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Emergency Room Care

Selena Pham, Victoria Nguyen, Victoria Mignone, Brooke Limeberry, and Marty McHale
● Capacity
○ Overcrowding due to non-emergent patients
■ “There were 3,667,601 first time attendances to
Emergency Room EDs, of which 554,564 were defined as
non-urgent (15.1%)” (O’Keeffe, Mason, Jacques,
Issues ○
and Nicholl, 2018).
High flow of uninsured patients - cannot deny care
○ Patients visit the ER more on weekends to avoid
missing work
○ Admitting more patients than the amount of hospital
beds available
● Length of stay
○ Doctors utilizes Triage Assessment Form meaning that
they evaluate the severity of the patient’s conditions
○ Patients are not discharged immediately
● Staffing
○ Understaffed because more people are covered by
ACA. This result in more people visiting emergency
rooms but, not enough staffs to assess each patient
problems
■ Emergency departments are opened 168 hours
a week/365 days a year. More hours means
more burnout for doctors, resulting in less
on-call doctors
● Population:
○ Black patients

Who is effected? ○ The uninsured


○ Southern and Western residents

What Population ○ Women


○ Recipients of Medicare and Medicaid
○ Lower income populations
○ The elderly and individuals with chronic
illnesses
○ Individuals with public insurance
● Who is effected:
○ Citizens living in cities have longer waiting
times
○ Patients being misdiagnosed
○ Sick patients who wait in overcrowded ER’s
○ Nurses and physicians
○ The community, insurance companies,
hospitals.
Health Status

How does it affect


● With Anthem, one of the nation’s top health insurers
not covering the costs of minor ailments in the ER,

health status, this could be potentially detrimental. Where does


one draw the line at “minor” ailment? How many
utilization of patients that carry Anthem are scared to go to the ER
for the potential cost? What if a person is concerned
health care, health about having the flu but Anthem said they won’t

care costs, and cover for visits concerning sore throats and runny
noses because they are not life threatening.
access to health Utilization of Health Care
● ED use reduced after the implementation of ACA due
care? to young adults being covered until the age 26. This
allowed for more office visits for nonurgent illnesses
or injury, clearing up the ER
● The ACA did not decrease the burden on ER visits
because there was not enough focus on primary
care visits
Health Care Costs
● Even with less people visiting the ER, NEMJ Catalyst
How does it affect states there is no evidence that the cost of care has
been reduced as well
health status, ● The ideal situation would be improved access and

utilization of lower costs


Access to Health Care
health care, health ● According to a study by John Hopkins, there was a 6
percent decrease in uninsured patients visiting the
care costs, and ER

access to health
● Those with Medicaid and expanded coverage
actually utilized the ER more. This finding was

