Last week the Public Policy Institute of California (PPIC) released an interesting report on “Emergency Department Use in California–Demographics, Trends, and the Impact of the ACA”.  As the report’s title suggests, a primary focus was whether the Affordable Care Act (aka “Obamacare”) increased utilization of hospital emergency services.  

PPIC’s study found that while what they called “ED outpatient visits” did significantly increase it was not due to the implementation of the ACA.  “ED outpatient visits” was defined as patients “being treated and released the same day”.  Sort of like catch and release when fishing. PPIC expressed concern about the cost of such care and whether alternative ways of dealing with patient needs should be developed.

There is nothing new about the kinds of concerns the PPIC study noted.  Emergency services seem to meet a need but that is vexing to policymakers.  Everyone knows increased emergency service use  is not a good thing, right?

I will now commit heresy.  What’s wrong with something that meets a need, a need which keeps growing?  If I was a member of the pundit religion, I would be excommunicated for that statement.   There is nothing wrong though in questioning orthodoxy.

Emergency services clearly fill a need beyond the traditional idea of saving a life. Mothers with a baby with a high temperature want the reassurance of a physician doing an assessment–even if it is midnight on a Saturday.  An older man with a bad cold and a memory of once having pneumonia wants someone to reassure him that all he needs is some chicken soup and time and he will be better–even if the cost is a hospital bill and several hours time. It goes on and on.

Consider members of the millennial generation who appear not to be particularly enamored with an on-going relationship with a primary care physician. They are young and not creaky. They have a smart phone and if a health app does not cure what ails them there is always the corner urgent care center, assuming it is open after a hard night of playing Fortnite.

Most urgent care clinics are not open late at night and have limited capabilities when they are open.  Some restrict what insurances they will accept.  Don’t believe me? Look at their websites.  The same goes for the clinics in stores.  They are at best partial solutions to a bigger need.

Then there is the difficulty in accessing your primary care physician if you are lucky enough to have one.  Most offices are overwhelmed with patients, some of whom have waited a long time just to get a physical.  When the need is urgent in your mind, you want more rapid accessibility. and the ability to just drop in.

Emergency services have everything a patient may need all in one convenient place, 7 days a week, 24 hours a day.  Yes, they are more expensive than an urgent care center.  The analogy I have used in the past is that a loaf of bread in a 7-11 convenience store is more expensive that the same loaf at a supermarket but try finding that loaf in the early hours of the morning.  Accessibility and comprehensiveness comes with a cost.

In any other field, a service which finds itself in great demand would be considered something worthwhile and worth expanding.   Instead of  devoting more resources to making the patient flow process better in emergency services, we look to alternatives which the market place is not interested in buying.

I don’t believe we should be fighting what the market wants.  Providers and pundits are wrong to do that.  Instead, let’s find a way to make emergency services more efficient and able to take care of the growing demand.  Give emergency services more room to live in and continue to increase the use of nurse practitioners and physician assistant working together with physicians specializing in emergency medicine.

At my core, I am a hospital guy.  Despite the learned but ignorant claims of academics and pundits, hospitals are not dead.  They live and if you doubt it, just go to your local emergency service. People are voting with their feet.

I know all of this is a minority opinion and counter to the punditry religion.  Consider me excommunicated.






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