I only recall going to the emergency room once in my life. It was afterhours and I fell and cut my knee on a floor HVAC grate putting, parallel cuts on my knee cap. I was 12 or 13 at the time and had to have between 20 and 30 stitches. The cost to have my knee sewed up afterhours was around $150 as I recall. When adjusted for inflation that’s about $800. Go figure. If I had the same injury today the ER cost would be just short of $1 million assuming it was in-network. Of course, ER providers are never in-network thanks to private equity buying up emergency medical practices and investing in ER staffing firms.
National Public Radio (NPR) reported that those same private equity firms are hiring fewer doctors to staff ERs in order to save money and boost profits. NPR told an anecdote about a pregnant woman in Tennessee who went to the ER for bleeding and was sent home. She had to go back two more times before she finally was able to see a doctor. She got three separate ER charges to confirm her suspicion that she was having a miscarriage. According to a confidential company document obtained by KHN and NPR the staffing firm that runs the Tennessee hospital ER boosts profits by having fewer licensed physicians staffing emergency departments.
According to NPR/KHN:
This staffing strategy has permeated hospitals, and particularly emergency rooms, that seek to reduce their top expense: physician labor. While diagnosing and treating patients was once doctors’ domain, they are increasingly being replaced by nurse practitioners and physician assistants, collectively known as “midlevel practitioners,” who can perform many of the same duties and generate much of the same revenue for less than half the pay.
“APP has numerous cost saving initiatives underway as part of the Company’s continual focus on cost optimization,” the document says, including a “shift of staffing” between M.D.s and mid-level practitioners.
I’m a fan of nurse practitioners and physician assistants practicing up to their full potential. I’m not a fan of three separate ER visits for the same problem, however. The emergency room is a unique environment. In an clinical environment complex patients can be referred to a specialist for a second opinion. The ER doesn’t always have that luxury. I’d like to see a range of providers specializing in emergency medicine helping triage patients in the ER. It makes sense to have a mix of training levels and research seems to support that idea.
A working paper, published in October by the National Bureau of Economic Research, analyzed roughly 1.1 million visits to 44 ERs throughout the Veterans Health Administration, where nurse practitioners can treat patients without oversight from doctors.
The researchers found that costs in the ER increased 7% and wait times increased at VA hospitals triaged by nurse practitioners. Subsequent length of hospital stays were also 11% longer. That is not a huge increase by any means and researchers caution that does not mean midlevel providers do not belong in ERs.
Yiqun Chen, who is an assistant professor of economics at the University of Illinois-Chicago and co-authored the study, said these findings are not an indictment of nurse practitioners in the ER. Instead, she said, she hopes the study will guide how to best deploy nurse practitioners: in treatment of simpler cases or in circumstances when no doctor is available.
Other experts are quick to say there is no evidence midlevel practitioners have worse outcomes or higher costs than physicians.
But definitive evidence remains elusive that replacing ER doctors with nonphysicians has a negative impact on patients, said Dr. Cameron Gettel, an assistant professor of emergency medicine at Yale. Private equity investment and the use of midlevel practitioners rose in lockstep in the ER, Gettel said, and in the absence of game-changing research, the pattern will likely continue.
“Worse patient outcomes haven’t really been shown across the board,” he said. “And I think until that is shown, then they will continue to play an increasing role.”
The trend is likely to increase and if done right makes sense.
For example, Envision once encouraged ERs to employ “the least expensive resource” and treat up to 35% of patients with midlevel practitioners, according to a 2017 PowerPoint presentation posted by the company online. The presentation drew scorn on social media and soon disappeared from Envision’s website.
It’s likely that more than one-third of ER patients are relatively simple cases that don’t need the services of an emergency physician and can easily be treated by a midlevel practitioner with no oversight. Indeed, it is likely that more than one-third of ER patients don’t need to be in an ER at all. Despite the social media backlash the Envision PowerPoint suggests a ratio of two physicians to one midlevel practitioner. That does not sound out of line to me.