Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

How Much Is the Nation Spending on ER Care? Wrong Question

5/8/2013 11:31:14 PM | 1 comments

Recently, Drs. Lee, Schurr, and Zinc published an article in Annals of Emergency Medicine that detailed three different approaches to estimating the percentage of total national healthcare costs that were expended for emergency department care. The statement in this article that most healthcare journalists have picked up on is related to the authors’ assertion that spending on ER care could amount to as much as 10% of the national healthcare budget. This clashes significantly with ACEP’s assertion that these costs represent just 2% of overall healthcare outlays. However, the key takeaway from this article is that we really don’t have accurate models and reliable data to be able to determine with any certainty just how much money is spent on ER care in our country. I even have doubts about the accuracy of the $2.6 trillion denominator (total costs for all care) used in calculating this percentage. In any case, the authors assert that “rather than minimize the issue of cost, we should recognize the economic and strategic importance of the ED within the healthcare system and demonstrate that costs are commensurate with value.” I am not sure how it will be possible to demonstrate the true value of emergency department care if we can not accurately determine the true cost of this care; but I agree with the authors that the question of how much is spent on ER care is not nearly as important as the question of how to maximize the value of this spending.

The urge to under-represent the financial impact of ER care on our healthcare budgets is directly proportional to the over-exaggeration of this financial impact by health plans, government healthcare programs, legislators and policy makers. I have often wondered why, with so much wasted spending in healthcare, there is a disproportional focus on ER care spending. In a prior post, I pointed to this pie graph that shows that eliminating so-called ‘unnecessary ER care’ is but a small portion of the potential savings we might be able to achieve in overall healthcare spending. No doubt that ER care is involved in several other pieces of this pie, but the brunt of the pressure being applied to ER care providers (particularly emergency medicine physicians and hospitals) is related to avoidable ER visits, unnecessary diagnostic testing, and the high costs and charges (mostly hospital related) that come into play in ER care.

The most recent journalistic assaults on ER care in the WA Post and NY Times often cite other news articles about the high cost of healthcare throughout the system like this one in Time Magazine, and fall closely on the heals of complaints by CMS about the inappropriate up-coding of ER physician claims, and by patients about outrageous hospital charges. Unfortunately, many of the studies quoted in these news articles, including the one that prompted this blog, rely on data in the Medical Expenditures Panel Survey, which I previously criticized as terribly flawed survey drivel. As a result of this assault, ACEP, the American Hospital Association, and physicians and hospital administrators in your local hospital, find themselves on the defensive; and are searching (if not frantically, at least deliberately) for ways to highlight the value proposition for emergency care services. Although it is possible that if most ER patients had to pay for their ER care out of pocket, these patients would avoid the ER like the plague: the fact is that the number of ER visits in this country continue to grow by the millions every year. You would think that with this many patients and families ‘voting with their feet’, journalists and policy makers and even researchers would temper their inclination to point the fickle finger (sorry) at ER care with some recognition of the importance of these services, and the perception of the value and necessity that so many of our citizens place on high quality, readily available ER services. Unfortunately, the good PR that is all too often generated by the incredibly effective, even heroic, ER care response to tragedies like the Boston Marathon bombing seem to fade in the public consciousness as quick as the next news cycle.

I agree with the authors of the Annals article, cited at the beginning of this post, that rather than trying to refute the allegation that ER care is too expensive, ACEP and the AHA need to focus on why ER care is so valuable to our communities. As emergency physicians, we need to find ways to get more and better ER care at lower costs, and prove to policy makers, legislators and health plans that investing in quality ER care and the maintenance of the emergency care safety net is both a sound investment, and a critical one. ACEP is certainly making an effort here, both on the PR front and in programs like those of ACEP’s Cost Effective Care Task Force and Delphi Panel, which I have the honor of participating in. We undoubtedly need more and better data on the costs and outcomes of ER care, but we cannot wait for ACEP leadership to turn the PR tide, or for elaborate databases to materialize and academicians to find the answers: these issues must be addressed by working emergency physicians and emergency department directors in each and every ER in the country. The best ways to highlight and enhance value are nearly always home-grown.

This post was first published in The Fickle Finger.

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