That Sucking Sound: Low Acuity Care Leaving the ED | Creating a World-Class Emergency Department

but I'm going to talk about it I think is maybe to some of you kind of contrary to where you think we should be going I was er director for 25 years in a year in Los Angeles I'm on it I've got a clinical appointment at USC small intimate real residency there in Los Angeles that has cranked out more ER doctors in any residency in the country right now they have 68 House staff in emergency medicine small you know intimate little place so here's what I kind of view is what's happening in one sphere of emergency medicine there's money going out the door where it's going down into the black hole it's being shut down and we have an ability to intervene in this should we have a mindset that says we're gonna look what we found let's kind of fix this kind of thing what I want to talk about is not the big shark er is the big shark it is the credible big dog of emergency medicine but I want to talk about the little fish a little fish that swim with the big shark a little fish that live off of the big shark a little fish that live off the droppings of the big shark and they're nice and fat if you know they're like that are very happy kind of thing up there and but but I'm kind of concerned about them why do people want to go to emergency departments you are the most credible provider of health care in the community by and large no doubt about it look at assigns it a beautiful building they have their kind of thing we know that they check out the doctors to make sure they're not felons they do PR and peer review those kinds of things it's a very credible kind of place they have every piece of equipment you can think of it's a state-of-the-art cat scan machine they got five of them and so if I get into some kind of medical problem I want to go to this place they got the best of everything that's for sure why wouldn't I go to go to this place because it's perceived that you will have to wait when you go and people say well you know I understand that but if I have a heart attack I want to go to that place I have something more minor well you know I do know that there is this wait there is we have a reputation a national reputation for making people wait as far as I know emergency medicine and the Department of Motor Vehicles are the only two businesses that have a reputation for making people wait and I think that it's it's embarrassing that we have not been able to address this very effectively so we have want long waiting times generally I know everybody's working in to get a door to provider times down to a half hour more or less and I think that's a really great initiative and I said I think it's about time that the Joint Commission took a look at things like VR processes rather than the head circumference is of the children that come in there that may be measuring head circumference is as important then we're giving those mosquitoes but in any case it wasn't before so the charges are high the weights are can be long and patient satisfaction can be an issue let's I'd like to make this as factual as possible so here's the story eighty percent of emergency arms are discharged that's the national average 80% go home 20% get admitted and you know you're the big dog for admission you know 60 70 percent of the hospital patients for a minute came through the ER they appreciate that that's great thank you but 80 percent go home now there's always this conversation about how many of those people really really in the emergency department are sick and need to be there kind of thing it really depends on who you ask like this first if you want to be a student of this topic there's two papers were written in the New England Journal the July 23rd issue get those two papers it could it goes into all of the details about how you're crowding is going to be relieved but in any case this paper this freight New England Journal paper says between one and eight and one at four people don't that can be seen in a retail clinic or an urgent care center and that if they were we're talking about four plus billion dollars so that's one analysis National Hospital Ambulatory Medical Care Survey says between 33 and fifty percent of 80 patients are non urgent well if they're non urgent automatically says they can go to the urgent care center in fact the urgent care center ought to be called the non urgent care center because all these people can go there the third thing is in New England Health Institute says 56% of patients are totally avoidable now I'm not exactly quite sure how they define totally avoidable kind of thing but the numbers basically go up go up look in terms not what people who can be treated in other venues other than the emergency department and lastly what does Aesop has to say about it well Asaph says 92% of easy visits are from gets just very sick patients who need to be seen within one minute to two hours what a joke what a joke you know that that's not correct ninety-two percent I get in one minute I gotta see this person or two hours or this this snotty nosed kid basically is going to get better yeah we have to intervene in these cases before they get Patterson since so many have some self-limiting disorders you know you don't have them waiting in the yard and I'm all better now it's generally believed that the quality of the emergence department is clearly better than the quality delivered and then the other