A Prescription For Decreasing Emergency Department Demand.

I think it needs to be stated at the beginning that there will always be some public discontent with health care systems, just as there is always some discontent with life itself. As I’ve stated before, all normal creatures move to and desire survival and comfort, so just determining the parameters of Health care”, yet alone society’s obligations to its citizens (as opposed to personal responsibilities) in this area, presents enormous controversy. The purpose of today’s blog entry is to show that no matter where you stand on most health care issues, improvements can and should be made to the present system. I will discuss solutions that fall within the Canada Health Act and solutions that fall outside of the Canada Health Act.
A) Solutions within the Canada Health Act.
1) Graduating more medical, nursing, and technical practitioners. This is a given; however, unless we retain these practitioners, the money invested in them has been wasted (Retention of practitioners is a topic in itself and will be addressed separately. Basically it involves giving more autonomy, independence and control over a myriad of working conditions, to workers in the health care field). This solution lends itself to “long term” approaches since training time for various professionals in the health care field varies from four to fourteen years.
2) Fast tracking the qualifying foreign graduates is given as a solution but is far more complex than the general public perceives. Matters of language, training, attitudes, beliefs, social customs, and many other factors come into play. Doesn’t it make more sense to try to recruit back the thousand of Canadian graduates that have sought employment in other countries? To do that we have to look at the reasons they left, and address those issues. Providing a more “comfortable” work environment for health care providers in Canada could start a significant and immediate return to Canada of many of them.
3) Put incentives into the system that encourages doctors and other health care providers to look after sick people outside of the hospital and emergency department settings. At present there are only negative incentives in the community for caring for the chronically ill, acutely ill, complexly ill, and frail elderly. At present a community physician, by limiting their practice to trivial episodic care, can generate 200 to 300% more income than a practitioner doing complex ongoing care. My suggestion would be that for the next five years all fee increases be applied to increasing the fees for complex care. If the fee for seeing a diabetic seventy five year old with pneumonia was five times more than seeing a twenty year old with a sore throat, we would see a renewed interest in the care of the sick and elderly. When I retired one of my elderly patients with Parkinson’s disease was interviewed by several family practitioners as a prospective patient and rejected on the basis that” the practitioner was not THAT knowledgeable about Parkinson’s Disease”. I would suggest to you that most “interviewing” done today to see if there is a “patient/physician fit” is primarily done to see how time consuming a patient may be, and whether taking them on as a patient would be cost effective. Perhaps if the complex/ill patient visit paid five times what a “routine” visit paid, there would be competition for the seriously ill patients by the community physicians. As a consequence these patients would show up in the emergency department less frequently because a physician actually seeks, assumes, and takes responsibility for their care in the community! The same principle should apply to the medical care in extended care facilities in the community and to hospital care.
4) Use and payment of “physician extenders”.
At present, if a group of physicians hire a physician extender, nurse practitioner, etc, there is no payment system in place to recapture that provider’s salary. Years ago, dentists found that adding an hygienist to the office practice was both cost effective and a benefit to their patients. A registering system for qualified physician extenders/nurse practitioners should be set up and a payment system for their services undertaken. This payment system could be part of the “Medicare” System, private, or a combination of both. This addition to an office setting would enable physicians to direct their TIME to the more seriously ill, as well as increasing their capabilities in dealing with the more seriously ill. The end result will be better access to care in the community, better use of the physician’s skill and training, and fewer visits to the emergency departments.
5) Fast tracking of community patients who are of considerable concern to their community family physicians. This basically means that community physicians who take on the care of patients who are seriously ill, and/or have special needs, must have better access to resources. For example, as long as the emergency department physician can get an MRI the same day and the community physician can’t get an MRI for the same patient for two months, patients of concern will be downloaded to the emergency departments. As long as emergency physicians can refer directly to cast clinics and community physicians can’t, telephone triaging of traumatic injuries directly to emergency departments will occur, and these people will not be seen or cared for in the community by community doctor’s offices.
6) Having physicians do the triaging in the emergency departments, and fast tracking those patients that have the greatest medical needs.
Physicians are trained to diagnose illnesses and know the consequences of the various diagnoses. Priority must be given in the public system to those individuals in an emergency department that may come to harm. Those that will not come to harm will have to wait or be seen in the community. Some of our emergency departments have accepted and implemented the U.S. Hospital System of fast tracking minor conditions. This is wrong on several fronts. In the American system, hospitals MAKE money from seeing minor conditions in the emergency departments. In our Canadian system, it takes from the hospital budget and takes the time of personnel that should be attending to the more critically ill. Today, only a small percentage of patients use the emergency departments for trivial complaints. If we shorten the waiting times for trivial complaint, more and more people will use the emergency departments inappropriately.
7) We must develop more capacity in community facilities (both physical and care-giver), to deal with patients that do not need the acute multidisciplinary approach of a full general hospital. This entails transitional care facilities (patients simply slow to get well enough to return home), rehabilitation facilities, palliative care facilities, etc. This has been done to some degree, but has been marginalized and not supported sufficiently with appropriate diagnostic and financial care-giver support. This type of a program is both medically sound (if done properly), and cost effective. It is imperative, however, that the care givers in these settings are given the tools, autonomy, and financial rewards for their complete buy-in. The Calgary region has attempted to implement some of these ideas, but since there has not been financial and medical back-up for them, most care givers view these attempts as “dumping” into the community. As such, there is continued resistance on the part of community doctors. If this were to be done properly, with the appropriate incentives, many acute treatment hospital beds could be freed up for emergency department admissions, and patients could be triaged directly to these community physician/facilities, by the emergency physician.
The above suggestions are only a few that I think would improve the provision of health care in Canada within the terms of the Canada Health Act. Most of these suggestions are based on the premise that if we pay people for what they do, we will get a better return for our taxpayer dollar. The present system IS NOT a fee-for-service system; it is a fee for visit system. As such practitioners are rewarded financially for taking the least time and the least responsibility for a “visit”, and penalized financially, time wise, stress wise, and from a medico-legal perspective, for looking after complex and significant health problems in the community. In most areas of our society, people get paid for what they do; whatever and whoever decided medical caregivers can and should be treated differently?
Since this dissertation has gone on long enough, I will make suggestions that may well fall outside of the Canada Health Act on my tomorrow’s blog. Any comments or questions are welcome!