Don’t look in the emergency rooms for the solution

James Joyner of Outside the Beltway notes a study that has identified serious problems with emergency rooms in the United States:

Half a million times a year — about once every minute — an ambulance carrying a sick patient is turned away from a full emergency room and sent to another one farther away. It’s a sobering symptom of how the nation’s emergency-care system is overcrowded and overwhelmed, “at its breaking point,” concludes a major investigation by the influential Institute of Medicine.

That crisis comes from just day-to-day emergencies. Emergency rooms are far from ready to handle the mass casualties that a bird flu epidemic or terrorist strike would bring, the institute warned Wednesday in a three-volume report.

“If you can barely get through the night’s 911 calls, how on earth can you handle a disaster?” asked report co-author Dr. Arthur Kellerman, Emory University’s emergency medicine chief.

That ERs are overburdened isn’t new. But the probe by the IOM, an independent scientific group that advises the government, provides an unprecedented look at the scope of the problems — and recommends urgent steps for health organizations and local and federal officials to start fixing it.

The article goes on to summarize the proposals from the report which include increased federal funding, guidelines, and a (presumably federallly-funded) management system for ambulances.

I agree completely with James when he notes:

There are certainly huge gaps in our system and the patchwork of part capitalism, part socialism may indeed be worse than either extreme. The fact that someone else pays most of our medical costs takes away any incentive to cut costs, especially when combined with a tort system that further distorts the economics.

He goes on to point out some cases which suggest that other countries, including those with single payer systems and fully socialized health care, have problems with emergency medicine, too.

I think it’s pretty difficult to draw too many conclusions by comparing health care systems between different countries—there are too many variables to control for. Additionally, the market for health care is becoming ever more globalized and you can’t consider a single country’s experience in isolation. I’ve pointed out the supply bottleneck in our own health care system pretty frequently. When you combine that with our enormous wealth and willingness to pay, it’s apparent that our system raises the cost of health care worldwide.

However, there are a few hints for a more systemic approach to correcting the problem with emergency rooms. For example, in the years following the adoption of TennCare (remember TennCare?) there were some interesting studies that suggested that TennCare had succeeded in one of its objectives: participants were more likely to use relatively less expensive internists as primary care physicians rather than relatively expensive emergency room physicians.

We require emergency rooms to accept patients regardless of ability to pay. They must make up those costs somewhere and that must be done by increasing the fees paid by those who do have the ability to pay. So it’s higher taxes (to pay for more generous health care for the poor) or higher insurance premiums—take your pick.

As I see it there are only a limited number of alternatives:

  • abandon the requirement that emergency rooms treat regardless of ability to pay (unethical, immoral, and politically impossible)
  • provide for more generous health care for the poor (politically difficult)
  • pay higher health insurance premiums (this will result in marginally fewer company-paid plans)

I suppose you can go naked yourself and be part of the drag on the system

It also bears mentioning that there’s an intimate relationship between our immigration system and emergency room care: illegals pretty typically don’t have any kind of coverage. The emergency room is their only recourse.

I think the cross-ruffing that results from the specific mix of private and public funding of health care in the United States has created a death spiral for the system and without seriously considered reforms soon a hastily adopted and poorly considered single payer or more fully socialized system of health care is inevitable. The cage match between those for whom no system other than a fully socialized system is acceptable and those who get the vapors whenever they hear the words “socialized medicine” very nearly guarantees it.

If the proposals suggested by the report are being described fairly by the article cited above, it looks to me like a rather brazen instance of rent-seeking. How appealing is a patch on a patch?

UPDATE: I also agree with Shakespeare’s Sister when she notes that our system isn’t as good as it could be or should be. Especially for what we’re paying. I also tend to wonder about the societal impact of the enormous movement of investment from other industries into health care which pays relatively fewer people relatively well.

3 comments… add one
  • Another issue is that the ERs themselves are going out of business. In LA, for example, the closest level one trauma center to the majority of poor/minority folks is more than 10 miles away. As ER costs skyrocket, the hospitals (and frequently the government entities that run public hospitals) are closing them or downgrading them as a cost-cutting measure. In LA, this was the King/Drew medical center ER, which served Southwest and South Central Los Angeles (now known as “South LA”)….

  • As I noted, the money to operate an ER has to come from some where. If they can’t recover from patients without insurance and they can’t raise the rates for insured patients, closing the doors may be the only alternative. Expecting them to operate at a loss isn’t a reasonable option.

  • jill Link

    This is the only country in the entire world where anyone from any where can land at JFK Airport in New York, then take a cab to Jamaica Hospital and have a knee replacement or any other surgery or treatment for FREE. The hospital will also provide an interpreter because they must. Most people I tell this to are incredulous but it is the truth. It is true for every hospital in the U.S. If they bring their children, the children will get a free education and free medical care, no questions asked.
    This is insanity. In New York, Medicaid is 40% of the budget, over 40 billion dollars. The New York Times estimates close to half is outright fraud but thats another story.
    Any person from anywhere in the world, unreal.

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