place because some well they got all this stuff there they get the best doctors they got the best everything so the quality's got to be great here's a study history you know and it's not the only kind of study i canna tell you that is and it's old it was done by Rand there's a think tank people in Santa Monica and basically they looked at paid paid from a large insurance company in Minnesota paid visits for three different disorders otitis media pharyngitis and UTI otitis you all three of these are 0 nothing diseases and they looked at what was the paid amounts to a convenience clinic like CVS doctor's office urgent care center emergency department so those 3-nothing visits going into this for venues it was a hundred dollars paid into the CVS type clinic $160 in the emergency to the doctor's office $160 to an urgent care center and $570 the emergency department for the same nothing diagnosis so the emergence Bartman was between three and five times more expensive than the other places but of course we know the quality is much better in the emergency department there is it so twelve standardized measures of quality regarding the treatment of these three disorders and the emergency department finished a dead last so so we're slow expensive and our quality mm-hmm you know worthy of a worthy of chunk of challenge I mean I want to wear the white hats and say how great we are all the time but I think that my my this is the purpose of this twenty five or thirty minutes is to kick you in the shins and tell you that there's a great opportunities that we're living just leave them leave the building because of a certain premises here are some prices I think the prices and Merchants departments really are kind of most of you I've never seen in the era bill many of you have not seen in Europe bill I think I think he or bill should be sent to you every week to shoot to see what bills you're generating when you a person comes into the hospital so here's a large survey of a sample of a thousand visits but of and it was the largest circuit group from what that sample came was like about seventy five million visits it sold 2006 to 2008 means a mean and median mean you know the difference between the meeting and the median I mean mean is average median means hazard charges are below it have to charge they're above this number well if you look at the mean a URI is eleven hundred bucks and this is like six seven years ago an open extremity woman is sixteen hundred bucks your bottom line is you're not getting out of the emergency our burden for the most minor of stuff that you have because this is a top ten complaints for less than fifteen hundred dollars which is the CVS will be able to beat these prices by a by a tenfold in terms of what you will see what they get paid now there are some businesses that talk about getting done quick the things done quickly you would think that the two businesses where you would do things quickly is in the emergency department because I'm sick I have a headache I thought I'm throwing up I got a pain and I got a cut here come on listen but let's move guys kind of thing oh yeah yeah yeah we have a nice big waiting room here big saltwater fish tank you'll love it but the fact of matter is is they want they want to see that the treating person pronto so our business should do that these businesses make it very clear we're gonna change your oil in ten minutes we're quick speedy speedy lube Express services quick care quick car lube ten minutes we're in and out do you think we have anything like that here here's our his this is us making excuses I know you think we're slow and we are slow but we're going to respond to that by putting up all of these boiled birds to say we're not as slow as you think oh this is embarrassing this is embarrassing I like some of these faster boo-boo relief that's it that's at one place some get home before others get in you know they have these meters up there this is our waiting time those meters finally never changed you know it looks like it changes you but then they never change why wait you know all of these have it what other business does this what are the business does is this not an embarrassment then we do this I think it's absolutely nothing and then you have this have you seen this thing where you can this model is called in quicker and it started out where patients would pay some amount of money 15 bucks or something like that and they would save a space for them in the line of the emergency department how they did that was HIPAA thought I was EMTALA I I don't know but they got around it somehow so you are in the internet you make a spaces and they'll give you a call mr. Smith will be able to see in about 15 minutes so the idea is you're sitting at home and not in those plastic chairs that they have in the emergence bar when you're sitting at home that you need a nice big chair waiting to be called in if you could read the small stuff in the bottom left there it says something about facilitating your place in line well the fundamental question is why is there a line when I suppose double line in the emergency department kind of thing lines are for you know we're more discretionary places like the DMV thank you they can have a line you can have a line for not for health care for certainly but they've kind up with a whole freaking industry to deal with our with our scrubs oh I think that this happened 40 years ago this guy wasn't walking on the