care. (con’t) shocking because researchers expected them to


take advantage of primary physicians
Stakeholders

● Patients
○ A study by Dr. Leana Wen M.D. stated:
■ A total of
● 85% of patients want a doctor that listen to them
● 71% want a doctor who is caring and compassionate
● 69% want a doctor that explains well
● 47% want quick and convenient access to care
● 41% want pleasant interactions with medical staff
● 29% want to be able to talk about cost with their doctor
● 22% want a doctor that discloses financial conflicts of
interest.
Stakeholders (cont.)
● Communities (NO PROBLEMS WITH IRON TRIANGLE)
○ Communities want no issues with Access, Cost, and Quality
■ No Discrimination due to an individual’s socioeconomic status
■ Self assurance that medical services will be covered
■ Excellent quality of medical services (NO SHORTCUTS)
○ Benefits for communities near Non-Profit Hospitals
■ Providing funding and staff to community health clinics so uninsured and low-income patients with
chronic illnesses can get preventive care and avoid the emergency room
■ Sponsoring food banks and farmers’ markets in communities without grocery stores
■ Supporting to reduce youth violence or substance use
■ Offering programs that encourage healthy behaviors and lifestyles
○ If the Hospital is not a Non-Profit in the Community?
■ Some states have laws about financial assistance, billing, and community benefits but speaking up will
improve the communities health and engagement with the hospital.
Stakeholders (cont.)
Physicians
○ Patients have misconceptions of the job of an ER Physician
■ The ER is designed to provide emergent care to make sure the patient is safe, healthy and comfortable.
■ The ER is not an in-and-out clinic or primary care office
● The primary care physician will give quicker care and help you follow up on the issue, whereas ER
physicians cannot
■ If someone comes into the ER with something minor, they’ll have to wait
● If you wait, you are not dying. Feel sorry for the people who get rushed back.
■ An individual in a worse state of health will be attended first
● If you assume it's serious, contact your primary care doctor to see if they can take care of the
problem before the ER
● Patient Satisfaction?
● ER Physician Advice to Patients?
Stakeholders (cont.)
● Insurance Companies
○ INSURANCE COMPANIES LOVE MONEY
○ Access to quality health care is a concern for many Americans, due to rising premiums
and the future of the Affordable Care Act.
○ Americans also don't realize that if you can afford health insurance, quality could be
limited due to tactics practiced by insurance companies, specifically focusing on
prescription drugs and medical procedures.
○ Insurers seek to cut costs by preventing coverage for certain treatments and passing
payments onto customers. (Ginsberg, 2018)
■ Increases profitability for Insurance Companies
● What tactics do insurance companies use?
○ Questioning Doctor’s Orders
■ “Prior Authorization”?
Stakeholders (cont.)
● Delayment of Effective Treatments
■ Step Therapy
■ Fail First
● Excluding Medications
○ Insurance companies can refuse to cover a medication due to the price being too high
■ The costly medications are placed on “Formulary Exclusion Lists”.
(Ginsberg, 2018)
● Administered by Pharmacy Benefit Managers for example CVS
○ People are denied medical treatments even though they’re in a chronic health state
○ Do insurance companies think of profit?
Stakeholders (cont.)
● Messing with Success
○ Insurers can force an individual to switch medications for a non medical reason
■ How do Insurers do this?
○ Individuals with chronic illness are at risk due to medications causing their symptoms to worsen along with
taking multiple medications until their health improves. (Ginsberg, 2018)
● Forgetting about Mental Health
○ Insurance companies offer low reimbursement rates for mental health specialists.
○ Mental Health Professionals refuse to take insurance due to payors not providing a “living wage”
○ Insurance companies have refused to accept mental health specialist plans
● Due to being aware of these tactics
○ Coalitions in states formed, which were filled with patients and providers
○ 15 states passed legislation focusing on prior authorization and step therapy so patients could have access to
proper medical drugs (Ginsberg, 2018)
○ Speaking up about what you believe in could limit these insurance company tactics
■ A PERSON DOESN'T HAVE TO BE INVOLVED WITH POLICIES BUT AN INDIVIDUAL WITH A
PASSION TO IMPROVE ACCESS TO CARE CAN MAKE A DIFFERENCE!
Additional Regulations
Anthem’s New Policy ACA (Affordable Care Act)

● As stated earlier, Anthem’s new policy will essentially ● The ACA expanded Medicaid and instead of
pick and choose what they deem “necessary” as an ER those patients taking advantage of primary
visit. However, this can get tricky by certain coding that care, referral med reports that there was
is done because the coding doesn’t tell the whole story
almost a 40% increase in ER visits from
about the visit. An example used by the LA Times talks
Medicaid patients. Also with the age gap
about a patient that got hit by car, was taking to the ER
widen to 26, a lot of younger adults took to
in an ambulance and had to get a CAT scan and X-ray
and luckily found no serious injury. The only serious the ER as opposed to prior ACA. However, like
injury was to the patient’s wallet because Anthem would stated earlier the amount of uninsured
not cover the visit because no serious injury was found. decreased.
A doctor stated that out of all the complaints in his ER
45%of cases could have expressed life threatening
changes and another 5% could only be treated in the ER.
So is Anthem trying to help overcrowded ER rooms or
possibly costing lives?
What are the various remedies that could be
implemented to resolve the problem?
● Staffing to demand
○ By staffing more people it can avoid wasting
hospital resources.
■ Doctors and nurses would rather work
during the weekdays and normal
business hours, however most
Emergency Departments are under
staffed during the “off-hours”.
■ Patients usually decide to go to the
emergency rooms due to the fact that
everything else is closed.
What are the various remedies that could be
implemented to resolve the problem? (cont.)

