Emergency services, COVID, and the health system: Your life could well be at risk

I recently had a very unpleasant health event, involving severe abdominal pain for most of a day and night, and many days of recovery. The details of my specific condition are not particularly important, other than to say it is a chronic, recurrent problem, resulting from an event decades ago; it could well need emergency surgery and can have serious results. The point is that I had to decide whether to go to the emergency room that night, and to discuss the issues, both personal and structural, that impacted that decision, and what it demonstrates about our healthcare system, made even worse by the stress of COVID.

Considerations on the side of “go to the ER” were 1) I was in a lot of pain that was lasting longer than it generally has (say twice a year), and wanted to not be, 2) I knew pretty well what was causing it and that, while it had happened before and usually resolved, it could also NOT get better and maybe require emergency surgery, or worse. Considerations on the side of “don’t go to the ER” were 1) it has usually in the past resolved, eventually, on its own, and 2) the idea of getting in the car to go to the ER, and then waiting to be triaged and seen, and maybe imaged, which was likely to take many hours, all while in such pain, was a very negative incentive. If I was going to be writhing in untreated severe pain, I would prefer it to be in my own bed than in the waiting room of an ER. Plus, COVID. Both because it has made the crowding and wait times in ERs and hospitals much worse than “normal”, and because being there increases the risk of exposure and infection. I happen to live in what is currently a “high COVID” state, but nowhere is a really “low COVID risk” area. As it turns out, I didn’t go, and by morning, after about 18 hours, the worst was past. This time. But it will happen again and I will again have to decide what to do.

As do many, many thousands of others, every day, in the US. For many people, a major concern is cost – because visits to the ER are costly for those with no or poor insurance (really a lot of people). Fortunately for me, I’m not in that group. For others, it is because of fear of finding out what the problem is, and that it will be something really bad that they don’t want to know about. That also wasn’t really my issue; as a physician who has dealt with this, I knew what the problem was. Unfortunately, that can make it worse, since my fears and realization of the possible outcomes are based in evidence and not just fear. For yet others, it is the expectation that because of who they are (not White, poor, poorly insured, not well-dressed, have a history of alcohol or drug use or mental illness, or something else that doctors tend to associate with making one of less value) that they will be pushed back in the line, not believed, have their stories discounted, and generally be treated badly. Not really me either, although my physician privilege is decreased now that I am retired in another city, and do not get to go to the ER in the hospital where I work every day and people know me. For a lot of people, it is a combination of these, synergistically making their experience, and expectation of that experience, worse.

In case there may be anyone who is skeptical about my saying it is likely to be hours of waiting even when one presents with an emergency condition and is obviously educated and “respectable” (as a physician or nurse), it happens, and is happening much more continuously in the Age of COVID, when facilities are completely stretched to their limit and resources and people who work there are stressed to the max. Just recently, the last few months, two people who are close to me and are healthcare professionals have been through this experience. One had acute appendicitis, and needed emergency surgery, and after waiting many hours at home before venturing to the ER, waited there for 7 more hours before being seen. Luckily, they are now OK. It was not a positive experience! The other had a similar serious need, a ruptured diverticulitis causing peritonitis. She also waited in excruciating pain for hours, despite the fact that she was accompanied by her husband, a physician from the community who has practiced here for decades who was reduced to screaming at staff before she got her necessary emergency surgery. (For the record, these two people and I are all “seniors”, but these scenarios can and do affect everyone; my initial crisis was when I was 40 years old.)

The best advice anyone can give me is “get an ambulance”; they’ll see you sooner than if you arrive by car. This may well be true, and it may be good advice for me or for any other individual who is not worried about an additional $2000 bill, but in no way addresses the systemic problems that obviously exist.

The first of these is the incredible stress put on the system and the individuals working in it, doctors, nurses, and other healthcare workers, by the COVID pandemic. The burden on hospitals and healthcare workers has been phenomenal. In this sense, doctors and nurses and others on the front line are our heroes, as they are often portrayed. Yes, sometimes they can exhibit inappropriate behaviors. These can even be exhibited by folks in whom they rarely manifested before as a result of the continuous stress of working in the situation that they, and we as patients and as a society, find ourselves in. The governmental response to the pandemic, led by a federal administration who acted as if their intention was to do everything completely wrong, was shockingly inadequate. Yes, building new hospital capacity is possible and usually slow, but some localities did it, and yes, training and equipping more healthcare workers takes time. But there is no conceivable justifiable excuse for not having sufficient PPE, for example, months into the pandemic. This could only happen because of the worst possible management. Remember that this is the country that put a person on the moon 8 years after the first suborbital flight, that built the interstate highway system, that could assemble battleships in weeks during WW II, that has enough money to give trillions of $$ in tax cuts to billionaires and corporations. It only did not happen because of more than ineptitude; it happened because of an intent to do evil. We can hope that at least much of this can be reversed by a Biden administration.

