Is the integration of urgent, emergent, inpatient and
care of patients with
acute medical conditions.
With an additional 30 million people to be added to the rolls of the medically insured in this country over the next year, common wisdom is that they will all be going to the emergency department (ED). That’s what happened when Massachusetts added more enrollees to their state funded insurance program, to the tune of 3 million additional ED visits between 2004 and 2008. A key driver behind this was that there were not enough primary care physicians (PCPs) to meet the need. As the Affordable Care Act (ACA) now rolls out across the country seniors will increasingly feel the pinch. Their numbers are increasing as the baby boom ages, while at the same time many PCPs are becoming reluctant to take on Medicare patients due to payment reductions.
I predict that non-physician providers and new models of providing primary care will present themselves to fill the gap in primary care. Nurse practitioners (NPs) are already trying to rewrite state laws to allow themselves to practice independently, and several states already give NPs many of the powers the physicians have. The American Association of Colleges of Nursing is also proposing that they add a "PhD" to their training; and California Healthline is reporting that California State Senator Ed Hernandez is planning on introducing legislation this month to enable nurse practitioners to establish independent practices. Physician Assistants (PAs) will also see new opportunities to increase the scope of their practices in the reports of this proposed legislation. Over forty percent of CEP America’s clinical hours are already provided by PAs and NPs, and I believe we will surpass 50% or more in the very near future.
My prediction about the effect of the upcoming Presidential election on healthcare is that, because neither candidate can change reality, both of them will be forced to resort to similar solutions for healthcare reform.
The healthcare system is an economic and access disaster. We are at the tipping point: forty million people have no medical insurance. The cost of providing medical care for our aging population is increasing. The practice of medicine itself is becoming more complex and expensive. And still, the cost of medical care continues to increase and is becoming unsustainable for our economy.
Most of the press has been focusing on the individual mandate. What a victory for Obama! Yet the Medicaid decision could be a much bigger issue than the one regarding the individual mandate. The Supreme Court has ruled that the Federal government cannot coerce the states into expanding their Medicaid programs to cover all people (not just the elderly, blind, pregnant women, and children) below a certain income level by threatening to withhold existing Federal funds as it would violate the Spending Clause of the U.S. Constitution and exceeded Federal authority to encourage states to regulate. This would have been a big stick. Now states are free to do as they choose and several have already said they don't have the money to increase Medicaid enrollees.
The government could still use new Federal money to entice the states to increase the number of people covered by Medicaid. But no matter who gets into the White House, there is little money to do that. This may not help poor people or the people who care for them, and, in particular, will not facilitate the care of uninsured people in our EDs. Healthcare exchanges are another potential aid for the poor and jobless, but several states are stalling on this [PDF].
In the United States many people feel it is their God given right to sue anyone, anytime for anything. Whether you are successful or not may be another story. So what are the cost implications for healthcare in the United States? Few other developed countries rely upon this method for resolving malpractice issues. What is the cost-benefit equation? To protect themselves, American physicians practice what is called defensive medicine designed to ward off the attacks of plaintiff’s attorneys. There was a recent study which concluded that the additional cost for defensive medicine in this country was only about 2.4 percent for 2008. That is a very low number if you have anything to do with healthcare, but this is at least a number that someone has come up with to quantify the cost.
If I were an attorney (and I am not), I would argue that the value of malpractice cases are many: injured parties should be compensated in some manner for material loss of work, comfort and pain and suffering; expenses for rehabilitation and subsequent health maintenance should be paid by the injuring party; attorneys who take on these cases must be compensated for their diligence; cases won by defendants act as a deterrent to further injuries to patients and improve the quality of health care; and whether there is fault or not should be decided by an independent analysis of the case-like a jury.
Should the title of this blog strike fear in the hearts of emergency physician specialists? There is an erroneous urban legend which says the Chinese character for “crisis” is composed of elements that mean danger and opportunity. While the legend may be incorrect, the notion sometimes has truth behind it. Is that the case with PAs and NPs working in EDs?
The fact is that producing emergency medicine residents at the current rate, we will not be able to fill the number of open emergency department positions in the United States -- ever. That certainly seems like job security for those of us who are Board certified. I am certainly glad I have kept my Boards current, but how will that solve the man/womanpower shortage in EDs that we face now and in the future?
Discount the posturing of politicians reaching for the healthcare issue that will attract attention and garner votes. Set aside the drama of the Supreme Court’s proceedings to determine the constitutionality of recent health care reform. Beneath that is something much more important. Don’t look at what politicians are saying, but watch what healthcare providers and insurers are doing.
Individuals, hospitals, insurers and others who are responsible for actually providing health care have already decided what they need to do. They are not waiting for the government to solve the health care crisis of the United States. During the debates that preceded the enactment of the Affordable Care Act, the providers and insurers saw the ugly and disjointed aspects of the American healthcare system : lack of end of life care for the burgeoning population of baby boomers, medical technology that seems to have no economy of scale, and the inability of the system to address wellness to reduce costs. In short, the horrendous expense without attendant increase in quality has been made apparent.
Most of those who understood the issues concluded that the current system is not sustainable. If we continue on this path, we will bankrupt the country. We simply can’t afford to have 40 million or so people without health insurance. Cost shifting their medical expenses onto the tax payers and private insurers has reached its limit. And, oh yes, don’t forget the national debt that must be paid down somehow.
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