If Boarding is So Terrible, Why is the House of EM Doing So Little About It?

Also: VACEP's Prudent Layperson win, Michigan Medical Society wants CPOM laws enforced, Medicare doesn't like us, taking health insurance away from Americans leaves them uninsured, & MRI is a magnet.

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Patient boarding in US emergency departments is bad. And it’s getting worse. 

Even randomly selected Americans surveyed in October 2023 by Morning Consult and ACEP know this. Per the survey: “Four in five adults (80%) are concerned about the boarding crisis, and two in five adults (43%) would delay or avoid going to the ED if they knew that they, or a loved one, could face a long wait in an ED before being admitted to the hospital or transferred to another facility. Nearly half of adults (44%) said that they, or a loved one, experienced a long wait time after receiving care in an ED.”

Both ACEP and AAEM have communicated their concerns about boarding, most notably in an open letter to the White House sent in November 2022 and signed by 38 organizations. From the letter: “In recent months, hospital emergency departments (EDs) have been brought to a breaking point. Not from a novel problem – rather, from a decades-long, unresolved problem known as patient ‘boarding,’ where admitted patients are held in the ED when there are no inpatient beds available. While the causes of ED boarding are multifactorial, unprecedented and rising staffing shortages throughout the health care system have recently brought this issue to a crisis point, further spiraling the stress and burnout driving the current exodus of excellent physicians, nurses, and other health care professionals.”

The ACEP letter features several emergency physician quotes about boarding. An example: “We are a 38-bed ED, usually with 30-40 pts in the waiting room and many EMS patients waiting for rooms in the hallway. Patients come in agitated, acutely psychotic, and occasionally violent. We cannot provide these patients with high-quality medical care when they are waiting for a bed for hours/sometimes days. We also have critically ill patients requiring a higher level of care who have to wait in hallways. It’s not unheard of for these patients to decompensate before we are able to get them into an ED room. This is not sustainable. Saving beds for elective surgical patients while truly ill, critically ill patients waiting in hallways in the emergency department is disheartening. It’s unsustainable, morally wrong, and dangerous for staff and patients. How did we go from being healthcare heroes to an afterthought of the medical system?”

Moreover, multiple recent studies have shown that prolonged ED stays increase mortality rates for admitted patients. A JAMA Internal Medicine paper, published November 2023, concluded: “Those who spent a night in the ED showed a higher in-hospital mortality rate and increased risk of adverse events compared with patients admitted to a ward before midnight.” This finding echoed a 2022 article that found worsening mortality rates for every extra hour admitted patients spent in an emergency department after five hours. 

The cause of ED boarding is not mysterious. Boarding is due to exit block. Too often, hospitals do not staff enough inpatient beds to admit the predictable number of sick ED medical and psychiatric patients. Emergency clinicians are all too familiar - on practically every shift - with ED charge nurses arguing, cajoling, and pleading for hospital beds to be opened for admissions.

The New England Journal published a passionate commentary about the scourge of boarding, written by a who’s who of tenured emergency medicine academic chairs, in 2021. The authors explain: “Often seen as a local ED problem, the cause of ED crowding is misaligned health care economics that pressures hospitals to maintain inefficient high inpatient census levels, often preferencing high-margin patients. The resultant backup of admissions in the ED concentrates patient safety risks there. Few efforts (even well-meaning ones) address the economically driven root causes of ED crowding, i.e., the need to achieve minimal financial hospital margins. The key to a sustainable solution is to realign health care financing to allow hospitals to keep inpatient capacity below a critical threshold of 90%; beyond that, hospital throughput dynamics will inevitably lead to ED crowding.”

In other words, ED boarding is a hospital problem. The authors write: “We assert that the largely unrecognized cause of ED crowding and its negative impacts on patients are due to misaligned healthcare economics and financial pressures on hospitals… Many hospitals are servile to financial drivers that virtually ensure frequent hospital and ED crowding.”

If boarding is terrible for patients and clinicians - and the fundamental problems are hospital staffing levels and hospitals prioritizing elective procedural admissions - one would expect organized emergency medicine’s response to focus on hospital-level change. However, this is not what has happened.

Remember that ACEP letter about the evils of boarding? It was sent to the White House. The White House. When sick ED patients languish in EDs for days, do you think ED physicians and nurses are looking to the White House for a solution? Of course not; they know boarding is a hospital-level problem, not a political one. 

What was the action ACEP wanted from the White House? A summit. From the letter: “ACEP and the undersigned organizations hereby urge the Administration to convene a summit of stakeholders from across the health care system to identify immediate and long-term solutions to this urgent problem.”

ACEP held a boarding summit in September 2023. The resulting action items were listed in three categories: 1) Governmental Role; 2) Technology Role; 3) Other. Though the summit’s summary document includes the line, “Boarding and ED crowding are not caused by ED operational issues or inefficiency; rather, they stem from broader health system dysfunction,” hospital dysfunction was not addressed in top-line action plans. 

Emergency medicine leaders can be forgiven for not wanting to confront hospital administrators directly. Imagine you lead an emergency medicine practice group. Your company’s contract with the health system can be terminated with four months’ notice. If you request changes from the hospital’s CEO that would harm the hospital’s financial performance, you put your group’s contract - and your doctors’ livelihood - at risk. 

