“Waiting Doom” Hogwash

I know I’m a little late to the party after being away for a week, but I had to put in my two cents about this article titled “Waiting Doom” that was put up on Slate.com on Thursday. What a bunch of horsepuckey.

Kevin broke the news about the same thing on Thursday. Kim at Emergiblog and David Catron at Health Care BS have already posted excellent rants on the topic. Now it’s my turn.

First, it’s a pet peeve of mine when people call the emergency department the “emergency room” or the “E.R.” There are waiting rooms. There are bath rooms. It is an emergency department. Within that emergency department are trauma “rooms,” psych “rooms,” gyne “rooms,” multiple general treatment “rooms,” clean utility “rooms,” dirty utility “rooms,” plus labs, ultrasound, and on and on and on.

I know that someone is going to ask me “Well then why do they call the TV show “ER” then? It’s going off the air, isn’t it?

It’s the emergency department, not the emergency room.

Now that’s off my chest.

These Waiting Doom authors first sensationalize Esmin Green’s death. I think that bandwagon is a little full, but hey, if it you can get some extra mileage out of it, go for it. Shouldn’t have happened. People should have helped.

Then the authors focus on something that is a growing problem in the US – waiting times in the emergency department. Great! We need to vet this issue more! Longer waits contribute to higher morbidity and mortality.

Then the whole article gets a flat tire, crashes and burns.

So the authors appear to be accusing hospitals of murder because the hospitals intentionally board patients in the ED to save money. Give me a break. I just don’t buy this conspiracy theory for a lot of reasons.

Reality is that if a hospital is boarding patients in the ED, it means the hospital is at its capacity. Maybe all the beds aren’t full, but if the beds are all not full, then there isn’t enough staff available to care for the number of patients in the hospital. I have worked at a lot of hospitals in my career and I have friends that work at dozens of other hospitals. Never have I heard of hospitals boarding indigent patients in the ED while sneaking “direct admit” patients with insurance through the back door. I can’t say that it never happens because I haven’t worked everywhere. I have been around the block a few times and the whacked out allegations in this article are news to me.

How exactly do hospitals benefit from admitting patients versus taking care of the same patients in the ED? If you assume that 100% of the patients that use the ED are uninsured, the author’s little scheme might work. But think about it – if the community in which the hospital sits has 100% uninsured patients coming to the ED, are the demographics going to be that much better for the directly admitted patients?
Are indigent patients going to take taxis, trains and buses to hospitals in the affluent suburbs? Doubt it.
Are multimillionaires going to call their docs and request a direct admit to a ghetto hospital? Of course not. I don’t have any formal studies to back up my assertions, but the hospitals at which I work have similar percentages of paying vs. non-paying patients in the ED and on the floors. By keeping ED beds full, it seems to me that you’re just as likely to turn away a paying patient as you are to turn away one that doesn’t pay.

Do floor nurses play “hide and seek” with floor beds as the authors suggest? Definitely. A lot of times the floor nurses are as overworked as everyone else in the system. In fact, bed hiding has risen to an art form – especially around shift change. But I still don’t see how an hour delay in transferring an ED patient to the floor improves the bottom line of the hospital.

Does the “auto-triage” that the authors describe happen? Absolutely. Patients who have minor complaints have to wait while those who have more serious complaints are seen first. That’s just the way the system has to work. If you were the one having a heart attack and there were ten kids with ear infections ahead of you in line, you would want things that way. After waiting in the waiting room for 24 hours, there may be an incentive for the patient with a runny nose and cough to actually see a primary care physician.

Another thing that doesn’t make sense: In order for the authors’ scheme to work, the medical staff would also have to be complicit in the hospital’s little conspiracy. All the doctors and nurses would have to secretly look up the demographic information on the patient charts, put on our black overcoats and dark sunglasses, go to whoever is in charge of bed control and say “Pssssst. You. Yeah you. Commere. The patients in beds 2, 5, 17, 31, and 33 have insurance. Bump them to the head of the line. Pass it on.” If we assume that non-paying patients are undesirable, wouldn’t the ED staff try to make those patients the first ones to be admitted to get them out of our hair?

Hospital administrators have little ability to correct the problem with ED waiting times. In many instances, administrators are working on a shoestring budget. They can’t admit patients if they can’t afford to hire the staff. They can’t hire the staff if they don’t have the funding. Did your representative vote for the 10% Medicare cut? They’re just asking for longer waits and more bad outcomes. Think that $10 million judgment against the hospital “serves them right” for missing some obscure problem in a 99 year old granny with terminal cancer and three days left to live? Think of all the staffing that $10 million could have purchased. When you have to travel three times as far to get treatment for your heart attack or stroke, maybe granny’s relatives will send flowers to your family after reading your obituary in the newspaper.

The silly thing with this article is that the authors recommend that patients “vote with their feet” and go to EDs that don’t have long boarding times.

Knock knock knock. Hellooooooo.

If the practice of boarding indigent patients in the ED really saves money, and if the hospitals really board indigent patients to try to make them leave, isn’t the hospital across town going to treat indigent patients the same way? You get fed up waiting in line at one hospital’s ED because you have no insurance and the other hospital is just going to say “Sure we’ll butt you in front of all our insured patients. Come right this way.”

Oooh. Maybe not all the hospitals know about this instant revenue stream. Hey – these authors are from the University of Pennsylvania and Penn’s profits were up by 6.5% the last fiscal year – the best performance since the Pennsylvania Health Care Cost Containment Council started keeping records in 1995. Compare this to the fact that one quarter of Western Pennsylvania’s hospitals lost money in the last fiscal year. Maybe they’re on to something. Maybe Penn needs another federal audit to make sure it isn’t committing any more health care fraud.

Seriously, though, I have to question whether these authors actually work in the emergency department at all.

If they did, instead of telling the uninsured patients to go where the boarding is the shortest, they would have told the uninsured patients to go to the EDs where they have the best cable TV selection.

At least then during their waits, they could catch up on the latest reruns of “E.R.”