Everyone is talking about it... healthcare is broken. We've been transitioned to where healthcare is not only available to everyone but required, employed or not. Here's my opinion on how it's effected healthcare on the front lines. There's been a flood of insured patients which have overwhelmed primary care offices. I can't tell you how many times I've heard patients on the Oregon Health Plan (OHP) tell me, "I've been enrolled in insurance but I'm waiting to be assigned to a doctor." Or, "I just got insured but my first visit is scheduled for a ridiculous amount of time in the future." The physicians are burned out and making an exit faster than Taco Bell burritos. Well if you're sick and can't get in to your PCP what's the next rational decision? Urgent Care! Oh wait, most the Urgent Cares in our area aren't accepting Oregon Health Plan patients. Why? Because I assume they get paid crap from OHP. So now you can't see your PCP, or Urgent care, so the only available option is the Emergency Department (ED).
Thank you EMTALA for completely tying the hands of emergency care providers. EMTALA is a law enacted in 1986 that was supposed to protect sick patients from being turned away from life saving medical care based off inability to pay. It requires anyone coming to the ED to be stabilized and treated, regardless of their insurance status or ability to pay. Sounds great right? Oh wait... a medical professional has to perform a medical screening examination to assess whether their condition is life threatening. A medical professional would include an MD, DO, NP, FNP. etc. NOT A NURSE. Anyone whose been to an ED knows who you see first... a nurse! And in some areas/hospital a nurse is all you're going to see for HOURS! So a nurse can check in a patient with a bug bite. Bug bite people, and we cannot give them reassurance or advise them to treat their bite at home until their seen by a medical professional who deems their bite non life threatening. And because they have OHP they don't pay anything out of pocket for their visit.
So now you can see where we're getting in to trouble here. I'll shortly touch on another subject. I'm not sure where the lack of self care has come from in this current population. Maybe it's the invention of google- where everyone looks up their symptoms and immediately thinks they're dying. Maybe it stems from both parents working outside the home and not passing knowledge onto their children. Maybe it's big Pharma telling us there's a pill for everything. Maybe it's the world of technology where everything is at our fingertips and has to be instantaneous. Maybe it's the movement to protect and guard your children closer because the world is such a scary place. But I tell you what... the generation of "Rub some dirt on it, tough it out, and if it hurts just don't do that" is a dying breed. And I wish I knew who to blame. Because people are coming to the ED for everything. I see patients do it out of convenience, "I have a dr appointment in 2 days but I didn't want to wait that long." I see patients do it out of ignorance, "I think this bug bite is going to kill her." And then I also see it out of desperation, "I haven't been assigned a primary care doctor and I need to be seen."
Lets summarize. We have a population where the vast majority has health insurance, 94% in fact according to Oregon.gov. We have primary care offices inundated with patients. Urgent Cares not accepting OHP. And the cherry on top is no deductibles for OHP. Couple that with a climate of Dr. Google and the obsession with immediate results and you have overwhelmed emergency departments. It's too easy to present to the ED for any trivial complaint. I remember as a child I would have to be near death before my parents would agree to take me in.
Now, just when you thought I had made my point, I haven't even started. Two words. Press Ganey (or in some places Hospital Consumer Assessment of Healthcare Providers and Systems- HCAPS). If you've been hospitalized recently you may remember being sent a survey in the mail asking you to rate your experience. Key word here is experience. They don't ask you to rate: Did I die, did I develop an infection, was I treated for the correct disease, were my medications given on time, etc. No! They ask questions like: Was the environment quiet, were people friendly, did they show concern, and would you recommend this hospital to a friend. You can't make this stuff up people, these are real questions. Some of you right now are asking why I'm so upset... these all seem like things you'd want in your hospital experience.
Here's why I'm upset. Because the reimbursement the hospital receives from the government is partly based off these scores. SUBJECTIVE scores of the patient's EXPERIENCE. So if someone feels they didn't get enough Dilaudid and turkey sandwiches then scores the hospital poorly, the hospital could potentially start getting paid less than competitors in their area. Because everyone knows people perform better with competition right? But why on God's green earth did they decide to score a hospital's performance off the patient's EXPERIENCE. Hospitals are not hotels or restaurants. They need to be scored on outcomes. And everyone knows you're more likely to complete a survey if you feel strongly about something. Humans love to complain. If you had a run of the mill hospital stay with no real complaints or exuberant compliments you probably won't fill out the survey. But if you're upset you know you're going to be filing in those bubbles and writing comments explaining how terrible the place was.
Because no hospital, private or not for profit, can stay in business without being in the green, they're forced to put emphasis on tailoring their care to receive the best experience scores. And what's the one thing people hate most? Waiting. So in order to stay competitive and appeal to the patient experience some hospitals are promising short wait times. Short wait, happy patients, more money (and it's obviously safer to have shorter wait times). I can't tell you how many times I've heard, "So this will only take an hour right I have somewhere to be." This is an unrealistic expectation that frontline healthcare workers have to take the blame for.
