Solid alternatives to ERs still lacking

Austin American-Statesman, January 22, 2014

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The incentives to avoid the ER are there. People just need a place to go to meet their needs. When they do, ER costs will be reined in.

On the second day of the new year, I slipped on a rock and fell into Shoal Creek. When I saw the gigantic splash coupled with the look of abject terror on Ian’s face, I laughed out loud. But about an hour later my right arm began to hurt.

I looked down and as I saw the bruises, I closed my eyes. Birds were singing, harps were playing. “Ian, dear, would you mind terribly driving me to the neighborhood drive-thru X-ray store?” We arrive and get in the short line. Ian presses the button, and a pleasant voice comes through the intercom to take our order.

“My wife here will have two views, right forearm,” Ian says. We drive through. I roll down my window, stick out my arm and X-rays are shot. We’re told that in about an hour I’ll receive a text message telling me if it’s fine or if I need to drop back by for a quick casting.

The music screeched into minor key as I opened my eyes to reality. The only way to get my arm checked out would be to brave an emergency room. Only a bone sticking through the skin could have compelled me to do that.

The disincentives for going to an ER for any reason are solidly built in. You will likely wait for hours and hours. No one there wants to be there. You’ll be with folks who are hurting, sick and possibly contagious. Many are afraid of what they’ll hear from the doctor. An annoying television will be blaring some god-awful channel. Children and babies will be crying. (Every parent knows that no self-respecting infant or toddler would spike a fever or get sick during normal working hours.)

On Jan. 2, the day I fell, the journal Science published a study showing that the newly insured in Oregon made 40 percent more visits to the emergency room than their uninsured counterparts in the 18-month study period. That same day, a New York Times article suggested that the Oregon study casts doubt on the hope that expanded insurance coverage under the Affordable Care Act will help rein in ER costs. Really?

The Oregon study does not prove that the law insuring more people will not decrease ER costs. Rather, the study shows that alternatives to the use of hospital emergency rooms were not yet in place; an adequate primary care infrastructure was not yet established.

It’s helpful to look at world experience. The other industrialized nations have had universal health coverage for many decades. Based on their experience, the architects of our law knew that when everyone is insured, you’ve got a single-tier system where care is delivered in the proper settings. Those nations have evolved primary care systems where people can go for fevers, sore throats, routine screenings, blood pressure checks, etc. Their ERs are comparatively empty and used for actual emergencies, like motor vehicle accidents, broken bones and stroke and heart attack.

Seeking medical care in those countries is convenient and doesn’t carry the threat of financial ruin. Illness is treated early and screenings prevent disease. The population of those countries have longevity and other positive health indicators, and they are satisfied with their health care. A much lower percentage of their total economic outputs is spent on health care.

Our country has a long way to go to fully establish its primary care infrastructure. It’ll take all hands on deck, and it will take many years. Primary care needs to be better compensated. Medical schools need to turn out more primary care docs. Nursing schools need to increase the number of nurse practitioner slots. Faculty needs to be better paid.

With the highest rate of uninsured in the country, the Texas Legislature needs to do what other medically underserved states have done: remove all barriers to practice for nurses in advanced practice to increase the number of providers. That’s a no-brainer and won’t cost a dime.

Ideally, primary care would be delivered in models such as those of Austin Regional Clinic where 24/7 telephone nurse consultation steers you to timely appointments. Care is delivered by a collaborative team of physicians, nurse practitioners and physician assistants. The clinics have laboratory and radiology onsite and extended evening and weekend hours.

The incentives to avoid the ER are there. People just need a place to go to meet their needs. When they do, ER costs will be reined in. By the way, my arm is fine.

Toni Inglis, MSN, RN, CNS, FAAN, is a lifelong Austin resident and retired editor and neonatal intensive care nurse. She writes a monthly opinion column for the Austin American-Statesman editorial page.