ER Volume

[SeekerOfTheTree]

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Random question but is anyone else noticing a decrease in ER volume throughout the country? I do travel alot for work so I have had a bit of exposure through the midwest but want the input of others.

Thanks!

 

[Alvarez13]

Working in the Midwest, No. My sites are up.

 

[RustedFox]

Gulf coast of Florida here. They're opening new hospitals and freestanding ERs in both my county and the next one north and south.

 

[SeekerOfTheTree]

Perhaps I should move...

 

[suckstobeme]

We're up also (Great Lakes region), but if it had gone down I wouldn't be surprised. There's been a big push for years to move things to Urgent Care, get easier access to PCPs, etc all in the name of avoiding the ED. At some point, or in some locations, those strategies will be effective and ED census will level off or dip.... you would think.

 

[RustedFox]

Volume at "home base" ER is way up.
A competing hospital opened a freestanding ER a few miles away in an attempt to compete for business. I got credentialed there, too.
The volume at the freestanding is far exceeding projections, and we just hired two new full-time docs for next (tourist/snowbird) "season".

 

[Redrox]

Volume crashed for about a month or two after flu season, way back up again now.

 

[OneTwoThreeFour]

The national stats my PD gave during orientation showed nationally visits are up particularly in states with expanded medicaid.

 

[The White Coat Investor]

Up at one place, down at the other.

 

[Hercules]

My shop went from 30k to 60k in the past 6 years. Slowing a little now but still keeping 5-10% growth each year.


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[deleted245139]

Large system in the Northeast... Most facilities are flat to slight positive. My main site is +4% this year (6% last year)

 

[southerndoc]

We're on part for seeing 160,000 this year (saw 148,000 last year).

 

[RustedFox]

So, we're all on here reporting steady growth in our volumes.
Lets take a hot minute to think about the purported "glut of ER docs" coming from a "surge in residency slots" that gets bandied about on here.
Should we pump the brakes?

 

[migm]

about average in the SE US

 

[bravotwozero]

volume was becoming somewhat anemic at my new gig, until the hospital 3 miles away from us declared bankruptcy and closed...now it's way up

 

[Jlaw]

I don't know the numbers at the moment but feels busier, the other week we had a couple days where the waiting room started backing up because there was nowhere left to put patients in the ED...haven't seen that since flu season.

 

[namethatsmell]

While there may be dips here or there, I don't see how numbers will significantly go down (and truly stay down) anytime soon. While Obamacare may have caused a spike in visits that's worn off, even those who are now losing their insurance still know the one place they can always go: to you and me. Until there's a federal/state law that creates a legit alternative safety net to us, we'll remain many folks go-to resource. In the meantime, our healthcare "system" will remain a headless beast that nobody can control.

 

[alpinism]

The use of the ER for everything and anything is essentially a part of american culture now.

As long as the we remain the fastest and most convenient way to see a doctor people will continue to come in ever increasing numbers.

 

[deleted245139]

The use of the ER for everything and anything is essentially a part of american culture now.

As long as the we remain the fastest and most convenient way to see a doctor people will continue to come in ever increasing numbers.

This.
And still not fast enough. I just reviewed our PG surveys, and had a pt gives scores on 1 because '30 min is just too long for my toothache' and we didn't have a good enough variety of sandwiches. Single review, but really a cross cut of current sentiment - we are a victim of our own success to some degree.

 

[RustedFox]

This.
And still not fast enough. I just reviewed our PG surveys, and had a pt gives scores on 1 because '30 min is just too long for my toothache' and we didn't have a good enough variety of sandwiches. Single review, but really a cross cut of current sentiment - we are a victim of our own success to some degree.

These people should be found and *educated*.

 

[namethatsmell]

These people should be found and *educated*.

How amazing would it be if ABEM used a little part of our fees to them to run a series of ads like the Aussies?

 

[wholeheartedly]

How amazing would it be if ABEM used a little part of our fees to them to run a series of ads like the Aussies?

oh that is sooo much awesomeness!!

 

[VA Hopeful Dr]

These people should be found and *educated*.

 

[RustedFox]

How amazing would it be if ABEM used a little part of our fees to them to run a series of ads like the Aussies?

For real. People all over need to get a grip. Anyone else remember the lady that called 911 because McDonald's was out of chicken nuggets?

From the audio clip: "My McNuggets ARE an emergency!"

 

[Interpolfanclub]

Volumes going up here in the south every year. 69/day when I started 6 years ago to 80/day now with days routinely 90 or 100 which was unheard of when I started.

