The Third Shift of Healthcare

As we enter the second week of the government shutdown, there is a focus on “healthcare” as perhaps the most important budget item.  In reality, it is not “healthcare” that is at issue but rather the Obama and COVID era subsidies for Medicaid and the exchanges.  The price tag is said to be $1.5 trillion dollars.  Not chump change, even in this era of incomprehensible government expenditures.  What is missing, what is never even talked about, is the efficacy and efficiency of the American healthcare system.  In other posts, I have highlighted the focus on symptom reduction through prescription medication, even in the absence of a medical diagnosis.  That in itself is bad enough but there are other important issues at play as well. 

In the 1980’s, there was a system-wide effort to reduce costs by managing care.  The behavioral health area was a favorite target but the effort also looked at imaging and elective surgery among others.  What was never addressed in my experience was emergency room care.  Even though the average ER visit costs between $1500 and $3000, making it probably the most expensive out-patient visit in healthcare, health insurers apparently did what just about everybody does with third shifts i.e. ignores it.  If you have ever worked in a place that has a third shift, you know what I mean.  Everyone knows it exists but no one really knows what goes on.  It’s almost like an alternate reality.  There is healthcare that occurs in the daylight where everyone can see what goes on and there’s the healthcare that occurs in the darkness of night that few know anything about. 

To really understand the emergency room, one must understand EMTALA.   EM what? You say.  Yes, the Emergency Medical Treatment and Labor Act.  Enacted in 1986, EMTALA requires any ER that accepts Medicare i.e. all ER’s, to provide medical screening and stabilizing treatment to ANYONE who presents at the ER, regardless of their ability to pay or, in today’s political world, citizenship.  Unlike the shows on television that depict hospital emergency rooms as last resort bastions of heroic care, the real emergency room is a chaotic mess where, after midnight, a significant percentage of the patients are intoxicated or drug seeking.  At Rhode Island Hospital in the early 2000’s, a study found that 30% of the 115,000 patients presenting at the ER were legally intoxicated.  If no medical condition was identified, the patient would be warehoused until their blood alcohol level dropped below the legal limit, at which point they would be discharged.  And this was before the narcotic epidemic, which has led to an increase in the number of patients presenting after hours with all manner of “pain” in order to secure a prescription for narcotics.  That would be bad enough but each new day/night is treated as a virgin so if the same patient who presented yesterday presents today, EMTALA requires that they be evaluated/treated despite the previous contact.  Groundhog Day all over again, because this time might be different from the previous ten.

Most of you probably know of someone who presented at an ER thinking they were having a heart attack, only to be told that it was anxiety, a panic attack, and were perhaps told to follow up with their PCP or to find a mental health provider.  If they presented the next week with the identical complaint, they would likely be evaluated with the same procedures and given the same recommendations for follow up care.  At Blue Cross of RI, we required our network providers to be available 24-7 and forbid an after-hours voice message that began with: “if this is an emergency, hang up and dial 911”.  We wanted the doctor to decide whether the patient should go to the ER. We also required that the ER make an attempt to contact the member’s PCP so that they would have the benefit of that provider’s input with regard to the patient’s history and treatment and to facilitate follow up care, thereby better ensuring continuity.  I’d like to say that everyone complied but they did not. 

When I was involved in managing the substance abuse system in Rhode Island, we were asked by the hospitals and substance abuse facilities  to establish a “substance abuse protocol” so that known substance abuse patients could be diverted by police or outpatient providers from the regular medical ER to a specialized facility where appropriate treatment and follow-up could be provided.  Seemed like a good idea since the sheer number of intoxicated people was overwhelming the capacity of the ERs which had become a revolving door for many patients with repeated visits and no effective follow-up care.  NO! said EMTALA.  Every patient has to be treated as a mushroom who had sprung up out of the ground overnight.  At $1500 to $3000 a copy, the requirements of EMTALA insured that inefficient and ineffective care would continue at maximum cost ad infitnitum.  One of the hospitals did establish a mental health emergency room but the patient had to first be evaluated at exorbitant cost at the regular ER before being transferred to the specialty program.

Although well intentioned, EMTALA is ripe for abuse.  A patient without a regular doctor or who doesn’t want to wait for a scheduled appointment can present at the ER for a sore throat, difficulty breathing or a backache and the ER staff is required to evaluate and provide stabilizing treatment, again at maximum cost.  Everyone is guaranteed to be seen.  The predictable result is overcrowding and often hours-long waiting time to be seen.  The advent of private urgent visit units has helped to reduce the pressure on the hospital ER but lack of insurance and the requirement that a 911 call must be transported to the closest hospital ER means that inappropriate presentations will continue.

In the 1950’s and 60’s, when my father was practicing as a general physician, the ER was called an “Accident Room” and it was literally a room with gurneys divided by curtains where doctors met their patients to suture a laceration or set a fracture.  It was also a time when doctors had evening hours made house calls.  Due to doctors no longer providing care outside regular office hours that end at 4:00PM and the requirements of EMTALA, the ER and private urgicenters have become after hours’ offices, often completely separated from the healthcare system that operates during the day Monday through Friday.  This significant change in healthcare delivery has literally transformed outpatient care and divided it into two time zones, before 4:00PM and after 4:00PM.  And in addition, there is the “third shift” that begins around midnight every day of the week.

My wish, therefore, is that whenever you are discussing healthcare or witness others discussing it on TV or elsewhere, please be aware that there is a third shift that operates under the cover of darkness with virtually no visibility and which adds significant cost to all of healthcare both private and publicly funded.