Last week I spent an evening shadowing in a small local Emergency Department (ED) with Mike Shear, MD. Mike is an Attending Physician with an interesting background – he did his undergrad studies in electrical and computer engineering, before moving into medicine and is quite passionate about medical informatics and good quality data recording.
Before talking about my experience in the ED, I thought I would take this opportunity to describe some of my high level learnings about the American Healthcare system – most of which I have taken from Chapter 4 of the brilliant Essentials Of Health Policy And Law, (Teitelbaum et Wilensky 2016).
1. No unified healthcare system
The key heuristic that underpins most of my learning is that the USA does not have a unified healthcare system – it provides healthcare through a “patchwork” of public and private insurance plans; federal, state and local governments; and institutions and individual providers who are often unconnected to each other.
2. Double the cost but not double as good
Per capita, the USA spends double on healthcare compared to other developed coutries – and whilst it does some things very well (eg cancer care), it ranks low on important measures such as life expectancy, infant mortality and adult obesity rates.
3. There are many players in the provision and delivery of healthcare
There are numerous ways to split this but the most simple way to think about this is in terms of:
- Consumers (ie The Patient)
- Regulators and Policy Makers
- Private health insurers
- Public health insurers
- Advocacy organisations
- Individual providers (individual clinicians, private clinician groups)
- Institutional providers (eg you can think of this as “hospitals” for the most part)
- Educators / Researchers
TANGENT WARNING! – of note, this separation of roles of the payer, the provider and the user has lead to some of the interesting economic challenges in health.
Healthcare is an imperfect market where the user does not bear the cost of the service, nor knows what the most appropriate service is. The agent (healthcare professional) does not bear the cost of the service, but guides the user to the best service. Finally, the health payer foots the bill! The video below provides a great basic overview of some of these problems:
4. The Insured
Around 92.7% of the population are insured – up from around 83.3% prior to the Affordable Care Act (“Obamacare”).
Of the insured:
- most people receive this through their employer (employer-sponsored insurance). The employer has two options for this:
- self-funded – employers set aside funds for employee health insurance claims
- fully insured – employers pay a premium to a private health insurance company
- Another significant proportion of the population are funded by
- Children’s Health Insurance Program (CHIP),
- the Veteran’s Administration, or
- Department of Defence
By the way, what is Medicaid, Medicare, CHIP???
Medicaid – a “government insurance program for persons of all ages whose income and resources are insufficient to pay for health care”. It is a means-tested program that supplies healthcare to 74 million low-income and disabled people. “Obamacare” (ACA) significantly expanded both eligibility for and federal funding of Medicaid.
Medicare -a single-payer, national social insurance program providing health insurance for 1) Americans aged 65 and older who have worked and paid into the system through the payroll tax and 2) younger people with some disability status – provides healthcare to around 55 million people.
CHIP – in simple terms this programs covers care for children in families that earn a modest income, but earn too much to qualify for Medicaid
5. Even if you are insured, there may be barriers to access of care
These barriers are:
- Not all providers accept all payers (eg Medicaid may pay less for a procedure than a private insurer, so a provider might just say “No Medicaid here”.)
- You may be underinsured – see section 7
- Needed services aren’t covered by your health insurance
- Your deductible (I’m more used to the word “excess” in terms of insurance) is very high
- Provider shortage
- Providers not available in a certain area
6. The Uninsured
- Pay for services themselves (“Out of pocket”)
- Find services provided at no cost
- Direct services programs
- Federally Qualified Health centres provide primary care services to medically underserved populations on a sliding scale basis
- HIV/AIDS services
- Family Planning
- Safety net providers – see below
- Direct services programs
- Go without care
Safety Net Providers
There is no formal definition or system for the safety net, but these are providers who serve a disproportionately high number of uninsured, underinsured and publicly insured people.
These providers struggle financially because they do not get fully reimbursed, and the grant money they do receive has not kept up with the growing costs of delivering care.
7. The Underinsured
Around 25 million people are considered to be “underinsured”.
This means that they do not have the financial means to pay for the gap between a) what their insurance cover pays for and b) the total cost of their medical bills. Features of insurance plans that lead to this problem include:
- Deductibles (excess) in the USA are extremely high
- some plans can be over $1000
- Reimbursement and visit caps
- an insurer may limit the amount they will reimburse for a certain service, or limit the number of visits
- Service exclusions
My ED Experience
Now that you are saturated from reading the above about the American Health System, I’ll tell you some salient points about my experience in the ED.
I arrived at the hospital at 1530 for a late shift in the department.
If I am going to be honest, my vision of an American hospital was a futuristic, space-age centre with loads of room and polished white surfaces, high tech gadgetry and white coats. I’m not sure where I got that impression – perhaps it is because the centres we read about in the UK are the high tech, advanced, leaders of the field.