As above posters have stated you can come to the ED for anything day or night, and we will see you. We are truly victims of our own success but I see the ED as an extension of the expectations brought by a capitalist society. People want what they want when they want it, which is RIGHT NOW.

 

[deleted109597]

How amazing would it be if ABEM used a little part of our fees to them to run a series of ads like the Aussies?

Well, if the government were paying for it, they would. Remember, the government pays for the lines at the post office and the DMV. ABEM, ACEP, and AAEM all depend on people going to ERs. Hospitals don't actively want anyone turned away for the same reason. It makes money. The places that close are the ones that get Medicaid patients, which doesn't pay enough to keep the lights on.

 

[namethatsmell]

Well, if the government were paying for it, they would. Remember, the government pays for the lines at the post office and the DMV. ABEM, ACEP, and AAEM all depend on people going to ERs. Hospitals don't actively want anyone turned away for the same reason. It makes money. The places that close are the ones that get Medicaid patients, which doesn't pay enough to keep the lights on.

Oh I do get it. ACEP would be the last group to do this and probably never ABEM from a dollars and sense perspective. I do wonder though when the monetary and personal costs of burnout/doctors going insane from unrealistic pt expectations will exceed the $ collected from the 12th well appearing pt w/uri while they complain about their hour wait and lack of ESPN in their room after you just coded a now-deceased kid.

As long as the venture capital guys who now run much of EM never have to step into the trenches and experience it, it will almost certainly never change. Unless ownership changes.

A guy can hope.


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[deleted859535]

Oh I do get it. ACEP would be the last group to do this and probably never ABEM from a dollars and sense perspective. I do wonder though when the monetary and personal costs of burnout/doctors going insane from unrealistic pt expectations will exceed the $ collected from the 12th well appearing pt w/uri while they complain about their hour wait and lack of ESPN in their room after you just coded a now-deceased kid.

As an aside, I have started calling these folks out. Typically in some sort of way to highlight that there were Very Bad Things happening around them that kept me busy while protecting details. Most people have become more gracious. Some people, you just can't help.

 

[Boatswain2PA]

These people should be found and *educated*.

It is the damn administrators who need to be *educated*.

 

[Boatswain2PA]

I see the ED as an extension of the expectations brought by a capitalist society. People want what they want when they want it, which is RIGHT NOW.

If they are paying for it then it's capitalism.

If they are getting it free, then that ain't capitalism.

 

[WilcoWorld]

For real. People all over need to get a grip. Anyone else remember the lady that called 911 because McDonald's was out of chicken nuggets?

From the audio clip: "My McNuggets ARE an emergency!"

wait, whaaaaaaaat?

 

[Dustb2000]

wait, whaaaaaaaat?

 

[WilcoWorld]

Oh boy.🙄

There are unfortunately a lot of recent examples of people calling the police for bad reasons.

 

[GeneralVeers]

It's not capitalism. Capitalism would sort out the problems of supply and demand just as it does everything else. Arguably most medical care is anti-capitalistic because the users are separated from the costs, and have no incentive to curb their usage. The system could very easily be fixed by demanding a co-pay from everyone (after they've had an MSE) including medicaid and medicare patients. I will take a quick history, do any necessary exam, and then if it's not an emergency, you get no treatment or instructions from me unless you pay up.

 

[namethatsmell]

It's not capitalism. Capitalism would sort out the problems of supply and demand just as it does everything else. Arguably most medical care is anti-capitalistic because the users are separated from the costs, and have no incentive to curb their usage. The system could very easily be fixed by demanding a co-pay from everyone (after they've had an MSE) including medicaid and medicare patients. I will take a quick history, do any necessary exam, and then if it's not an emergency, you get no treatment or instructions from me unless you pay up.

I don't see how capitalism works in your example. Eventually people would get wise to the MSE and start saying they have CP, feign belly pain, etc so they can stay for a bit and work in their true CC an underhanded way. I think until you add in some state/federal legal protections for EPs (along with changing the way people pay for their care) nothing will change to allow us to do more MSEs than we do now.

Technically pure capitalism isn't to blame given many of the backwards regulations in healthcare that prevent a true free market. But the capitalistic features of our current system have given us some terrible gifts like Envision, Team, USACS, HCA, United, Antham, etc. It's also resulted in an incalculable amount of lame start-ups entering "the healthcare space" that put on a good show for investors and whose prime directive is to get bought up by a bigger fish rather than forging something that's actually useful. Along the way our costs get higher, our outcomes remain unremarkable, and our work environment worsens.

