Asking patients to determine that while at home, anxious and with inadequate information, can be a recipe for disaster.

Perhaps [the Executive Office of Health and Human Services] is suggesting that these patients could instead be seen elsewhere. While that prospect works sometimes, it certainly does not apply during many night, weekend and holiday times. Ask an anxious patient how easy it is to see their primary care physician at 11 p.m. on Friday night. The vast majority of the time a call to a primary care physician at that time will yield the appropriate response: “Go to the nearest Emergency Department.”

Health care expenditures on ED visits in the U.S. are about 6-8 percent of total health care costs. Eliminating many of these “preventable” visits would yield meager savings at a very high cost down the road. Remember, none of these analyses take into account the cost of delays in seeking care – such as more Rhode Islanders with strokes, severe heart attacks and other devastating conditions. The cost of one Rhode Islander with delayed care leading to a severe heart attack far outweighs many, many so-called preventable ED visits.

The emergency departments of Rhode Island have been at the forefront in both public health and in seeking ways to decrease overall health care costs. We have pioneered coordinated care with primary care physicians, increased care management in the ED, and increased observation care to decrease admissions. Several EDs in Rhode Island have started new protocols to decrease the number of people with chest pain who ultimately are admitted. However, all of this is done after someone is actually evaluated in an ED, and can’t reasonably be done before. Perhaps we should decide if something is preventable based on their initial symptoms, not on their ultimate diagnosis and whether they were admitted. There are much better places for Rhode Island to save money than in seeking to dissuade patients with potentially significant symptoms from seeking emergency care. •

Dr. Catherine A. Cummings, Dr. Achyut B. Kamat, Dr. Christopher P. Zabbo. Dr. Cummings is an emergency physician at Rhode Island Hospital and The Miriam Hospital, Dr. Kamat is an emergency physician at Rhode Island Hospital/Hasbro Children’s Hospital and The Miriam Hospital, and Dr. Zabbois an emergency physician at Kent Hospital.

No posts to display