Is the integration of urgent, emergent, inpatient and
care of patients with
acute medical conditions.
The following blog by Wesley Curry, MD is a ten year forecast, and it has also been our most popular blog for 2012, with over 2,000 clicks. Perspectives on the Acute Care Continuum congratulates Dr. Curry, and we look forward to a new year with your thoughts, comments, and solutions for the challenges of the next decade.
Patients have been arriving at the doors of Emergency Departments in increasing numbers over the past decade, and this trend will only grow in the future. I believe there are five key factors that suggest every ED should brace itself for a never-ending rush hour.
As the CEO of a physician group that provides medical care to over 4 million patients per year, I have the opportunity to study in great detail the trends in patient acuity, demographics and yearly visits in more than 80 emergency departments and watch the monthly variations. I recently asked staff, with the assistance of our in-house biostatistician, to project the ED patient volume in the future based solely on the incremental increase in the past patient volume in the past decade, while making no other assumptions.
The results were startling. If nothing changes, the “people curve” of patient visits to the emergency departments we serve will rise dramatically by 2020. These futures are merely a projection of actual growth rates from the past decade and they showed a doubling in ED patient volume between 2000 and 2020. At a hospital in California’s Central Valley, for example, we saw the volume of ED patients rise from 50,000 in 2000 to 70,000 in 2010 and they are expected to grow to 95,000 by end of this decade. Most noteworthy in the analysis were the number of hospitals with ED visits that are projected to exceed 100,000 patients per year.
These projections do not even include five major forces at play right now:
The U.S. Census Bureau projects that from 2010 to 2020, the population will grow to 336 million. The CDC reported national ED visits as 136 million in 2009, the latest data available, which was a 9.9% increase over 2008. Extrapolating total national ED visits for 2012 using our internal data for the period 2010-2012, I would project over 150 million ED visits across the nation.
The AAMC projects a shortage of 91,500 physicians by 2020. 45,000 of these physicians will be needed in the primary care setting. If nothing else changes, my experience leads me to believe that most of those people without dedicated primary care will access the ED for urgent, primary care, and specialty evaluation which is unavailable from other sources.
A study in the Journal of the American Medical Association indicated that from 1990-2009, the number of EDs in non-rural areas declined by 27% and some have predicted the closure of an additional 30% of EDs by the year 2020. The Governance Institute believes 5% of hospitals will close by 2020. As consolidation or closure of hospitals continues, the burden only grows on those hospitals that remain to adapt to rapid increases in patient volume that were not anticipated when their respective emergency departments were built.
Today’s healthcare system is incredibly complex. This article does a good job scratching the surface of some of the layers of administrative complexity, while a 2010 World Health Organization Report looks at the complexities that have arisen in the practice of medicine itself. At every level, from the entire country, to the hospital, to the department, and to the provider, we are experiencing increasingly complex budget, management and oversight which all add to the burden of providing care.
Healthcare consultant Nate Kauffman has summarized this concept best: “There’s no new money, only consequences.” As counties, states, and the feds struggle to balance their budgets, we have begun to see the inevitable pushback on reimbursements going to hospitals. Government and other payers will be expecting hospitals to continue with their standard of care but with far fewer resources.
I believe the ED will continue to be the nation’s safety net because there doesn’t appear to be any foreseeable alternative for the future.
Trackback from Perspectives on the Acute Care ContinuumThe number of PAs in the United States is rapidly rising. According to the National Commission on Certification of Physician Assistants, the number of certified Physician Assistants has increased 75 percent in the past eight years from 48,000 to 84,0... ...
Absolutely, we can and should diversity as we have done so with Galen Hospitalist group, MedAmerica, and MBSI. We can hire case managers and Emergency Transport Teams, and psychiatric facilities. However, we as owners and partners of a robust and growing business, must have the financial backing to take on such risk. Optimistically, with higher risk, we may reap higher rewards. Pessimistically, we lose our name, our shirts, and pull up on our boot straps and try again. At least, we would have tried.
A business can grow internally or externally. A restaurant chain can expand by opening more restaurants (external growth) or by attracting more customers per unit (internal growth). Dr. Curry points out that our internal growth is robust. Things could be worse. You could open a restaurant and then wait in bored anticipation while no one shows up to eat there. Sorry, lonely restaurant guy but.... that's not our problem! Our tables are over flowing with customers. Unfortunately most of the customers are paying steep discounts for their meals and some are eating for free. Of course, discounted or free food draws quite a crowd but is the job of CEPAmerica to not not only serve every customer who arrives but to provide delicious, fresh, creative nourishment with no delays, no mistakes and with the utmost attention to customer satisfaction. CEP has a history of vertical integration. We have our own billing company and our own medical liability insurance company. Vertical integration and product diversification have served us well in the past. We have some problems at the restaurant that can be fixed through some creative product diversification. 1) The Insane: The insane show up with police and paramedics. Some times they are shouting loud obscenities and need to be restrained. Sometimes they are quiet teenagers with cuts on their forearms and floppy bangs covering their sad eyes. A major problem with these customers though is that they never seem to leave. Medical clearance is done in an hour and then they occupy space for 12 hours, 24 hours, sometimes 48 hours while we look for an inpatient psychiatric unit to accept them. Why can't CEPAmerica open it's own in patient psychiatric facilities. We are told there is a shortage of psych beds? A shortage of a critical input is not a problem--it is a business opportunity. We we can build are own psych beds and hire our own counselors and psychiatrists and then decompress our own ERs so that the broken ankle in the waiting room has a place to be seen. Some will say that inpatient psych is outside our area of core competence. Well, you could have said the same thing about hospitalist programs, scribes and EMRs. Competence can be acquired, the core can be expanded. 2) The Youth and Mobility Challenged: These people don't stay as long as the insane but they stay a long time. The 80 year old from the SNF who is weak today has a UTI and a sodium of 129. After some Ceftriaxone and saline she is ready to go back to the SNF but not a single one of her 6 relatives at bedside can or will take her there. Hours later, two young people in red jackets and baseball caps show up and load her unto a gurney. Was that so difficult? Why can't CEPAmerica own and operate medical transport vans to ferry our patients home and out of our crowded restaurant? You can charge for that. What started as a group of emergency physicians now sells insurance, bills patients, and takes care of inpatients on hospital wards. The problems that Dr. Curry forecasts should call us to think outside the box, to expand our core competence into areas like inpatient psychiatric services, counseling teams, non-emergent transport vehicles and personnel. These moves will not only help decompress the restaurant--they will open up new lines of profit and opportunity within our partnership.
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