This comment was written by Ben Smith, MD, an emergency physician and director of the emergency department at Central Vermont Medical Center in Berlin. Lives in Duxbury.
As an emergency physician and director of a small emergency department in Vermont, I am pleased to see some of Vermont’s health policy thinkers embrace investment in outpatient services such as primary care, mental health, home health, and social determinants of health.
Emergency department corridors nationwide, including here in Vermont, are a vital, powerful educational program in the social determinants of health and scarcity of outpatient care. These investments are badly needed, as are major investments in home aged care.
However, the notion worth wondering is that any of these investments could be made by simply reallocating money from emergency care and hospital care, which are often described as “avoidable” and “low-value.” Although there is data indicating the magnitude of the so-called avoidable care problem, which is assumed to be on the order of 30% of emergency and inpatient stays, this data is startlingly separate from the following facts on the ground:
- First, emergency departments and hospitals are the safety net for the most vulnerable—the elderly, those with poverty, mental illness, disability, substance abuse, homelessness, social distancing, geographic isolation, transportation difficulties, domestic violence—both health and basic equality. Safety currently depends on viable and functioning emergency departments and hospitals.
- Second, the statistics on so-called avoidance potential completely fail to account for the exact realities of people’s lives (when one’s grandfather, for example, needs hospitalization for vomiting and diarrhea—usually a benign, self-limiting condition—because he too is weak in standing, and needs assistance Two to four people cleaning every 15 minutes). This confession can only be “avoided” in the eyes of someone far from bed by many layers of spreadsheets.
- Third, 66% of all Americans over 75 will visit an emergency department this year, and we know that seniors need more extensive testing, longer stays, and more hands-on care. This is not a systemic failure – it is simply the reality of our demographics and the aging human body, and it is worth wondering if the apparatus of health policy has wrapped its head over how much work is required to morally care for this population.
- Fourth, even as I write, we always feel overwhelmed and under-resourced, to the point where the quality of everyone’s care is now affected.
- Fifth, this resource crisis, caused in large part by underinvestment in the front-line workforce, has roots long before Covid-19 and the triple pandemic, and it will not end with it.
Intentionally stripping away emergency and acute care, as has been repeatedly suggested, before robust outpatient systems are fully built and visibly operational, would be a profound failure of health quality and equity, emulating the catastrophic failures that already accompanied the abolition of psychiatric institutions.
We’re actually living with a version of this already, where resource constraints have contributed to chronic hospital power shortages, stocking of admitted patients—both psychiatric and medical—in emergency departments (a phenomenon known as “boarding”), and poor quality of data-proven follow-up care.
So the big question is precisely how to fund the construction of outpatient systems fit for the task at hand without jeopardizing quality, safety, and equity in the meantime. And it’s hard to see how that wouldn’t require more money being distributed to the front lines – both outpatient and in-hospital – rather than less.
Although this may be a shocking disagreement for some, there are strong economic theories that explain why labor costs in health care are increasing faster than inflation, and we need to seriously consider decoupling labor from the debate over health costs if we want the system to survive sound. .
One last note, about our poor concept of “value”: EDs have been described as “low-value” and “bad end game politics.” But I wonder if we feel the same way when we show up at 3 am to find a highly trained team, with many years of sacrifice and education, ready to diagnose and treat us, and resuscitate us if that happens; a secretary, to record us on the computer, answer phone calls to our loved ones; radiology tech, to perform our CAT scan; a lab technician to perform our blood tests; a housekeeper to clean and prep our room; And a security guard to keep us safe from the violent drunk patient in the next bed.
I mean how much should that cost? Have we really considered the societal value, security, and fairness that emergency departments and hospitals provide?
I implore policymakers and officials to reconsider their concept of “value,” and to use gentler language when talking about your neighbors who continue to show up to work—in the midst of inadequate resources, increasing moral trauma, pandemic risk, and workplace violence—day after day, night after night. Night, to take care of us all.