Economic Stimulus, Health Care, and the Definition of Emergency

The U.S. is engaged in a fundamental and complex struggle reflected through various sectors. This struggle is particularly evident in economically sensitive sectors. In trying to solve problems, it is a tendency of government to remain peripheral in insight, while powerful in hand-out. Indeed, the announcement of a stimulus bill of magnitudes never before imagined has created a feeding frenzy in many quarters, health care among them.

Consider for a moment the definition of the term "emergency" with respect to both the US economy, and as applied to health care. And consider their interplay.

Most Americans, for example, would agree that emergency departments (EDs) or emergency rooms (ERs) are not the preferred place to spend time, either as patient, or as family of a patient. EDs are generally overcrowded. Many appear chaotic. Others are so busy that personnel seem stressed & distracted.

On the other hand, most in need--if given first place in line--would opt for the ED. Why? The ED—as is generally known--gets things done like nowhere else in the health care system.

While EDs treat and remain available for major emergencies, disasters, and other unanticipated events, the large number of patients might be classified as non-emergencies, depending on who was asked. If patients—the consumers of services--were asked, most would indeed say “yes,” I am here because of an emergency.

On the other hand, the factors which lead into any decision to come to the ED are often multiple, and they often do not meet the societal definition for an emergency medical condition. However, one can always find some reason for any ED visit that meets someone's definition: the patient may be unable to get an appointment with a private doctor, the private doctor may have sent the patient to the ED for an urgent complete diagnostic workup, there may be no other route to get a needed hospital bed, there may be no available private doctor, or the patient may simply have no other resources.

So here sits the question: is an “emergency” determined by the perception of the one in need; or is it determined by the one charged with addressing that need? You could ask the same thing about the current economic “bailout” emergency. Is it the consumer or the provider of goods and services that determines the urgency of the call? For an ED, its open arms are its goods and services, while for the US it is its open wallet.

An emergency, therefore, is a problem that begs for immediate or prompt solution.

Indeed, is it not, in all cases, consumer demand that determines the necessity brought to bear? For an ED it is the perception and/or fear of the patient or family. Chest pain is an emergency until proven otherwise. A teen’s hyperventilation is an emergency when her mother fears the deadly blood clot in the lung she read about in a magazine.

The analogy of consumer demand determining need, urgency, emergency, applies. One might ask whether the issue of freedom on which the US was founded was a consumer demand; it was sure not determined by the authorities in vogue. Foreclosures are an emergency for anyone on the cold street in their wake; the shivering and now desperate consumer of government services asking for relief defines an emergency.

So with respect to EDs and health care, the bottom line is this. Why not admit what is going on. People do not—indeed cannot--wait for care via private doctor’s offices for many reasons. Among them, an appointment is but a distant hope; diagnosis and treatment are even more distant. So they opt for the ED, where the testing, answers and treatment are all wrapped into one simple package. The ED is both a dependable diagnostic center and a dependable treatment center; and it functions well despite extreme stresses.

If the health care system can sufficiently morph to see the ED in its actual and real role, instead of some imagined role, the back doors of hospitals might be opened enough to relieve overcrowding. Then, the possibility exists to use EDs as the central health care resource they really are. See-->diagnose-->treat--> refer for follow up. Or, if an immediately life-threatening emergency, see-->treat-->diagnose-->refer/admit.

Is there an emergency with respect to health care availability? By all means. Are there solutions at hand? Yes. Consider this one. Instead of trying to divert people from EDs to save funds, divert people toward EDs to save funds.


How? Incentivize hospitals to empty out the back doors of the ED, opening up the front doors. Make the ED patients preferential to elective surgeries instead of vice versa. Open up channels for referral from the ED, once patients are diagnosed, for follow up care. In a single swipe this would streamline office visit demand, and increase system wide rapid diagnosis and triage to the appropriate long-term care physician.

We are all hoping the right decisions are made.