 

[24GaugeEJ]

I don't see how capitalism works in your example. Eventually people would get wise to the MSE and start saying they have CP, feign belly pain, etc so they can stay for a bit and work in their true CC an underhanded way. I think until you add in some state/federal legal protections for EPs (along with changing the way people pay for their care) nothing will change to allow us to do more MSEs than we do now.

Technically pure capitalism isn't to blame given many of the backwards regulations in healthcare that prevent a true free market. But the capitalistic features of our current system have given us some terrible gifts like Envision, Team, USACS, HCA, United, Antham, etc. It's also resulted in an incalculable amount of lame start-ups entering "the healthcare space" that put on a good show for investors and whose prime directive is to get bought up by a bigger fish rather than forging something that's actually useful. Along the way our costs get higher, our outcomes remain unremarkable, and our work environment worsens.

Everybody says they have chest pain, anyway.

 

[enalli]

The system could very easily be fixed by demanding a co-pay from everyone (after they've had an MSE) including medicaid and medicare patients. I will take a quick history, do any necessary exam, and then if it's not an emergency, you get no treatment or instructions from me unless you pay up.

For $25 you get a differential diagnosis.
For $75 more you get an actual diagnosis (not including the cost of diagnostic tests).
For $150 more you get a treatment plan (not including the cost of treatment).
Bundle it all for $225 -- that's $25 in savings.
Act now and we'll include a work note (a $30 value) for free!

 

[GeneralVeers]

For $25 you get a differential diagnosis.
For $75 more you get an actual diagnosis (not including the cost of diagnostic tests).
For $150 more you get a treatment plan (not including the cost of treatment).
Bundle it all for $225 -- that's $25 in savings.
Act now and we'll include a work note (a $30 value) for free!

👍👍👍👍

 

[Jlaw]

25-35% of my patients on any given day were "sent in by their____(PMD, Urgent Care, Surgeon, Cardiologist). A few of these are legit but many are complete punts. I had a young patient with some vague chest tightness sent in from urgent care last week with an EKG that some PA had written "r/o ACS, inverted T waves in V1, with a helpful circle around the offending T wave".

Even better are the ones sent in by their PMD or past surgeon for evaluation of some problem who tell me "you must call Dr XXXX immediately, he is very concerned and wants to be kept in the loop". Of course when I call said Dr to discuss the patients and see what their expectations were they say "I have no idea, he/she is crazy, just admit them to the medical service to get worked up...or discharge them home....or do whatever you want, they're fine".

Not sure if this happens everywhere, I think in some places its an insurance thing, easier to bill from an admission through the ED...in others the MD doesn't want to deal with doing paperwork, orders, etc so they just scut out the ED...or even worse they don't want to expend the mental energy and would rather we make the diagnosis and admit for them to bill for the inpatient treatment. Either way I think there are a lot of ways we could cut these visits down

 

[GonnaBeADoc2222]

25-35% of my patients on any given day were "sent in by their____(PMD, Urgent Care, Surgeon, Cardiologist). A few of these are legit but many are complete punts. I had a young patient with some vague chest tightness sent in from urgent care last week with an EKG that some PA had written "r/o ACS, inverted T waves in V1, with a helpful circle around the offending T wave".

Even better are the ones sent in by their PMD or past surgeon for evaluation of some problem who tell me "you must call Dr XXXX immediately, he is very concerned and wants to be kept in the loop". Of course when I call said Dr to discuss the patients and see what their expectations were they say "I have no idea, he/she is crazy, just admit them to the medical service to get worked up...or discharge them home....or do whatever you want, they're fine".

Not sure if this happens everywhere, I think in some places its an insurance thing, easier to bill from an admission through the ED...in others the MD doesn't want to deal with doing paperwork, orders, etc so they just scut out the ED...or even worse they don't want to expend the mental energy and would rather we make the diagnosis and admit for them to bill for the inpatient treatment. Either way I think there are a lot of ways we could cut these visits down

This all day long.

"if you're admitted, the upstairs doctors will call Dr. Smith. If you're discharged, you can call to have your records sent over."

If I'm not busy, and there's an semi-important piece of clinical information, I'll make the call. I actually really like talking to the PMDs sometimes. They offer good perspective. Often, I'm just too busy to do it. Sorry, I just don't need Dr. Smith's input to work-up / treat dad's septic shock, grandma's abdominal pain, or your K of 8.3 after you decided not to go to dialysis because of "weakness."

 

[Old_Mil]

.. visits are up ****particularly in states with expanded medicaid.****

One of the smartest things you can do as a graduating EM resident is go to state that hasn't done this.