Now, imagine you are an ambitious, young attending emergency physician. Your training at the country’s best medical institutions has taught you to put patients first. You see patients dying in the waiting room, patients dying waiting for ICU beds, and patients attacking nurses after being held like ED prisoners for weeks. You think, “I’m going to talk to the CEO about boarding.” You get a respectfully cold reception from the CEO but no follow-up action. You then write an op-ed for the local newspaper to raise awareness about what’s happening in the town’s ER. How long do you think it will take for you to lose your job?

The New England Journal article concludes, “Like the ailing canary in the coal mine, ED crowding is a symptom of health care system dysfunction. The canary’s condition is critical. Without action, patients will continue to be at a heightened risk of harm. Time for real action is now.”

If the time for real action is now and hospital-level change is the key to real action, how can emergency physicians advocate effectively for health system changes without endangering their jobs? 

Nurses have found the answer: unionization. Check out these recent headlines about nursing union actions:

“Registered nurses in Texas and Kansas at three Ascension hospitals gave notice today to their employer that they will hold one-day strikes on Wednesday, December 6 to protest unsafe conditions management has failed to remedy.”

“In New York, 7,000 nurses engaged in a three-day strike this January demanding more investment in low-income communities and accusing executives at nonprofit Montefiore and Mount Sinai of prioritizing finances over patient care. The New York State Nurses Association won sizable wage increases and updated staffing ratios with stronger enforcement mechanisms.”

“Nurses to hold press conference to announce a vote of ‘No Confidence’ in Hennepin Healthcare CEO Jennifer DeCubellis.”

If emergency physicians had job security and organizational support from a union, achieving hospital-level changes would become more feasible. Rather than trying to solve boarding problems through the White House and summits, emergency physicians (and their nursing allies) could engage and win where it matters most - with health systems’ administrative leadership.

EM Practice

Interesting discussion in ACEPNow about whether EM residency should be three or four years.

The Virginia state government tried to take a legal sledgehammer to the Prudent Layperson Standard. “In April 2020, amid pandemic financial concerns, Virginia’s legislature approved the Governor’s budget amendment, which included a Medicaid ‘Downcoding Provision.’ This amendment downcoded Medicaid reimbursements to a Level 1 visit if the patient’s final diagnosis appeared on a list of 790 diagnoses, deemed ‘avoidable emergencies,’ for Medicaid patients. The list was created to penalize Medicaid Managed Care Organizations for not managing their beneficiaries’ care, resulting in ‘preventable’ ED visits; however, the health plans successfully argued that emergency medicine groups and hospitals should share this responsibility. The Downcoding Provision included diagnoses such as heart failure, diabetic ketoacidosis, and acute asthma. This meant that professional E/M services would be downcoded and paid at just under $16, a considerably lower reimbursement than the charges submitted.” VACEP, with the leadership of Dr. Todd Parker, fought back and won.

House of Medicine

The Michigan State Medical Society sent a strongly worded letter to Michigan’s attorney general about enforcing the state’s Corporate Practice of Medicine laws. From the letter: “The Michigan State Medical Society (“MSMS”) and the undersigned specialty organizations are writing to request that your office investigate what we believe are widespread violations of Michigan’s prohibition on the corporate practice of medicine (the “CPOM Doctrine”) by Michigan Professional Corporations (“PCs”) and Professional Limited Liability Companies (“PLLCs”) owned by Michigan MDs and DOs in name only. The CPOM Doctrine protects the public by prohibiting unlicensed, for-profit businesses from practicing medicine. Enforcement of the CPOM Doctrine will ensure that the quality of medical care furnished by physicians to the public, a physician’s independent medical judgment, as well as the confidential physician-patient relationship cannot be interfered with by unlicensed business decision-makers motivated solely by profit.”

Epic Research: “The proportion of self-pay emergency department (ED), hospital, and primary care encounters increased starting in April 2023 when states could start terminating Medicaid coverage for patients who no longer met Medicaid requirements following the pandemic.”

UnitedHealth’s Optum keeps hiring more physicians. Optum now employs or affiliates with 90,000 US physicians.

Hospitals & Health Systems

New York Times: “Why Are Nonprofit Hospitals Focused More on Dollars Than Patients?”

Mount Sinai Health System named Brendan Carr, MD, an emergency physician, as its next CEO.

Uncompensated care is more common in rural hospitals and in states that did not expand Medicaid.

Survey about the US healthcare system: The majority think the system is heading in the wrong direction and needs fundamental change. They believe it puts its profits above patient care. 69% think the system is fundamentally flawed and in need of major change vs. 7% who think otherwise. 60% believe it puts its profits above patient care vs. 13% who disagree. 74% think price controls are needed vs. 7% who disagree.

Nursing & Allied Health

Annals: “What Is Driving the Nursing Shortage?: Hint: It is not a lack of nurses.” From the article: “Staffing shortages are often blamed on nursing shortages and staff burnout from the coronavirus disease 2019 pandemic. But nurses say that there is no shortage. Rather, there is an exodus from hospitals because staff are fed up with subpar working conditions."

“Michigan has 8,500 open hospital jobs and 50,000 nurses who aren’t filling them.”

Nurses strike at three HCA hospitals over understaffing.

The Dispo

Source: https://themessenger.com/health/mri-gun-shot-self-inflicted-injury-prevention

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