This commentary is by Ben Smith, Emergency Physician and Director of the Emergency Department at Central Vermont Medical Center in Berlin. He lives in Duxbury.
As an emergency physician and director of Vermont’s small emergency department, some of Vermont’s health policy thinkers have helped invest in outpatient services such as primary care, mental health, home health care, and social determinants of health. Glad to see you are accepting.
Emergency department corridors across the country, including here in Vermont, are vivid and intuitive tutorials on the social determinants of health and the scarcity of outpatient care. is desperately needed.
What is questionable, however, is that any of these investments can be realized through a simple redistribution of emergency and hospital care costs, which are often viewed as ‘avoidable’ and ‘low value’. It’s an idea. Although there are data suggesting the magnitude of the so-called avoidable care problem, perhaps in the order of his 30% of emergency and hospitalized patients, this data surprisingly disconnected from reality.
- First, emergency departments and hospitals serve the most vulnerable, including the elderly, poverty, mental illness, physical disabilities, substance abuse, homelessness, neurodivergence, geographic isolation, transportation difficulties, and domestic violence. It’s a safety net, health equity and basic. Safety now depends on viable and functioning emergency departments and hospitals.
- Second, so-called avoidability statistics fail to fully account for the detailed realities of people’s lives (e.g. when a grandfather has to be hospitalized for vomiting and limited status). He has trouble standing and every 15 minutes he needs help from 2 to 4 people). That acknowledgment is “avoidable” only in the eyes of a person staying away from his bedside through layers of spreadsheets.
- Third, 66% of Americans age 75 and older will visit an emergency department this year. This isn’t a systemic failure — it’s simply the reality of our demographics and aging human bodies, and whether health policy institutions are racking their brains over the amount of work required to ethically care for this population. It’s worth asking.
- Fourth, even as I write this, we are constantly overwhelmed and under-resourced, and the quality of care for all is currently affected.
- Fifth, this resource crisis, largely the result of underinvestment in the frontline workforce, has roots long before Covid-19 and the triple epidemic, and will not end there.
As has been suggested repeatedly, intentional departure from emergency and emergency care before a robust outpatient system is fully built and apparently functioning is a serious failure of health quality and equity. and mimics the tragic failures that have already accompanied the deinstitutionalization of psychiatry.
As resource constraints contribute to chronic hospital undercapacity, emergency department warehousing of both psychiatric and medical inpatients (a phenomenon known as “boarding”), and poor quality care. We actually live in this same version. Data-proven care to follow.
So the big question, for the time being, is how do we fund the building of an outpatient system suitable for the task at hand without jeopardizing quality, safety and equity. And it’s hard to see why it doesn’t have to put more money into the front lines (both outpatient and inpatient) and even less.
While this claim may come as a shock to some, there is a solid economic theory that explains why health care labor costs are growing faster than inflation, separating the labor force from the health care cost debate. you have to think about it seriously. .
A final note about our poor notion of “value”: the emergency department has been characterized as “low value” and a “bad policy endgame”. But if we showed up at 3am to find a highly trained team with years of sacrifice and education, ready to diagnose and treat our condition and resuscitate us if needed. We all feel the same when we are Secretary, register us on the computer and answer the calls of loved ones. A radiological technologist managing a CAT scan. The laboratory technician who performs our blood tests. The housekeeper who cleans and prepares our room. And a security guard protecting us from the violent, drunk patient in the bed next door.
I mean, how much does it cost? Have you ever really considered the social value, safety and fairness that emergency departments and hospitals provide?
I urge policy makers and managers to rethink their concept of “value” and address inadequate resources, increased moral trauma, pandemic risk, and workplace violence — to care for all of us. to, every day, every night.
