Report Slams U.S. Emergency Care System A new report says the U.S. emergency medical system is overburdened, underfunded and fragmented. Doctors examine the problems of the emergency medical system and some potential fixes.
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Report Slams U.S. Emergency Care System

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Report Slams U.S. Emergency Care System

Report Slams U.S. Emergency Care System

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JOE PALCA, host:

This is TALK OF THE NATION. I'm Joe Palca, in Washington. Neal Conan is on assignment.

It's never good news when you need to go to the emergency room, but there could be more bad news when you get there. A new report out today says emergency rooms are full to bursting. Five hundred thousand ambulances are turned away from hospitals each year because the emergency rooms can't handle any more patients. The report says the nation's emergency medical system is overburdened, under-funded, and highly fragmented; to put it bluntly: in crisis.

Today on the program, we'll talk about the problems facing the country's emergency medical system, what's causing them, and what can be done to fix them. Later, our weekly visit with Political Junkie Ken Rudin. On the agenda today, the White House gets good news. Republican-turned-Democrat George Allen wins the Virginia Senate primary, and bloggers boo Hillary Clinton.

If you have a question about this week's political news, you can e-mail us now: talk@npr.org.

But first, crisis in the ER. If you have questions about what's gone wrong, give us a call. We'd also like to hear your stories, whether you live in a big city with lots of hospitals or a small rural area with fewer choices, call us with your ER experiences. What worked? What didn't?

Our number here in Washington is 800-989-8255. That's 800-989-TALK, and our e-mail address is talk@npr.org.

With us here in Studio 3A is Dr. Ricardo Martinez. He's an assistant professor of emergency medicine at Emory University, and Executive Vice-President of Medical Affairs at the Schumacher Group. That's an emergency medicine management organization based in Lafayette, Louisiana. Dr. Martinez was one of the reviewers of the report released today by the Institute of Medicine. The report is called The Future of Emergency Medical Care in the U.S. Health System.

Welcome to TALK OF THE NATION, Dr. Martinez.

Dr. RICARDO MARTINEZ (Professor of Emergency Medicine, Emory University; Executive Vice-President of Medical Affairs at the Schumacher Group): Thank you.

PALCA: So one of the findings of this report, of many interesting and sort of disturbing things, is that its not unheard of for a patient to be in the emergency room for up to two days before they can get admitted to the hospital. There are just not enough beds to go around. What's causing this?

Dr. MARTINEZ: Well, it's very interesting. You know, we've built the system that's actually very, very helpful in times of emergency. It's there when you need it. But the problem is is that during the last ten years we've seen five million people more per year go to the emergency department annually in the United States; it's about 114 million a year. At the same time, we've had about 700 hospitals close, and we've had about 450 emergency departments close.

And so what you're seeing is a huge growth in people coming to the emergency department now. We're overcrowding, hospitals have had to shrink back the numbers of beds that they have. And so once you're admitted you may actually board there, stay in the emergency department until you can be moved to a bed upstairs.

So the overall system is increased demand, decreased capacity, and we're at the breaking point right now.

PALCA: Well, I'm a little confused. What caused the decrease in the number of hospital beds that were available inside the hospital? I understand that there are more people going to the hospital, but why did the beds shrink?

Dr. MARTINEZ: Well, one of the things we do is, in trying to control healthcare costs, is we cut them. And, you know, just cutting something doesn't solve the problem. We have a growing problem of uninsured patients.

Another thing that you have to understand is that, by federal law, if I go to a doctor's office, that doctor may or may not have to see me. If I go to a hospital, they have to see you. So we've really become the access to care for most Americans, and we've become kind of the point of last resort. And, in fact, a story was told today of a patient who just needed a med refill who'd been to four different clinics and finally they were told to go to the emergency department.

So we've got the very, very sick patients now sharing the space, the resources, the time, with patients who need basically primary care, as well as uninsured patients, who don't have other access. So it's kind of the perfect storm, as it were, for our emergency care system.

PALCA: Yeah. But here's something I've always wondered. So you walk into the emergency room and you go up to the clerk at the counter and you say, look, I've gone to four different clinics and they can't fill my prescription. All I need is a prescription. Here's the one I had before, here's my medical record. It still takes six hours. I mean, what's the problem there?

Dr. MARTINEZ: Yeah, that's exactly right, because you have to be seen by a qualified medical provider. You know, the clerk is not a doctor or a nurse. And so what you'll do, usually, in that case is you'll be triaged. You'll be put in line like everybody else.