The other big structural issue is our terribly designed and implemented healthcare nonsystem that discriminates against people based upon wealth and insurance status, race and ethnicity, age and pre-exisiting conditions, geographical location, and in appropriate allocation of resources that in the best of (non-COVID) circumstances sends a hugely disproportionate number of true emergencies (medical, surgical, trauma) to some hospitals while others have relatively low, and more mild, usage of their emergency facilities. It is also the fact that many people cannot get into see their primary care physicians promptly, or do not even have primary care physicians (or other providers, such as NPs) so end up waiting until they are severely ill and going to the ER. These are people who, if they get hospitalized, can be considered “primary care preventable” hospitalizations. That is, if they had been able to easily and promptly see a primary care doctor for their illness, and at least as important, had their chronic diseases effectively managed and controlled, would have not needed hospitalization – or emergency care. This needs another set of structural solutions. It needs, first off, a universal national health insurance system. Every single person in the country needs to be completely covered for every medical necessity, without copays, deductibles, etc., and we all need to be in the same program.  The pandemic has clearly demonstrated the vulnerability of employer-based coverage. It is long past time, if it ever was, for ideas of gradual piecemeal expansion of Medicare, ACA, Medicaid, etc. If everyone is not in the same system, it is not a possibility but rahter a certainty that some will get better care than others. Separate, the Supreme Court ruled in 1954, is not equal in education, and separate insurance systems cannot create equality in healthcare.

A universal health insurance system, such as Medicare for All, is not going to fix all of the things that I discussed above. We need to ensure that there are hospitals and ERs available to all people. We need to ensure that all hospitals are welcoming to all patients, and that there is a rational system of referral from smaller to larger hospitals.  We must ensure that there is adequate primary care capacity so that everyone can have a provider that they can see regularly, and promptly when needed, and do not need to access ERs for either primary care or for urgent conditions that could have been prevented by good primary care. And we need to make sure that there is adequate emergency capacity for all emergencies to be cared for emergently, and that ERs, and hospitals, and health systems, are designed and funded and run based solely on what best needs the health needs of the entire community, and not on what makes the most profit for the owners. A universal health insurance system is necessary but not sufficient.

We need all that, and need it yesterday.

Why poor people choose ERs: we need a system designed to meet everyone’s needs

“Understanding Why Patients Of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care”[1], by Shreya Kangovi and her colleagues in the July, 2013 issue of Health Affairs, tries to help us answer that question in order, presumably, to help re-design ambulatory care in order to change that preference. A general assumption of health policy is that use of hospital emergency rooms for “routine care” is expensive, inappropriate, provides worse patient outcomes, distracts emergency room staff from caring for the true emergencies that they are presumably there for, and is a significant cause of the overall high health care spending in the US. Although the whole article is available on-line only to Health Affairs subscribers, a summary is presented on the Robert Wood Johnson Foundation (RJWF) website, because Dr. Kangovi was an RJWF Clinical Scholar.

The authors conducted a qualitative study interviewing 64 people who frequently used the emergency room as their source of medical care, using trained community members to engender greater trust on the part of the patients, mostly lower income African-Americans, to conduct the interviews, in two hospitals in the Philadelphia area.  “Study respondents (both the insured and uninsured) explained that they consciously chose the ER because the care was cheaper, the quality of care was seemingly better, transportation options were more readily accessible, and, in some cases, the hospital offered more respite than a physician’s office.”

These findings should be surprising to many students of public policy, but they were the legitimate perspectives of the people who were using these services, those Kangovi correctly notes, whose “…voices are seldom heard in policy discussions.”  Understanding their concerns is critical, not because they are always “right”, or represent everyone, but because those concerns reflect their experiences, and the degree to which our current strategies are not working, and the degree to which our future strategies are unlikely to work if they do not take into consideration these issues. Three themes generated by the researchers, with supporting quotes from the folks who were interviewed:

• Convenience. “You must call on the same day to set up a [primary] care appointment … whenever they can fit you in.” This open-access scheduling resulted in people taking days off from work and still being unable to see a doctor. It also made it impossible for many to access transportation covered by Medicaid because the transport arrangements had to made 72 hours in advance. Late hospital hours also made care more available.  
• Cost. “I don’t have a co-pay in the ER, but my primary [physician] may send me to two or three specialists and sometimes there is a co-pay for them. Plus there’s time off from work to go to several appointments.”
• Quality. “The [primary care doctor] never treated me or my husband aggressively to get blood pressure under control. I went to the hospital and they had it under control in four days. The [physician] had three years.”

