Emergency Medicine -- Clinical and Business Practice

John Stimler, D.O., FACEP
John Stimler, D.O., FACEP, is Immediate Past President of the Florida College of Emergency Physicians.
He is an Attending Physician in the Department of Emergency Medicine for
the University of Florida Health Science Center, and University Medical Center.

After practicing nearly 25 years of emergency care, it is apparent that the majority of physicians do not know many of the facts about modern emergency medicine. This has been evident in negotiations with managed care organizations, hospital administrators, physician representatives at the Agency for Healthcare Administration, physician medical directors of many hospitals, Medicare and Medicaid medical directors or the myriad of medical directors of the insurance industry.

Emergency medicine is a unique specialty that incorporates 1) variety, 2) acute care, 3) unscheduled care, 4) very rapid decision making, and 5) the "safety net" for the American health-care system.

The practice of emergency medicine deals with the acute aspects of all medical and surgical specialties. Patients with chronic conditions frequently present with acute worsening of these problems. All ages, socioeconomic levels, and ethnic and religious groups present to our nations emergency departments on a daily basis.

Acute trauma care is represented by the multitude of auto accidents, lacerations, contusions, abrasions, fractures, and penetrating trauma. Acute medical care encompasses those patients presenting with complaints such as chest or abdominal pain, shortest of breath, fever, weakness, dizziness, seizures, or strokes. Acute pediatric care is seen in the many children presenting with fever and pain in the ears, throat, chest or abdomen. Many children are also seen complaints of vomiting, diarrhea, and subsequent dehydration. OB/GYN acute care is represented by women complaining of pelvic pain, vaginal bleeding or discharge and complications of pregnancy such as miscarriages, ectopic pregnancies, or precipitious deliveries.

No patient schedules a visit to emergency departments except for those needing re-checks for such things as lacerations, foreign bodies, or abrasions of the eyes. The majority of patients decide to go to the emergency department because of acute conditions occurring within hours to days prior to presentation. Many complain of severe pain in different areas of the body or conditions such a shortness of breath or profound dizziness. The patient perceives his/her condition as a threat to life, limb, or bodily function.

The emergency physician must make a great number of decisions on an hourly and daily basis. Even though patients are triaged by the nurse on entering the emergency center, the physician must constantly re-triage each patient in the emergency department proper to determine which patients need to be seen immediately. The emergency physician provides each patient with a rapid assessment of their historical complaints and an appropriate physical exam. Treatment orders are generated and ancillary studies are requested. Unless the patient is too critical to remain in the emergency department or requires immediate surgery, the emergency physician will review and interpret these ancillary studies prior to contact with the admitting or consulting physician. The final decision to either admit, transfer, or discharge (sometimes the most difficult decision of all) is then made.

The emergency physician is the "doctor for the people". He or she evaluates and manages patients from all walks of life— rich or poor, young or old, insured or uninsured. Emergency visits nationally have gone from a recent low of 93 million two to three years ago to just over 100 million visits last year. These 5000 emergency departments across the country are open 24 hours per day, seven days per week and are staffed with the 32,000 emergency physicians who are the front-line of America's health-care system making split second decisions daily. Some of these decisions are immediate life and death issues but many others are less urgent.

Managed care contracts have conveniently separated all of medicine into primary care and specialty care and, although Emergency Medicine involves a great deal of primary care, it is frequently placed in the specialty area. The reality of emergency care, however, is that it is a true hybrid between primary and specialty care. Approximately 85% of the emergency physician's activity is in the cognitive not procedural area. Procedures performed are usually of the minor category such as lacerations, I and D's, dislocation reductions, lumbar punctures, endotracheal intubations and central line placements. If one examines the breakdown of CPT code used in billing, it is apparent that 85% of all codes billed are in the Evaluation and Management realm. Emergency Medicine is therefore a true hybrid with much more of a shift toward cognitive or primary care rather than specialty or procedural care.

