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Is the new health law a good opportunity?
[Editor's note: ED Management issued an e-bulletin to readers on March 24, 2010, about health care reform's impact on EDs. We also described recent studies on the impact of health care reform in Massachusetts on ED crowding. ED Management issues such bulletins to keep readers informed of the latest developments in emergency management. If you wish to receive future ED Management bulletins, contact customer services at (800) 688-2421 or firstname.lastname@example.org.]
Now that health care reform has become legislative reality, what does the future hold for EDs?
"I'm not sure anybody really knows," says Don Lombino, MD, FACEP, chairman and director of emergency medicine at The Stamford (CT) Hospital. "There will potentially be 32 million more people with insurance, and we do not have excess capacity as it stands today in the ED and among primary caregivers; this will really stress the system."
Angela F. Gardner, MD, FACEP, assistant professor, Division of Emergency Medicine, Department Of Surgery, at the University of Texas Southwestern Medical Center in Dallas and president of the American College of Emergency Physicians (ACEP), agrees. "I think the first thing people have to anticipate is that ED volumes are going to go up," Gardner says. "Our experience in Massachusetts saw a 7% increase across the board." ACEP cites two recent studies.1-2 "The nation can anticipate a similar event to occur," Gardner says. (When EDs become significantly crowded, remember the basics such as frequent vitals, she says. See Clinical Tip on p. 53.)
Karen Rieger, JD, shareholder and director of the law firm of Crowe & Dunley in Oklahoma City, OK, and chair of its health care practice group, offered a different opinion in a recent interview in a local paper.3 "Hopefully, what this will do, is with 30 million more Americans being covered, they will be able to get routine care earlier from their physicians or from a clinic before it becomes and emergency," she said.
However, a recently published study in the National Bureau of Economic Research looked at 19-year-olds who had just been dropped from their parents' coverage.(Reference 4) The researchers found that not having insurance resulted in a 40% reduction in ED visits.
Even if EDs see an increase in patients, that increase is not necessarily a bad thing, counters Steven J. Davidson, MD, chairman of the Department of Emergency Medicine at Maimonides Medical Center and professor of clinical emergency medicine, State University of New York Health Science Center, both in Brooklyn, NY. "There will be more patients, which will be a great opportunity for EDs and emergency physicians," Davidson says. "As a specialty, it creates the opportunity to re-tool how our EDs work with streaming rapid evaluation units so that the many minor illnesses and injured patients we see get expeditious care and are turned around quickly."
On a positive note, adds Gardner, "Under EMTALA the ED has to care for people regardless of ability to pay, and many do not pay now, but five years from now those people will have some form of reimbursement. From that perspective, EDs should have a slight increase in reimbursement."
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ED managers must take action now
While many aspects of the newly passed health care reform law will not take effect for several years, experts say that ED managers should waste no time in preparing for the changes to come.
"They need be thinking about those things now," says Angela Gardner, MD, FACEP, assistant professor at the University of Texas Southwestern in Dallas and president of the American College of Emergency Physicians.
"Many conditions are best treated by an ongoing relationship with the primary care physician, and we will have to gently lead our patients to that conclusion," Gardner says. For example, she notes, with conditions such as diabetes, hypertension, and asthma, the patient needs to see the primary care physician to have their disease managed.
ED managers should emphasize educating patients and have their staff tell such patients "We'll get you started on these meds, but do not come back to us for refills. Get seen by a primary care physician," she says.
In fact, that education should begin before these patients end up in the ED, via public service announcements and similar vehicles, Gardner says. "I think it's up to us as leaders to lead the way in helping people get to the best place for the care they need," she says. (For examples, see resource box, below left.)
Don Lombino, MD, FACEP, chairman and director of emergency medicine at The Stamford (CT) Hospital, agrees that patient education will become an even more important issue for EDs. "Hopefully [this law] will be the first step in a process, and as this process proceeds, we need to make sure our patients are part of that process that they take some responsibility for their care on some level," Lombino says. "We should be there to guide them and help them as a partner."
Every time a patient is seen in the ED, there is an opportunity to educate them on safety and prevention, he says. "It can be simple things like using seat belts in a car, wearing bike helmets, or stopping smoking," Lombino says. "We need say in a non-dogmatic but strong way that we want to see them have an improved quality of life."
EDs and primary care will be inextricably linked as this new health care reality unfolds, predicts Steven J. Davidson, MD, chairman of the Department of Emergency Medicine at Maimonides Medical Center and professor of clinical emergency medicine, State University of New York Health Science Center, both in Brooklyn, NY. "In the next few years there will be a deluge of patients coming to us because of improved access, which we can address through rapid evaluation units and patient flow and processing techniques without spending much on bricks and mortar, while primary care improvements, if successful, will eventually draw the less urgent patients away from the ED, giving us the opportunity to appropriately respond to aging baby boomers who will be coming in sick and horizontal," Davidson says.
Don't forget vitals in crowded ED
If health care reform makes EDs even more crowded, as many predict, it will be critically important to remember to maintain the frequency of vitals, says Angela Gardner, MD, MD, assistant professor at the University of Texas Southwestern in Dallas and president of the American College of Emergency Physicians (ACEP).
"This clinical 'pearl' will help ED doctors stay out of trouble," Gardner says. "When crowding is at its worst, be sure the vital signs on patients get reassessed frequently because they tell you what's going on."
If you don't, she warns, on "crowded crazy busy" days, you'll inevitably discover that a patient who hasn't had vitals taken in four hours is "suddenly" worse, "You should take vitals at least every two hours," Gardner advises.