What's Wrong with Healthcare?

Thinking inside and outside of the healthcare box. After 41 years of family practice, what's happened to Canada's healthcare system?

Sunday, August 27, 2006

Innovation/Cost Effectiveness Equals Emergency Room Crises.

I suppose it will be interesting to see where the Health Quality Council of Alberta goes with their assessment of Calgary’s emergency departments; but I’m not optimistic that anything good will come of it. To really look at emergency services in Calgary, one has to understand that emergency services are only one part of a continuum of health services (although one of the more visible parts), that ranges from the care of relatively healthy people in the community, aged and chronically ill, people with assisted living and aids to daily living in their homes, institutionalized people with assisted living, transitional care, rehabilitation care, long term care, and palliative care, in combination with community health care providers (family doctors, home care, E.M.S, palliative care providers, etc), to the care of people in the intensive care units of our Acute treatment hospitals. The demands on the emergency departments of our hospitals, to a great extent, reflect our failures in the community as a whole, and in the care and discharge processes of our hospitals. In short, the innovation and striving for cost effectiveness that has taken place over the last fifteen years. Do we really think that a government appointed body is going to point a finger at “innovation” or cost effectiveness? Now I’m not saying that all that has happened is wrong; I’m just saying it was predictable and could be expected.
Let’s start with the healthy people in our society. They impact our emergency departments because of accidents, acute illnesses, anxieties, etc. The truth is that this group is actually decreasing its demand on emergency services. As we put in helmet laws, seatbelt laws, and safety standards in the work place, as a group, the healthy people in our society are taking a smaller toll of our emergency resources. Contrary to popular opinion, only a small fraction of the visits to emergency departments these day are from people who are there inappropriately. So far, so good!
But lets take a look at where innovation and cost effectiveness has taken us in the care of the aged, chronically ill, and others needing more ongoing interventions.
1) To be more cost effective, smaller community laboratories and x-ray (diagnostic imaging) facilities were shut down and centralized. In itself, no big deal for the healthy and mobile, but a huge factor for both the community physician and the aged/chronically ill patient. Rather than inconvenience a patient with pneumonia by trying to assess their risk in the community, it was expedient for the community physician to simply send them to emergency departments.
2) Stratification of patient care became the champion of cost effectiveness for those that needed on going care. The community physician no longer determined the level of care for the patient. A placement assessor and coordinator determined where a patient would get the most care (often rightfully most appropriately) for the health care buck. Each patient was given the maximum care with the minimum cost (services). This is good and well, but since the aged and chronically ill are a quickly changing group with regards to their needs, and since the facilities where they were placed did not have the capacity to assess their needs, little change was required to warrant a trip to the emergency (this of course was aggravated by lack of diagnostic community resources, see #1).
3) Early discharge from hospitals to communities with decreased resources in the communities precipitated the revolving door syndrome----- the patient was discharged in the A.M. and because of a multitude of factors (communication, follow-up, community resources, lack of community physicians, etc), the patient would be in the emergency department the next day.
4) Stagnant fees for family doctors, lack of visible appreciation for those that put out extra effort (charged parking for seeing their patients in hospital), did continuing care, nursing home care ,etc., forced family doctors to look at their practices in a cost effective way. This resulted in many dropping hospital privileges, nursing home privileges, restricting geriatric care and any other care that was time consuming. Many took on walk-in clinic care that gave more control over their lives, but did less to address ongoing or complex care issues. I tried for years to encourage the family doctor’s fees committee to build in incentives for doctors to take on more complex care, to no avail. At present, seeing a diabetic patient with heart and renal failure and pneumonia pays the same as seeing a healthy twenty year old with a sore throat. In Alberta, we get less that $2.00 more for seeing someone over the age of 75 years. So if we see someone in the office who is aged and ill, and will require time to assess properly, the reasonable thing to do for the physician, from a cost effective perspective and a malpractice perspective, is to send them to the emergency department (and considering all aspect of access to community resources, probably best for the patient as well).
5) Centralizing services for patients such as cast clinics at hospitals. For years many community physicians looked after a wide range of patients with fractures. With limited access to community diagnostic imaging, doing these things in my office became impractical. When I attempted to refer to the cast clinic I was told to send the patient to the emergency department (where the physician simply looked at the X-ray that was done and sent the patient to the cast clinic). With such a system in place, why would I even see injuries in my office, yet alone inconvenience the patient by sending them for an X-ray, having them bring the X-ray to me, and then sending them to the emergency department (where they have X-ray capabilities). If a patient phones the office with what sounds like a significant injury just triage them directly to the emergency department.
6) As emergency departments became busier, they soon realized that many of their visitors fell into the “revolving door category” due to inadequate placement, follow up, community resource access, etc. Soon emergency departments were given priority and resources to deal with home care, palliative care, mental health, placement issues, social service, and numerous resources that as community physicians we had difficulties accessing, but realized would be a benefit to out patients. Subsequently, when these patient needs presented in out offices, the best way to access these resources and benefit our patients was to send them to the emergency departments.
7) Lastly, and very importantly, patients cannot stay in the emergency departments for extended periods of time. This is due to lack of physical capacity and manpower capacity (once you are admitted to the emergency department a physician must be responsible). This means that at some point you must either go back to the community (and/or its institutions) or be admitted to hospital. Admitting to a hospital bed is dependant on two factors: a) availability of a bed, and b) availability of a physician who will agree to take on your care. Since we now have 1.6 acute treatment beds per 1000 population compared to 3.3 acute treatment beds per 1000 population fifteen years ago, and since most family physicians have discontinued hospital practice, the emergency holding beds frequently are taken up by patients requiring admission.
The above are but a few of the factors affecting our emergency departments, but constitute a significant impact. In short, there is a huge increase in acuity of illness and need for intervention in Calgary’s communities as a whole, and an abysmal lack of community resources. I find that, for the most part, community physicians feel they have been abandoned in our health care system, and are in survival mode. Since the emergency departments of our hospitals simply reflect the acute care needs of the community, it will be interesting to see what the Health Quality Council of Alberta will come up with, but as I said earlier, I’m not optimistic.

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