Monday, December 09, 2013

The ACA: An Emergency Room Workers Perspective

By ERdoc in PA on Thu Nov 28, 2013

One of the more hackneyed and deceptive statements throughout the Affordable Care Act debate was how we have “the best healthcare delivery system in the world”.  I’ve been an ER doc for about a decade, and I know from first-hand experience that it just ain't so.

But what really stuck in the collective craw of emergency physicians was the glib response to the lack of insurance coverage for millions.  More than one politician suggested that people could always go to the Emergency Room.  Uh huh.  News flash:  Emergency Rooms are for, you know, emergencies.  When folks visit the ER for conditions not deemed to be life threatening, well-intended providers often don’t fix the problems, or even dig deep to figure them out – there just isn’t time or resources to do it. And poorly-treated, less dangerous conditions can sometimes blossom into full-blown disasters. Without insurance, and therefore without access to non-emergency providers, these situations become very expensive, and… they can kill. The ACA, bringing many patients under the umbrella of coverage, will avert the severe outcome for many.

Consider the orange squiggle the front door to my Emergency Room on this Thanksgiving day.  Push through, and let me introduce you to a few patients (of course, all names and details are altered from actual cases, but I assure you, people just like these are extremely, painfully real).

It’s 10:35 AM on this Thursday morning, but the ER is full of activity.  Nurses and physicians scurry about, patients are wheeled into rooms on gurneys, overhead announcements blare.  A colorful plastic blow-up turkey sitting on the registration desk is one of the few signs that this is a holiday. 

Let’s visit Room 22:

Sitting in the exam room is John.  He is 48 years old, a married father of two girls.  He was the breadwinner until he lost his job at a call center, and is currently looking for work.  His wife Lauren works part time as a teacher’s assistant.  They have no health insurance currently, and are trying to get on the Medicaid rolls.  John is not thrilled to be in the ER, but went at Lauren’s urging– he has been having occasional shortness of breath and nausea, especially with exertion, and it’s getting her worried.  He feels fine right now, but with their extended family visiting for the holiday, she wanted to make sure he was alright.  He resisted for a week, but finally relented. 

John doesn’t have known medical problems, and his symptoms are fairly vague: no chest pain, no physical exam findings.  The provider team obtains blood tests, an EKG, a chest x-ray – and everything comes back normal.  Since he feels fine after a few more blood tests over the next four hours, the physician on duty says that he can go home…. with the strong recommendation that he get a cardiac evaluation as an outpatient.  It could be a coronary artery blockage, the doctor tells them.  In the modern U.S. healthcare system, there is no way a guy like John gets admitted to the hospital for evaluation.  And without coverage, John can’t get to a specialist or undergo expensive outpatient cardiac testing, so he and his wife wait, and hope for the best. Once he gets back in the workforce, they reassure themselves, they will get him to a doctor.

Two weeks later, John is helping clean up the house, and his shortness of breath comes on hard, only now it is accompanied by crushing chest pain.  Lauren calls 911, and an ambulance rushes John back to the ER.  He is diagnosed with a heart attack, and undergoes immediate (and expensive) cardiac catheterization to open up a clogged artery.  Turns out, the shortness of breath and nausea were subtle signs of coronary blockages, extremely common in the U.S. population – but when he visited the ER on Thanksgiving, the blockages had not yet caused a myocardial infarction (MI), the technical term for a heart attack, so his tests were normal. Although John’s heart sustained damage from the ensuing MI, he is luckier than thousands of Americans who share his story – in many such patients, the MI triggers cardiac arrest, a condition that is lethal in over 80% of victims.  And John wanted to do the right thing: with expanded coverage under ACA, John would have seen a specialist as recommended.  His coronary blockage would have been diagnosed, and medication would have been started to help prevent the ensuing attack. Taking these cases in aggregate, the ACA would very literally save lives.

OK, one more example – let us visit Room 31.

Emily is a 28 year old waitress.  Hard working and ambitious, she is saving up for graduate school.  She is currently uninsured, because for her the choice is either buy health insurance or save for her future education.  She is visiting the ER today with irritating abdominal pain that just won’t go away. In fact, this is her third ER visit in two months.  In two other ERs, Emily underwent blood and urine tests that came up empty. Given her age and mild symptoms (no fever or vomiting, for example), neither an ultrasound nor a CT scan was justified.  The recommendation to follow up in a clinic was of course useless to Emily.

Repeat visits to different ERs are a common and costly problem. With our fragmented healthcare system comes another nasty inefficiency: precious few ERs enjoy linked health care records.  Since the process of contacting medical records departments at other hospitals (usually closed on weekends and holidays, anyway) is time consuming, most ER providers don’t bother to do this for well-appearing patients – so they repeat the same battery of tests that were performed a week prior at another ER, if only they could have checked.

Today, Emily again receives blood and urine tests, all negative.  She is frustrated, but the providers don’t have any answers.  She asks for an x-ray or CT scan or something, anything, to figure it out.  My ER colleagues explain to her in sympathetic voices that it’s not medically indicated, but a primary care provider could maybe set her up for additional testing.  Emily shakes her head in frustration, signs her walking papers, and goes home.

Emily finally makes it to the free city health clinic, where an abdominal ultrasound is ordered.  However, it takes a month in the queue before she actually gets one performed since the free clinics are completely overwhelmed with such patients.  When completed, she receives bad news – she has abnormal growths in her abdomen, and a biopsy is recommended.  That takes an additional month of waiting, and Emily is eventually diagnosed with metastatic cervical cancer.  Her life is now in jeopardy.  With ACA coverage, Emily would have gladly visited a gynecologist regularly, and a Pap smear may have caught her condition much earlier, perhaps even before the cancer had spread.  A Pap smear costs pennies compared to the costs of treating metastatic cancer, and it represents an excellent example of the power of preventative care: cheap, effective, and often life-saving.  ERs don’t do Pap smears. 

As I join my wife’s family for Thanksgiving dinner this year, I will look upon a large assembly of educated and gainfully-employed cousins, aunts and uncles.  They are lucky, and they know it. How many similar dinners will be taking place where the gathered company is less fortunate?  How many uninsured people at American tables are silently weathering abdominal pains, chest discomfort, or headaches, worried about what these symptoms might mean but not sure what to do without the resources to seek appropriate care?

Despite its many flaws, the ACA will have a very real impact for many people, on this very day as we enjoy family and friends at the dinner table.  It sure won’t make our healthcare system “the best in the world”, or even close to it.  But if John and Emily can get the care they need, they and their families will have a better future, and will have many more Thanksgivings to celebrate in years to come.  DailyKos