Disadvantages to the practice of emergency medicine

Emergency physicians are often the first to see society's ills, i.e., violence, drug abuse, sexual abuse, or elderly abandonment, and one of the most difficult parts of emergency medicine practice is the inability to "save everyone". There are also frequent exposures to health risks such as HIV, TB, and hepatitis which creates a somewhat dangerous. Some patients are violent and ill-tempered while others may be unkempt. By definition, almost no patient or family in the ED is in a good mood and all this poses a challenge to both physicians and nurses. Routinely working all hours including nights, weekends, and holidays chronically disturbs a normal lifestyle.

Other disadvantages center around the frequent inability to learn either the outcome of many admitted patients or the result of emergent surgery. The inability to follow-up the majority of patients discharged also frequently frustrates the emergency physician.

Why do people go to the ED?

Most patients who go to the emergency department perceive their condition to be a threat to life, limb, or physiologic condition. They also bring children with recent injury or illness which the parents think requires care in a reasonable period of time. Patients who go for "frivolous" complaints do so because they have no other access to care. No one goes to the emergency department because they like the TVs in the waiting room or the proximity to a new Coke machine!

Why do these people have no access to care?

The majority of primary-care physicians have full daily schedules with no vacancies for patients with either acute conditions or ones that may require care taking greater than 15 minutes. Many patients have no transportation and must rely on neighbors or their families. Many patients have not been assigned a primary care provider (P.C.P.) by their managed-care organization. Those patients without funds will naturally seek care in an emergency department rather than at a private physician's office since many offices require payment up-front prior to visit.

The Emergency Medical Treatment And Labor Act (EMTALA Law) found in Section 1867of the Social Security Act mandates that all patients who seek care in emergency departments, regardless of their ability to pay or insurance status, be provided an appropriate medical screening examination. This exam must be provided to determine if an emergency medical condition exists. If necessary this medical screening examination must be provided using all the capabilities of the hospital and any consulting physicians. This law applies to all patients, not just those on Medicare but compliance with this law is a condition for participation in Medicare. These EMTALA mandates make it clear that Congress considers access to emergency medical services as a critical element of our health-care delivery system.

What is the medical screening examination?

The usual medical screening exam is frequently performed by the emergency physician but can be provided by other clinicians. It is not provided by the nurse at the triage area and usually consists of more than the just a quick history and physical exam. This medical screening exam must be provided up to the capabilities of the hospital and therefore includes things such things as consultations, admissions, ancillary studies, lumbar punctures and computed tomography.

What does emergency care cost?

The total health-care expenditure in this country is just over $1 trillion dollars annually. Total annual emergency department spending (combining hospital and physician bills) is $25 to 30 billion dollars. This represents 2.5% of all health-care spending. The average charge per visit is $330 for both the hospital and physician. This charge can be separated as follows:

Needless to say, the actual cost of the visit is significantly less due to the cost shifting of charges for higher acuities. But, the cost to health care for a primary care visit to the ED is nearly the same as the cost of a primary care office visit.

What is the amount of uncompensated care provided in our emergency centers?

Unlike any other physicians, emergency physicians do not determine, nor control, the number of patients who present for treatment. In fact, patients who may be turned away from office-based practices are frequently directed to emergency departments for care. As a direct result of both federal mandates and patients turned away from physician's offices for lack of funds, a substantial number of services provided by emergency physicians are never reimbursed. A very high percentage of uncompensated care is therefore created. While the American College of Emergency Physicians acknowledges that other specialties also incur the costs of uncompensated care. the impact on emergency medicine is significantly greater, and potentially unrestricted due to federal law, however.

Uncompensated care includes both bad debt and charity care. The Lewin group, a respected research consulting group in Washington D.C., performed an extensive research study to determine the extent of this uncompensated care in the emergency setting.¹ The mean bad debt and charity care provided per emergency physician was determined to be $144,080 per year with a median of $134,473.¹ This translates into a mean practice expense per hour of $69.27, with a median of $64.65.¹ The uncompensated care data in the study is mostly representative of bad debt since true charity care, care provided without bill submission, is really provided in an emergency department setting. Bad debt cases are usually patients for which a bill was generated but the payment never received.