Any health care provider who has worked in an ER or in ambulatory care can validate these concerns, and also respond to them. The most obvious is Cost. Obviously care in an ER is not free; indeed the cost is a major driver of efforts to get people to not use it. But the patient, at the time of service, doesn’t have to put down cash, put down a co-payment, put down real money now. There will be a bill, but that will be something that goes on their (likely existing and mounting) debt burden.

Convenience is, perhaps, a poor choice of words; it suggests something purely volitional, as if people were choosing to have their hair done during the day rather than go to the doctor. Convenience in the way that a middle class person understands it is not what these folks are talking about. They may not have a car or a family member with one (or perhaps it is being used by a family member to get to work), public transportation may be unavailable, unreliable or inaccessible to them given their medical problems, and if they have jobs, they are often not those that just allow you to take a sick day to go to the doctor, but mean they lose pay. Despite efforts to have “extended hours”, most ambulatory care offices are open mainly during regular business hours, during the day weekdays, when the folks who work there want to work, not when it is necessarily most “convenient” for patients. Let’s get this straight, it is not “convenient” to wait 6 hours in an ER to be seen; if this is better than the alternative, the alternative is seriously flawed!

Quality is another issue, and the quotation chosen is very open to criticism. The hospital had 4 days of complete control of the person’s life, giving them their medicines and minimizing any external issues, while the doctor had 3 years in which the person was responsible for taking their medicine, choosing their diet, and deciding where to rank health among the many competing priorities in their lives. As any of us who have worked in medicine know, the control that was achieved in the hospital may well evaporate once someone is back in their regular environment.

Really, this is largely an issue of money, of resources. The authors emphasize that not all the patients were uninsured, but those who had insurance almost all had Medicaid. Not only is Medicaid not equivalent to private insurance (it pays less and lots of doctors do not take it) but it is only available to really poor people. People who are poor enough to have Medicaid have all those issues listed above under “Convenience” and “Cost” that go beyond the direct cost of medical care, but inform every decision that they make in their lives.

Policy is made, in almost every area, by the “haves”, those with money and political power. At the rawest, it is a blatant example of “let’s do for us, and screw those without power”, as for example the farm bill that cuts food stamps for the neediest while continuing support for giant agribusiness (well discussed by Paul Krugman in  “Hunger Games, USA”, NY Times July , 2013[2]). More subtly, and with much less intentionality, not to mention hostility, it is made from the perspective of people who have a lot, who cannot even imagine the lives, decisions, and trade-offs made every day by “have-nots”. The “haves” may identify a lot that is wrong with the health care system, but they do not even think of things like not having transportation, or not being able to take off from work to go to clinics open during working hours, or not having childcare. They are not mean people, but they do not see.

In her comments, Kangovi looks at plans to develop Accountable Care Organizations (ACOs). “Our findings suggest that these efforts could backfire by making hospitals even more attractive to these patients. We also debunk the notion that people from these groups abuse the emergency room for no reason and need to be taught how to use it properly.”  The real issue is that there are not the financial incentives to provide high-quality care that is accessible in terms of both cost and the other obstacles people face (e.g., transportation, childcare, office hours). The financial incentives are to try to avoid these patients all together, keep them out of the ER, keep them out of your office; to develop “Patient-Centered Medical Homes” that are centered around the kinds of patients you want to have, and not those you would rather not have show up (and go to the ER!).

We need a system that, first of all, ensures that taking care of everyone is (at least financially) desirable. That means a system in which everyone has the same insurance coverage (a single-payer system), and one that is designed to pay more when providing care for people with greater needs, both medical and social. We need a wrap-around system that enables the most needy to have access to the transportation, childcare and other issues that they need to be able to utilize their medical coverage, and to the education, jobs, food, and housing that they need to be able to have a reasonable chance at health. We don’t need a patchwork system of “good ideas” that do not, in themselves or together, create a real safety net for people.

If we have one that is so full of holes that gaming it for profit is the main activity of hospitals, doctors, and other providers, we have no reason to be critical of the least powerful finding the ways around it that work best for them.

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[1] Kangovi S, et al., “Understanding Why Patients Of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care” , Health Aff July 2013   vol. 32  no. 7  1196-1203; doi: 10.1377/hlthaff.2012.0825  

[2] Krugman indicates the logic “…goes something like this: ‘You’re personally free to help the poor. But the government has no right to take people’s money’ — frequently, at this point, they add the words ‘at the point of a gun” — “and force them to give it to the poor.’  It is, however, apparently perfectly O.K. to take people’s money at the point of a gun and force them to give it to agribusinesses and the wealthy.”