moon 40 years ago and 40 years ago they were still belly aching about holding patients the emergency department there's too many people in there and awaiting them to be seen the they're all here with colds and they don't need to be here damn it and they're just taking advantage of us and that and the waiting room was packed can't we fix that and 40 years ago they did this and 40 years ago we have not been able to fix this since then the changes that we've made or have been modest at best I know this there's an effort to do it but a lot of you here have ers that are quite dysfunctional you won't be here now during this conference there's been a lot of talking about how to fix stuff and sherry in particular gives us these long litany of ways that things can be fixed however and I'm not going to go through this list because it's it's it's it's been done before but I think one of the things on the list that I don't see in any other that papers list is number one the CEO once needs to want to make your er better and if the CEO is not interested in making your ier better then it's not going to happen because this is top-down top-down works bottom-up painful painful bottom-up so you have to have a CEO who's invited who understands that more patients experience your hospital through the back door the bulletproof glass and the plastic chairs that comes through the front door with a big donor wall out there and they're nice and they're nice padded chairs and the smart ones will understand that and I don't really understand why that they they don't get on with the program because they are the ones that can fix this they are the ones who can deal with holding admitted patients in the emergency room because it's frankly it's easy your job is to basically assess all of these patients and see how they're doing and decide they decide was after treatment and testing which ones need to come into the hospital which ones don't and and with some time you can say on average we're going to admit X patients per day at our hospital on this day or that day or whatever and so and when the other side of the wall on the inpatient side the inpatient sides job is to create the space to pick these 20 patients that you know are going to be admitted into that hospital they have an obligation and they basically have turned their back on that obligation so what you need is some you need a physician that is well regarded by the medical staff who has the authority to go around and say frankness your patient really need to be there or we're gonna be we're gonna maybe need in that bed tomorrow their job is to create the capacity to see the patients that you are creating in terms of admissions and if they don't do that then you're gonna hold all these admissions and they're gonna and they're going to get dribbled in as patients come out but a more active process and those of you who have an active process of gotta be a kid nurses are okay but doctors are much more inclined to listen to doctors and say Frank come on give me a favor here get this patient now let's see what we can do what we need the bed we're gonna need the bed tomorrow for four hour ER admissions I think that that needs to be done I think that needs to be done routinely the CEO needs to fund a fund that person for doing that that person needs to be medically credible so that the doctors are willing to listen to them it can't be necessarily and if it's if it's generated from the medical staff the organized medical staff has created this position of helping move people out who need to be moved out more quickly because you know one of the problems with Medicare as an example is the longer the patients in the hospital the more doctors make and the longer the patients in the hospital the less doctor the hospitals make so there is this constant tension about length of stay and the fact the matter is is that most hospitals are not doing very well on least length of stay some are but most aren't which means that there's room for improving and getting these people through the process the doctors need to be motivated the doctors need to have a champion to basically kind of get this process done and if you don't have that you're coming up against a wall of well get these patients out when we when we get these patients out but there is relief at sight of all this overcrowding and all this that you know and the unwashed masses that you're dealing with the ER no problem here's one here's one option that retail clinics so the one on the left is Walmart or the one in the center is CVS which is the big dog right now one on the bottom is was target target stuff was bought by CVS and I think I wanted to write it's Kroger little data on this first of all go back to those two articles a lot of information in case it was about 1900 of these retail clinics out there and and the CVS is moving fast they got a thousand now looking at 1500 by the end of 2017 now when you look at capacity CVS Walgreens and Kroger altogether have 20,000 stores 20,000 stores eight percent of those stores have these clinics inside of them rendering 2% of primary primary care 8% so the capacity of you to expand that is huge and then there's the sleeping giant Walmart Walmart's got 4500 stores in this country virtually every one of them has a pharmacy in the store already to facilitate you know making their they started at 17 there they're way behind but they have the capacity to blow past a lot of these others