I'm making progress people stay with me. So far I've summarized why healthcare is broken, why patients don't see their PCP, why emergency departments are overwhelmed, how many patients don't have an immediate monetary consequence for using the ED, how they've been promised they'll be seen quickly, and then their experience may dictate how much the hospital gets paid for their visit. Are you seeing how this is all coming together? It's a repetitive self destructive cycle.
So what do we do about it? I think we have to change how we think about healthcare. Not as a place where you'll be treated like an MVP, where you'll get whatever you ask for, and where you'll never have to wait. Yes of course we try our best to make those things happen and we want you to have a good experience. But that shouldn't be the primary concern. We need to think of healthcare as a life saving service that is available to everyone, but prioritizes urgent complaints, where waiting is expected, where waiting means you can be thankful you're not as sick as the patient rushed back, where you can be treated with respect but may also be told you're wrong, where you may be denied, where you may not get to dictate your course, where you may be upset, and where you may leave in pain. Where the quality of care is not based on whether you left happy, but whether you were treated by professionals who recognized your illness, used up date knowledge and procedures, with sterile technique, had good outcomes, and sent you with the tools to prevent further illnesses and manage your disease. Where instead of hearing, "We'd love to see you again come back for anything" you may hear, "This is not appropriate for the emergency department next time wait to see your doctor." But because healthcare is now accommodating to the patient experience, providers may not always say what needs to be said, or may order unnecessary tests or medications in order to keep the patient happy. But if the patient is healthy do we always need to make them happy?
Lets treat healthcare more like we do the airline industry. Where you're willing to pay ridiculous amounts of money for an uncomfortable chair sandwiched between two strangers, where you're not allowed to walk about freely, where you're served miniature snacks, and where delays and overbooking are common, yet we still come back for more. If you had a bumpy landing do you demand to speak with to the pilot? If you have to taxi 10 minutes longer than expected does anyone throw a tantrum and demand to be in the air right away? If the refreshments are cancelled because of turbulence do you ask for a refund? Rarely! Yet this happens in healthcare. Why?
We asked for more affordable and accessible healthcare- we got it. Now lets ask for safe and effective healthcare. Let go of your expectations, trust that we're working as fast as we can, that asking us to work faster leads to errors- fatal errors. Sit in the waiting room for 6 hours, be thankful for that opportunity, and be thankful you're able to wait 6 hours. Because they are people that can't wait. Understand the system is strained. Demand to be treated with kindness and respect, but expect wait. Demand to be evaluated, but expect to be treated by the physicians protocols not your own. Demand to be treated equally regardless of your demographics, but expect to be be treated after the sickest patient. Demand a safe environment, but expect to be uncomfortable, double roomed, and sleep deprived. And above all, tip your nurse ;)
Thank you EMTALA for completely tying the hands of emergency care providers. EMTALA is a law enacted in 1986 that was supposed to protect sick patients from being turned away from life saving medical care based off inability to pay. It requires anyone coming to the ED to be stabilized and treated, regardless of their insurance status or ability to pay. Sounds great right? Oh wait... a medical professional has to perform a medical screening examination to assess whether their condition is life threatening. A medical professional would include an MD, DO, NP, FNP. etc. NOT A NURSE. Anyone whose been to an ED knows who you see first... a nurse! And in some areas/hospital a nurse is all you're going to see for HOURS! So a nurse can check in a patient with a bug bite. Bug bite people, and we cannot give them reassurance or advise them to treat their bite at home until their seen by a medical professional who deems their bite non life threatening. And because they have OHP they don't pay anything out of pocket for their visit.
So now you can see where we're getting in to trouble here. I'll shortly touch on another subject. I'm not sure where the lack of self care has come from in this current population. Maybe it's the invention of google- where everyone looks up their symptoms and immediately thinks they're dying. Maybe it stems from both parents working outside the home and not passing knowledge onto their children. Maybe it's big Pharma telling us there's a pill for everything. Maybe it's the world of technology where everything is at our fingertips and has to be instantaneous. Maybe it's the movement to protect and guard your children closer because the world is such a scary place. But I tell you what... the generation of "Rub some dirt on it, tough it out, and if it hurts just don't do that" is a dying breed. And I wish I knew who to blame. Because people are coming to the ED for everything. I see patients do it out of convenience, "I have a dr appointment in 2 days but I didn't want to wait that long." I see patients do it out of ignorance, "I think this bug bite is going to kill her." And then I also see it out of desperation, "I haven't been assigned a primary care doctor and I need to be seen."
Lets summarize. We have a population where the vast majority has health insurance, 94% in fact according to Oregon.gov. We have primary care offices inundated with patients. Urgent Cares not accepting OHP. And the cherry on top is no deductibles for OHP. Couple that with a climate of Dr. Google and the obsession with immediate results and you have overwhelmed emergency departments. It's too easy to present to the ED for any trivial complaint. I remember as a child I would have to be near death before my parents would agree to take me in.