But the first thing I noticed about the ED was that is felt EXACTLY like the ED I work in at St John’s Hospital, Livingston! It was a small “cottage” hospital, with an ageing ED (they are currently building a new one) and just as cluttered as hospitals in the UK that I have worked at.
When I say cluttered, I mean equipment stacked everywhere, paper and documents all over the walls, poor user design and user flow, terrible ergonomics for computers, noisy in terms of alarms going off everywhere, people in trolleys in the corridor waiting to be seen… as I walked around and observed (it is so rare when I am doing a shift that I get the luxury of observing!), I wondered why hospitals are always so cluttered and poorly designed.
Some other bullet points:
- The Emergency Department is staffed by a private group of doctors, who “bill” for “professional services”
- Therefore Dr Shear is the group’s accountant and treasurer!
- There are different ways Physicians get paid
- “Get what you kill” – not as dark as it sounds…. when a doctor treats a patient, they get paid directly from that patient/insurer – the problem is that certain payers pay better for certain things (eg Medicaid tends to pay less than private insurers for the same treatment)
- To avoid that problem, you split the bill depending on Value Units so that every clinician gets an even piece of the pie – but then there is no incentive to work faster because you’ll get the same share of the pie
- Split the bill but make sure everyone does the same amount of work – eg patients are handed out to Attendings (senior doctors) as they attend, not in a “pick up as you go” system
- The Hospital bills the patient separately for all the other staff costs, tests, drugs etc
- There were only two Attending for the whole evening shift, no junior docs as not an academic centre
- Patients were evenly distributed between the Attendings, not a “pick up as you go” system
- One patient attended because they had just moved to the area, didn’t know how much drugs would cost so just stopped taking them – including several important drugs like blood thinners and heart rhythm controllers.
- There is no anaesthetist or intensivist over night
- this shocked me, as we call for support from our intensive care team very regularly, and can have a consultant there very quickly to provide extremely advanced care to our patients.
- Onwards referral is quite different to UK
- if the patient is known to one of two specific private family doctors, they can be admitted under them. Otherwise they need to be discussed with a hospitalist who may not accept
- They have hospitalists and family hospitalists…
- the former are general medics or internists, and
- the latter are like GPs who do hospital work
- They treat all their abscesses including tonsil abscesses
- our particular department tends to refer these on to the surgical team. I’m not sure why we do that…
- Everyone was lovely
- They have “medical scribes”
- Because the Electronic Health Records can be such a pain, the USA healthcare system has a role called medical scribes
- scribes document in the EHR, and act as an “on the floor” personal assistant for the physicians
- EHR is a massive deal for billing – they had just started using EPIC
- I really liked the information entry system – Dr Shear could pick positive and negative symptoms to give a really robust data description of the patient’s attendance, which will have longterm value for outcomes analysis
- Very similar approach to patient assessment – and Mike is possibly one of the most efficient physicians I have ever worked with (certainly more efficient than me!)
- Doctor made orders online which were carried out without any chasing – bloods, ECG, X-rays
- Patient could pick up prescriptions from CVS 24 hours/day
Who has the right to emergency treatment?
The last point I want to make is about EMTALA, The Emergency Medical Treatment and Labor Act because there were big signs on the walls stating that anyone had the right to an emergency medical examination regardless of demographics or ability to pay
- EMTALA is a federal law (1986) that requires anyone coming to an emergency department to be stabilised and treated, regardless of their insurance status or ability to pay
- I don’t want to go too much into the politics, but it seems contentious. If you read on the American College of Emergency Physicians (ACEP) website, they state that
- the burden of uncompensated care is increasing
- local and state governments began to abdicate responsibility for charity care, shifting this public responsibility to all hospitals.
- EMTALA became the de facto national health care policy for the uninsured.
- ACEP’s point of view is that this should be recognised as a standard practice expense for Emergency Departments, compensated for at the state or federal level
Whilst I feel that emergency care is a basic human right, it does need to be paid for somewhere along the chain.
I feel like I am starting to get too detailed already, and I haven’t even started talking about the history or politics of healthcare in the USA… perhaps in another blog post.
One thought I would like to leave you with. It’s going to sound cliched, but learning about and seeing this healthcare system really made me value the NHS.
Imagine for a minute that you had to sift through different health insurance plans, deciding which one would cover you and your family, and then having to worry about paying deductibles of over £800 to receive care – not to mention the concerns if you didn’t have the means to pay for your insurance.
What a fantastic resource we have in the NHS, and even though there is plenty of room for improvement, this experience has solidified my desire to fight to preserve it.