● Reassigning and modifying the nursing and physician staff


○ Nursing ○ Physicians
■ Getting nurses away from triage to ■ Pair emergency physicians with family
direct patient care would make medicine practitioners and those who
physicians the first point of contact want to be trained for non-life
after patient registration. By doing threatening illnesses. Since many of
this it can help with the long waiting the patients who come into the ER are
time for the patients to get care. usually not life-threatening, therefore
doctors can treat and discharge them
quicker.
● Overall, forcing patients to wait is unnecessary and dangerous. By improving patient flow
can help reduce cost and clinical outcomes.
What are the various remedies that could be
implemented to resolve the problem? (cont.)
● Emergency Rooms adopting policies
○ “The American College of Emergency Physicians encourages chapters to
affect policy change at local and state level.” (Healthcare Emergency:
Overcrowding in the ER, 2017).
○ Apply a policy addressing that ERs are not for non-life threatening
emergencies and that patients should only go to the ER for potentially
life-threatening conditions only.
■ Decreasing the number of patients coming to the ER for non-emergency
problems will help physicians and nurses care for other patients with
actual life or death conditions. This would increase access and quality of
primary care for the patients.
Intended Consequences

● Staffing to demand ● Emergency Rooms adopting policies


○ Most doctors and nurses ○ Patients will continue to believe
would not want to work that their condition could become
during the the “off hour” life-threatening if not treated right
shifts. away.
● Reassigning and modifying the
nursing and physician staff
○ Doctors and nurses tend to
resist to changes on their
care-delivery methods.
Insisting that the traditional
way has been working for
centuries.
Unintended Consequences

● Staffing to demand ● Reassigning and modifying the nursing and physician


○ Even with an increase of staff
staff, there is no significant ○ ERs have to continue to stay as functional and
change in the number of affordable. Over time the change of traditional
patients who leaves the ER methods will impact how the ER functions as well
will be treated with great as cost.
quality. ● Emergency Rooms adopting policies
○ “The Emergency Medical Treatment and Labor
Act of 1986 is known to require all emergency
department to screen, stabilize or treat anyone
showing up at the ER, regardless of their ability to
pay.” (Hiltzik, 2018)

● Respondents expected increases in patients
Does the ACA ●
and overcrowding under the ACA.
There is a consistent increase in ER’s which is a
addresses this issue ●
result of the ACA.
Several elements of the ACA- the insurance
or problem and expansion, patient-centered medical homes,
accountable care organizations, and bundled

how it does? payments- will directly affect both demand for


ED care and expectations for its role in
providing coordinated care (McClelland, Asplin,
Epstein, Kocher, Pilgrim, Pines, Rabin, and
Rathlev, 2014).
● Health care will be more organized when the
ACA changes methods of payment and gives
reasoning to things such as care organizations.
○ Increased access to patient-centered
medical homes, which will allow more
care and access to providers.
○ EDs will play a bigger role in the
coordination of care, which will be
required with new payment models for
patients who don’t need to be
hospitalized.
● Capacity
○ Capacity could be decreased by doctors doing

Our Opinion ○
more home visits
Educate patients on the difference between
emergency and non-emergency cases
○ Encourage those with insurance, Medicare and
Medicaid to utilize their primary physician
before going to the ER
○ Don’t overcrowd by admitting more patients
than the amount of hospital beds - do not
exceed the limit
● Length of stay
○ Accurately place patient using the 5 R’s: right
level of care, right service, right nursing unit,
right bed and right time period
■ This will make the progress run
smoother and faster
○ Discharge patients as soon as possible - some
doctors keep their patients longer than
necessary
● Staffing
○ Increase staffing
○ Have more staff working the night shift
References
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https://www.nytimes.com/2017/05/15/well/live/strategies-to-navigate-the-emergency-room.html
Cerundolo, A., Dr. (n.d.). Anthem's new policy will scare away patients who need the emergency room. Retrieved April 22, 2018, from
http://newsroom.acep.org/letters_to_the_editor?item=165
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References
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ment_patient_visits
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