What other overhead expenses exist in addition to uncompensated care?

Emergency physicians, like other physicians, have office personnel to help manage financial aspects of the business. Attorneys and accountants are necessary in addition to business managers who help coordinate the practice. The typical office equipment in addition to office lease are standard expenses. Unlike other specialties, most emergency physicians practice almost exclusively outside an office setting in hospital emergency departments. Most emergency physician practice costs are classified by HCFA as "indirect" expenses. Except for the occasional purchase of personal medical equipment, emergency medicine office practice expense is composed almost entirely of the practice management costs associated with hospital and managed-care contracting, physician scheduling, physician recruitment and credentialing, and patient billing and collections. In addition, emergency physicians incur additional expenses associated with continuing medical education, Quality Assurance activities, legal and accounting fees as do other specialties.

Billing expenses for the emergency physician amount to an average of $7.50 per claim or up to 14% of money collected. Chart dictation can reach $9 per chart. Emergency care documentation requirements have become excessive and training in chart documentation also adds expense through the hiring of consultant educators to train individual emergency physicians. Malpractice expense averages approximately $26,000 per emergency physician. Many malpractice insurers charge by the patient seen at approximately $4 per chart. These malpractice expenses are generally three times the amounts paid by such specialties as Family Practice, Internal Medicine, or Pediatrics.

Another significant but often unrecognized expense is classified as "standby time". Emergency physicians are required to be "in-house" 24 hours a day, seven days a week. Patients with a variety of injuries and illnesses arrive in emergency departments any time of day or night. There is a value to the community and the nation in maintaining these readiness capabilities. As a result of the unscheduled nature of emergency medicine, emergency physicians may spend a portion of their time in an "availability" or "readiness" status awaiting the arrival of patients. There is substantial economic cost for this "down-time" which may account for an average of two to three hours per evening. Paying physicians for this "standby time" is a significant overhead expense for the emergency physician group and well above the expense incurred providing an LPN or medical assistant in the usual physician's office.

The mean practice expense in the Lewin study sites (excluding uncompensated care) was $56,838 per physician with a median of $49,329.¹ Excluding uncompensated care, the mean practice expense per hour is $27.33.¹ Combining the uncompensated care mean expense of $69.27 with the mean practice expense all of $27.33 equals an overhead expense of $96.60¹ per hour for each emergency physician.

What are the typical salaries of emergency physicians?

Emergency physicians receive wages that compensate them for high level of stress and tension associated with emergency medicine practice. These stresses and tensions are associated with the fact that emergency physicians 1) practice in an environment in which critical decisions must be made under intense time pressure and under adverse conditions; 2) provide coverage of emergency departments 24 hours a day, seven days a week and therefore routinely work nights, holidays, and weekends; 3) Handle multiple patients simultaneously; and 4) are expected to have increased technical and procedural expertise that is not expected of the usual primary-care physician.

Thus, attracting a sufficient number of physicians to emergency medicine means offering them a wage "premium" relative to the income they would earn as primary-care physicians. According to the Medical Group Management Association, median annual compensation for emergency physicians in 1995 was $176,439. This represents a 32% differential over primary-care compensation, but remains well below the salary level of many of the other major specialties.¹

In conclusion, many medical staff members, hospital administrators, insurance company representatives, and hospital executive physicians are frequently unaware of issues related to emergency medicine. By highlighting aspects of the practice of emergency medicine and presenting recent data about overhead expenses, the hope is to help educate the many physicians who are simply unaware of these facts. Working hand-in-hand with all the medical and surgical specialties and sub-specialties in a closer relationship will certainly lead to better care of our patients not only in emergency department but also after they are admitted or discharged back to the rest of the medical community. Acute care fulfills the circle of continuity of care with the remainder encompassed by chronic, scheduled care. All the medical and surgical community working together to help themselves and provide better healthcare.

REFERENCE

1. The Lewin Group. Emergency Physician Practice Expense: Presentation to HCFA. August 19, 1998.

Jacksonville Medicine / March, 1999

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