they are now providing in this 17 test stores medical care for their employees that's four dollars a visit four dollars a visit non-medical not employee visits are $40 they're interested in not only your urgent care kinds of things but they're interested in your cholesterol blood sugar blood pressure as well so these guys have them an expanded view of what urgent care centers can do if these guys wake up but you know you can see Walmart biggest retailer in the country if they don't see the opportunity here it's going to happen so that so that's the air of the convenience clinics then we move over to the urgent care clinics there's about 90 300 of them that are building three to six hundred a year I know some people who have a cluster of these things and they get bothered weekly by venture capitalists who want to buy up these things because they think that these things are going to be printing presses for for money with time and look at the numbers that they generate this is information from the Urgent Care Association of America this is a survey from 2012 they were bringing in 105 135 dollars in that so that was like the profit profit is a $135 look at a couple of the bullets under there what the Association has said in their website number one 95 percent of the members call or email the patient's from the they had just seen now that's it that doesn't happen in the ER we were way too busy can't you see that we're busy can't we'll get to you when we can but only a small number of IRS goes through this effort to make it clear it's just a courtesy kind of thing yeah you might find out if they're not doing better and have them come back but they're just so pleased that you took that take you've made the effort to call what is their throughput 84% of those saw patients within an hour or less an hour or less what's your throughput time for a discharged patient if it's three and a half hours you're considered to me that's terrific if it's three if it's two and a half hours wasn't wonderful there at one hour for a patient how they see for patients an hour you see two and a half so and two-and-a-half is considered at some places to be fairly aggressive they're seeing four and under scene 50 patients today so bottom line is they have they're making money on the droppings of the ER the ER cos be seeing these patients if we created the same kind of environment very called the patient's back nice environment no blood no screaming no nothing here here's the urgent care part of the emergency department and and so we've caught we've caught that part of the population that these guys are making a living on these making are making a good living on them that are expanding all the time so if they can live on your droppings then why don't you live on your droppings I like this orden I like this one dr. Phil dr. Phil is hooked up with Google pretty powerful combination well at least Google is and basically the idea here is that you on your your telephone basically trying to get a hold of a doctor so to have a consultation with that doctor and they see you on the telephone and the write the patient's on the top of the doctors on the bottom you may not be able to read that stuff along the bottom it says stop the guessing stop the guessing self diagnosis never ends well it doesn't and doctors online and by phone are available 24 hours a day and what happened is is that in the 30 2013 he started this thing up with Google and they have 1,400 board certified doctors who are willing to participate in this endeavor and they've had several million downloads of people who are interested in and participating $40 for a video consult I like this psych problem we have to charge more because you know it's just a hassle to talk about your depression thank you very much you know they say that they handle 95% of the cause and don't need to refer they refer only 5% I fighting that very very difficult who who uses telemedicine single mom basically it's about kids it's about kids married mom that's okay febrile iting those kid that they're going to go to work and they go to work they won't take the kid date they said they care if the kids can sick so this is happening for the moms there's big money in this and as a reflection of the big money tell a doc lost a 1.5 million dollar contract and it only represented 3.6 percent of its business so we're talking about thirty million dollars at least there I like the last number it says in that in 2015 1 million people 1 million people will have a webcam of a physician visit 1 million people 40 bucks I don't think it's very bad house calls this is I like the bottom one of the bottom right the doctor and a child both looked like they just got out of jail with this they're wearing the same shirt I think that they faked this picture to tell you the truth but in case they come through your house so wonderful and check your belly out on your couch and can console you in your bed while your child's looking on thing Oh mommy no mommy house calls basically a couple of them this one is the first one is an la-based they started by a nephrologist and and they're her husband and basically they come with they come with to you with a tech who brings on this high-tech instrumentation like you know the you know the the an otoscope well this otoscope takes a picture so as you can say look see how red it is there's your problem or this oh no it looks ok mom and they have the blood test it you can do what is