Now, just when you thought I had made my point, I haven't even started. Two words. Press Ganey (or in some places Hospital Consumer Assessment of Healthcare Providers and Systems- HCAPS). If you've been hospitalized recently you may remember being sent a survey in the mail asking you to rate your experience. Key word here is experience. They don't ask you to rate: Did I die, did I develop an infection, was I treated for the correct disease, were my medications given on time, etc. No! They ask questions like: Was the environment quiet, were people friendly, did they show concern, and would you recommend this hospital to a friend. You can't make this stuff up people, these are real questions. Some of you right now are asking why I'm so upset... these all seem like things you'd want in your hospital experience.
Here's why I'm upset. Because the reimbursement the hospital receives from the government is partly based off these scores. SUBJECTIVE scores of the patient's EXPERIENCE. So if someone feels they didn't get enough Dilaudid and turkey sandwiches then scores the hospital poorly, the hospital could potentially start getting paid less than competitors in their area. Because everyone knows people perform better with competition right? But why on God's green earth did they decide to score a hospital's performance off the patient's EXPERIENCE. Hospitals are not hotels or restaurants. They need to be scored on outcomes. And everyone knows you're more likely to complete a survey if you feel strongly about something. Humans love to complain. If you had a run of the mill hospital stay with no real complaints or exuberant compliments you probably won't fill out the survey. But if you're upset you know you're going to be filing in those bubbles and writing comments explaining how terrible the place was.
Because no hospital, private or not for profit, can stay in business without being in the green, they're forced to put emphasis on tailoring their care to receive the best experience scores. And what's the one thing people hate most? Waiting. So in order to stay competitive and appeal to the patient experience some hospitals are promising short wait times. Short wait, happy patients, more money (and it's obviously safer to have shorter wait times). I can't tell you how many times I've heard, "So this will only take an hour right I have somewhere to be." This is an unrealistic expectation that frontline healthcare workers have to take the blame for.
I'm making progress people stay with me. So far I've summarized why healthcare is broken, why patients don't see their PCP, why emergency departments are overwhelmed, how many patients don't have an immediate monetary consequence for using the ED, how they've been promised they'll be seen quickly, and then their experience may dictate how much the hospital gets paid for their visit. Are you seeing how this is all coming together? It's a repetitive self destructive cycle.
So what do we do about it? I think we have to change how we think about healthcare. Not as a place where you'll be treated like an MVP, where you'll get whatever you ask for, and where you'll never have to wait. Yes of course we try our best to make those things happen and we want you to have a good experience. But that shouldn't be the primary concern. We need to think of healthcare as a life saving service that is available to everyone, but prioritizes urgent complaints, where waiting is expected, where waiting means you can be thankful you're not as sick as the patient rushed back, where you can be treated with respect but may also be told you're wrong, where you may be denied, where you may not get to dictate your course, where you may be upset, and where you may leave in pain. Where the quality of care is not based on whether you left happy, but whether you were treated by professionals who recognized your illness, used up date knowledge and procedures, with sterile technique, had good outcomes, and sent you with the tools to prevent further illnesses and manage your disease. Where instead of hearing, "We'd love to see you again come back for anything" you may hear, "This is not appropriate for the emergency department next time wait to see your doctor." But because healthcare is now accommodating to the patient experience, providers may not always say what needs to be said, or may order unnecessary tests or medications in order to keep the patient happy. But if the patient is healthy do we always need to make them happy?
Lets treat healthcare more like we do the airline industry. Where you're willing to pay ridiculous amounts of money for an uncomfortable chair sandwiched between two strangers, where you're not allowed to walk about freely, where you're served miniature snacks, and where delays and overbooking are common, yet we still come back for more. If you had a bumpy landing do you demand to speak with to the pilot? If you have to taxi 10 minutes longer than expected does anyone throw a tantrum and demand to be in the air right away? If the refreshments are cancelled because of turbulence do you ask for a refund? Rarely! Yet this happens in healthcare. Why?
We asked for more affordable and accessible healthcare- we got it. Now lets ask for safe and effective healthcare. Let go of your expectations, trust that we're working as fast as we can, that asking us to work faster leads to errors- fatal errors. Sit in the waiting room for 6 hours, be thankful for that opportunity, and be thankful you're able to wait 6 hours. Because they are people that can't wait. Understand the system is strained. Demand to be treated with kindness and respect, but expect wait. Demand to be evaluated, but expect to be treated by the physicians protocols not your own. Demand to be treated equally regardless of your demographics, but expect to be be treated after the sickest patient. Demand a safe environment, but expect to be uncomfortable, double roomed, and sleep deprived. And above all, tip your nurse ;)
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