The Place Where They Have To Take You In

Days and nights on the front line at Minnesota's busiest emergency room.

"So we negotiate. We may get a social worker involved. We may talk to the primary care provider, and the HMO, and the family. This patient might at some point end up in a nursing home. But the nursing homes don't like to take people whose payor status isn't clear, and it's not easy to find a bed, and there's a strong emphasis on keeping people home as long as possible. And so he might be back here.

"We understand that the primary aim of managed care is to hold costs down by withholding services, and ideally you'd want to withhold unnecessary services. But that's a fine line."

This question of "withholding services" is something of a sore point with ER people. Like everyone, Sterner has heard the charge of "ER abuse," which comes down to the premise that anyone who's not critical shouldn't be here. He bristles a little at the figure generally thrown around--that an ER visit is three times as expensive as one at a clinic--noting that that's based on billings inflated to make up for insurance companies' discounts. According to a study published in last month's New England Journal of Medicine, the true cost of ER care for a noncritical case is only about 50 percent more than a clinic visit, due mostly to the expense of equipment and round-the-clock staffing.

That's still a fair chunk, and Sterner acknowledges that "a lot of the patients we see could be seen somewhere else in the health care system. But that's assuming"--now his trademark grin turns sarcastic--"that there is such a system."

If you've been sick lately, you probably know the story. You don't just walk into a doctor's office. You have to figure out which plan you're on, which clinics are approved, whether you have to call a help line first to get permission. You have to be prepared to wait a couple of weeks for an appointment. You need a phone, a babysitter, transportation, and of course you must be able to speak both English and insurance jargon. A recent study found that close to 40 percent of patients at large, public-hospital emergency rooms were "medically illiterate" to the point where they couldn't read the instructions on a prescription bottle, much less navigate the requirements of the average health plan.

"And even if they do all that," Sterner says, "and they finally get in to see a physician, if there's any barrier--education, language, whatever--then that physician is scheduled for six patients an hour. It's not like Marcus Welby. They don't have time to sit down and talk for an hour and figure things out."

"A lot of things are falling through the cracks. We're going from a cottage industry to a really, really big business that's turning out big dollars, and there are some very large corporations that are trying to make it a system by combining and coordinating services. But we have a tremendous number of patients who are bouncing all over the place, and they end up here."

During rounds, Sterner stops at one of the back cubes, where an older man is sitting on his bed, bent down so far his head points toward the ground. He's been letting out long, low moans every now and again. "What's wrong?" the resident asks as Sterner hangs back. "I'm just tired." "What--tired of the waiting? Your kidney disease?" "No. All of this. My whole body hurts. When I try to sleep at night, it just hurts all over. I can tell you there's something wrong. I can tell I'm getting weaker." "Well," the resident says, "you know, there's a doctor who's been following you for this--"

"Please," the man interrupts. "I just want someone to do something. Run a test. Do something. If you have to put me in the hospital, put me in the hospital. If I'm going to be in a wheelchair, at least get me prepared for it."

"But, sir, this is the emergency department. We don't have a lot of the equipment that we could use to run tests. We can look at your records, and maybe get an appointment for you and get things going in the right direction."

"But that's what everybody is telling me," the man's head drops again. "I'm telling you, this is getting too much for me. I can't take this anymore. I've been trying, but--I'm only keeping going because of my poor mother. She's real sick. I know that if something happened to me, it would kill her."

From the bottom-up perspective of the emergency room, it looks as if almost every time things tighten somewhere up the line--even when the changes appear benign--the chips fall down here. Like the advances in medical technologies that have made it possible to do complex procedures without keeping patients overnight. This has allowed hospitals to eliminate costly inpatient beds, which in turn puts more pressure on the people guarding the door.

"Our patient population has gotten a lot sicker," Sterner says, "and there's more of an effort to keep them out of the hospital. Here, any patient who stays for less than 24 hours [after being moved from the ER to a unit] is considered an inappropriate admission, and we catch heat for that. We've been able to keep our rate down pretty well, to about 1 percent. But it's always at the back of our minds. So we treat patients very aggressively for six or eight hours, and send them home. There's a girl back there who probably has a kidney infection, and that would have been a no-brainer 10 years ago--stick a line in her and send her upstairs. Now we load her up with antibiotics, check her white counts, give her some medication, and send her home. And she might be here tomorrow and we might start the same thing all over again."

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