Silly idea: plan to meet demand.

[mycrofft]

Not about street emergency medicine, but hospitals.

1. Hospitals are there to take care patients. And make money.
2. Emergency departments are overwhelmed.
3. Cost per pt due to mega-diagnostics and subsidizing no-pays (ER's have worst ratio of billed versus collected dollars) is very high.
4. A very significant percentage of ER patients use them as their primary care providers, or have been turfed to them by public and private health care providers, often basically as a means to force admission.

Hospitals do not expand emergency services because it is a money-losing dept.

Patients wait for hours, sometimes without ongoing appropriate triage and re-triage. Real emergencies, especially walk ins, are lost in the herd of backaches, cerumen impactions and incipient detoxers looking to score.
QED, their mission is failing because they are not willing to execute it intelligently.

Why don't hospitals put the accent upon their "emergency departments", with stiff triaging to non-emergency services available 24/7 side by side with the ER's? (Why are so many government agencies, including the Defense Dept., outsourcing their hospital care to private facilites who have higher admin overhead or fundrasing depts, PR depts, legal depts, aquisitions and property management depts...)

 

[Chimpie]

Excellent topic. Excellent post.

So how does an ESD recoup the money it loses on those who don't pay?

 

[VentMedic]

So how does an ESD recoup the money it loses on those who don't pay?

So many factors, where to even begin. There also so many regional and state issues that must be addressed. Illegal immigrant healthcare and near bankrupt states like Calfornia (not just from illegal immigrants) are enormous in the way it affects the way some physicians now practice. MediCal (CA's version of Medicaid) takes forever to reimburse when they do have the money. The facilities that depend on the MediCal checks ahve even had to risk not paying their employees.

Good article with more good references at the end:
The Impact of Unreimbursed Care on the Emergency Physician
http://www3.acep.org/practres.aspx?LinkIdentifier=id&id=30308&fid=

Washington Watch: Emergency Care System Still at the Breaking Point

http://www.medscape.com/viewarticle/565109_1

I post links because some may have different interpretations of the literature than I. Also, there is just to much info.

Many hospitals now do have a fast track lane for non-emergent minor injuries. Some do have access to clinics for referral on the hospital campus as long as it abides by EMTALA regulations. One hospital in north Florida has a call in system to allow people to know how long their wait will be.

Unfortunately, part of the backlog is the inability to move patients out of the ED to the ICUs or floors due to lack of space. Smaller hospitals may also be trying to do ER to ER or ER to ICU transfers for a higher level of care. Many of those patients end up dying at that little hospital while waiting for a transfer which may take several hours to several days.

Some EMS systems still transport to the nearest facility regardless of trauma, stroke or STEMI. Then, a rigid criteria with a long list of mandates must be met by that ED physician to get the patient transferred. There's the different criteria for the diagnosis, diagnostic tests, getting acceptance from the other hospital and doctors, insurance, EMTALA assessment/regulations to be met and finding transportation that meets the criteria or freeing up hospital staff to accompany the patient.

We even run more ventilators in our ED than some hospitals do in their ICUs because there is no room in the units. Some ventilator patients may even be in the ED so long they are extubated and down graded to another level of care.

I will say even iwth some of its faults Kaiser Healthcare has an efficient business model as do some of the Sutter Hospitals. The SDA are also masters of their healthcare care systems for running an efficient business model and still providing quality care for the most part.

Speaking of faults, California hospitals have another issue that is taking a huge amount of funds and that is retrofitting or relocating their hospitals.

 

[mycrofft]

Vent, I really value that post! Thanks!

What I see about the hospitals which do the best is that they are able to turf off patients to other facilities. Here in Greater Sacramento, despite lobbying for and receiving designation as one of two trauma centers, Kaiser is still able to delegate treatment for many cases off to UC Davis and other hospitals and is very unresponsive to case management and information requests from anyone, even the County. Mercy does what it can to deflect the medically indigent and is likewise uncooperative with other hospitals and government agencies. These are our best-billing hospitals. Sutter General takes more medically indigent (apparently being the divertment ER for UC Davis Medical Center, which is the area's "big dog"), but Sutter has had their ER recoupment as low as around twenty cents on the dollar.

The floors are being stacked with knee arthroplasties, gastric bypasses, and other well-paying and reimbursed non-emergency procedures. But then, while crying poor, the hospitals have been snapping up local properties, even before the economic downturn lowered prices, to expand their campuses. Their ED's expansions is have not kept apace.

Kaiser declared in 1989 after Loma Prieta that they were going out of the hospital business, going to manage medical properties other people would operate. Not only did they stay,but built new hospitals and here they still occupy a building they were going to demolish in 1990 due to seismic concerns.

 

[VentMedic]

Kaiser declared in 1989 after Loma Prieta that they were going out of the hospital business, going to manage medical properties other people would operate. Not only did they stay,but built new hospitals and here they still occupy a building they were going to demolish in 1990 due to seismic concerns.

CPMC in SF bought the Cathedral Hill Hotel which is supposed to be the sight of their new seismic correct facility. However, that keeps getting postponed and from what I have heard, the hotel business is doing very well for them.

Cathedral Hill Hotel
http://www.cathedralhillhotel.com/

 

[mycrofft]

The joke at my old ER since Mercy took them over..

Being out in the sticks when they moved in (not so much anymore), whenever they saw "the gray ladies" there it meant someone was about to be fired.

UC Davis did a bangup job getting more income to offset operating costs, but they still have pts waiting up to 24 hrs in ER to be seen.

24 hrs. That's Third World.:sad:

Any Los Angles folks want to comment on this?!

 

[silver]

What I see about the hospitals which do the best is that they are able to turf off patients to other facilities. Here in Greater Sacramento, despite lobbying for and receiving designation as one of two trauma centers, Kaiser is still able to delegate treatment for many cases off to UC Davis and other hospitals and is very unresponsive to case management and information requests from anyone, even the County. Mercy does what it can to deflect the medically indigent and is likewise uncooperative with other hospitals and government agencies. These are our best-billing hospitals. Sutter General takes more medically indigent (apparently being the divertment ER for UC Davis Medical Center, which is the area's "big dog"), but Sutter has had their ER recoupment as low as around twenty cents on the dollar.

The floors are being stacked with knee arthroplasties, gastric bypasses, and other well-paying and reimbursed non-emergency procedures. But then, while crying poor, the hospitals have been snapping up local properties, even before the economic downturn lowered prices, to expand their campuses. Their ED's expansions is have not kept apace.

Kaiser declared in 1989 after Loma Prieta that they were going out of the hospital business, going to manage medical properties other people would operate. Not only did they stay,but built new hospitals and here they still occupy a building they were going to demolish in 1990 due to seismic concerns.

well you know the state restricts the number of beds that a hospital can have including the ER? it is very hard to get an increase and the only practical way is to buy a hospital. so what people do is buy out old hospitals, and then tear them down so they get the beds, and then rebuild into their new hospital.

Around here the ERs are packed and there is a 24/7 fast track clinic, but the ER side normally has 150+ patients in it when its busy (excluding waiting/triage). There are times where ambulances are diverted because there are 100 patients just waiting for beds to be admitted. (mind you there is a peds ER as well).