that ice that stuff they can do all of that if they need to um look at this flat 300 bucks basically between 8 and 8 and they'll pick up a prescription and for you if they need it of course you're going to beginning prescription for bronchitis bronchitis and bronchitis getting prescriptions for bronchitis everybody will have bronchitis I like number two this one is far found by one of the guys who have found created uber this is going to be Medical uber 50 bucks for the first visit 50 bucks man I I was you know what I was thinking of doing I was thinking of calling one of these up right right from this stage and see how long they came on one and to say like one who says belly pain give me game check us please to see what how quickly they would get here but they're starting up popping up all over regionally to come to your house and then we have freestanding ers and Tim is Tim is absolutely the expert on this but there there is some downside of this and y'all are aware of it this is big money adept as health is looking at owning 63 of these and they are the revenue is are there but are they in the rural areas the underserved areas or the low-income areas tim was very frank and said no we don't build these things in those areas why would we do we build them where the hospitals are we in the affluent areas and that sound makes perfect sense but there's this issue of the charges and the confusion of the ER is this in ers and was the urgent care and there are four TV expose zuv sorts where people basically raised holy hell with the TV station about stuff like one kid got a a four stitches in his thumb and a DT shot and it was charged $4,200 and that's about a thousand dollars stitch there's a person and there's this Denver Denver news these are all reasons to they had multiple patients one of the patients had a bill for eighty two hundred dollars for a CT of a chest and abdomen so so there are some challenges and I think that Tim was pretty frank in just discussing what these challenges are there you can be on either side of the fence on on these to be very candid so in conclusions I basically think that you know you're gonna get 20% of the patient to be admitted you don't need to be nice to them you don't need a patient status accident doesn't matter they're coming by ambulance they're sick they're coming in it's the 80% that the discretionary 80% that can go out go to this place or I'll go to that place or I'll go to this place and those are the ones that I think that you has a lot of control over it but other people are saying oh you can't handle it you got a problem with it we'll take care of it for you we'll just take a look through all these will take care of all this low-hanging fruit we'll take these paying patients away thank you very much the CEOs can fix this and that we just need to acknowledge how important we could not survive if we only had the 20 percent of patients who admitted 80 at least 80% our fundamentals of the business of the emergency department and if you let take let people take them away then you will have more and more just admitted patients your volume will go down because they represent 80% of the people walk in your door so my sense is is that you need an initiative out there to say we're gonna cultivate these patients we're going to make the call we're going to charge them prices that are fair we are going to make it clear that we want you here and that you're not in the way you know the ers you know they've got this attitude often can't you see we were busy we'll get to you when we can kind of thing that's not what the attitude of the urgent care centers or CVS or or you know Tim's Tim's freestanding urgent care centers and I think one of the things that we haven't talked about particularly is the use of the right people we need to use pas and NPS we there we need scribes those doctors I don't know about you but we had um scribes we started off with scribes and weird scribes way way before it was fashionable and we had all old doctors you know old doctors new tricks but when we hire these scribes it was kind of like they got least it was kind of cool because not really scribes or personal assistants and they they would get your lab back you know studies to you and put the x-rays up on the on you more than those kinds of things and you know I one of our doctors got so addicted to his scribe that when the scribe would call in sick this guy would be in the corner sucking his thumb saying oh god oh god I have to do this shift around a scribe and pas and NPS therein in fact it's there they're exploding there's more and more and more of these schools generating there's a hundred thousand pas there's a hundred thousand and peace and that there there are tons of new schools for cranking out and PTAs in particular so we got to use the right one so that we've bottom-line and maybe we get this this is the goal this is a goal to have a free-floating brain in the department just oozing around the department just talking to the patients it doesn't it doesn't do any order entry it doesn't touch a computer screen it doesn't pull up any x-rays it doesn't all that labs are provided it doesn't do anything except think about the patients how many patients could a doctor see and do a well good job on if it was just free facilitated facilitated unencumbered medical brains that's what we're looking for I think all right thank you

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