You know, interestingly enough, we don't put the least sick patients in the front, we put the sicker patients in the front. And, as a friend of mine says, what part of emergency do you not understand? Because that's the way it's designed.

PALCA: Yeah.

Dr. MARTINEZ: So, by definition, the less urgent you are, the less emergent you are, the less we should put you in front of the line. So that person, by definition, will wait. Then after they come through their triage, and they say, okay, this is what the problem is, it's not a high-level problem, then you still have to be seen - by federal law - by a qualified medical provider, usually a physician, who usually decides you're not an emergency. And this has nothing to do with your finances. No one can even ask if you have insurance, don't have insurance - it's irrelevant whether you have insurance. It's just that that's the system right now.

Now think about this. If I'm in the back with two chest pain patients, a gentleman from a car crash and a mother who's having trouble with her pregnancy, my priority, in terms of ethically and morally, is not to run out and fill your prescription.

PALCA: Right.

Dr. MARTINEZ: Or do your evaluation. So that's where those waits come in on the back end. If you're in a major crash you will know people will go quickly and go straight to the back.

PALCA: So what about that business about emergency ambulances being told, you know, sorry, we're full. I mean, if a hospital has an obligation to treat the patient, you know, what happens if you've got an emergency case and...

Dr. MARTINEZ: Well, that's if I walk in and I get on your territory. I'm on your territory. And so what happens is is hospitals that are at the overcrowded area then turn to the incoming traffic from the ambulance and say we cannot take anymore, we're on bursting point. And so we are overcrowded, you have to divert to another hospital because we cannot add - remember, by definition a lot of these patients are sicker - so you're saying I cannot add a sicker patient, because I don't have the resources to give to them.

So something's got to give and, unfortunately, it's us; because all of us rely on that emergency system to be there at all times. Sounds like simple solutions, doesn't it?

PALCA: Right. Well, of course. But you know, I was - but I just have apropos of that, one of the things that struck me about the report as I was looking at it is, yeah, there's always an issue of money. And I know that hospitals, especially when they are obliged to treat patients without insurance, are running up costs that they're not in a position to get back; but one of the interesting things about this report is it wasn't saying, you know, money, money, money, money. Some of it was just structural, that we need to make structural changes. How are those going to help?

Dr. MARTINEZ: Yep. Yeah, absolutely. I mean, one of the things it says is, don't just throw money at the back end. Let's look at the system on the front end. Because, you know, even the best dedicated people - and I have to tell you I have not run across people who were not dedicated and totally caring about going to work every day - but the worst - the best people cannot do well in a bad system.

So they said, let's look at things; it's very fragmented, one hospital doesn't know what another hospital is doing. Remember, these hospitals compete in the marketplace. They're not actually cooperating in the marketplace, for the most part. So you have to find a way to create a system for them. And what they want to be able to do is they want to do three basic things: You want to coordinate the flow of patients within a region; and where the specialists are you want to be able to regionalize that care so that, as one hospital is filling, you begin to know ahead of time that they're filling up so you can begin to move and take action; and the third thing is hold them accountable.

Because, interestingly enough, it's not real clear who's in charge of the flow of patients and the number of patients on the healthcare system at any one time. Who's watching that? There's no flow master, as it were. And so they're talking about taking ideas from industry and applying them to the healthcare industry, which is, you know, in many ways very autonomous, unless you see hospital chains. Because hospital chains are probably the closest thing we have to some sort of a system. But even those are fragmented from other hospital chains in the region.

PALCA: Yeah. Yeah. I guess the last thing a patient wants to feel is like he's on a conveyor belt, but never mind. Let's hear from an emergency room doctor who's dealing with these problems every day.

Dr. Timothy Buchman is a Medical Director of the Trauma Center and co-Director of the Surgical Intensive Care Unit at Barnes Jewish Hospital in St. Louis. He's also a professor of surgery at Washington University. Welcome.

Dr. TIMOTHY BUCHMAN (Co-Director, Surgical Intensive Care Unit, Barnes Jewish Hospital, St. Louis; Professor of Surgery, Washington University): Hi, how are you?

PALCA: So you've been listening to the conversation. How does what you're hearing square with your experience at Barnes?

Dr. BUCHMAN: Dr. Martinez has hit the nail on the head.

PALCA: Well, that's good.

Dr. BUCHMAN: Flow of patients is increasing rapidly. The patients are older, they're sicker and everybody needs to be seen by a doctor soon.

PALCA: What - I mean, how has this changed, let's say, in the last three years or five years? I mean, would you have said the same thing five years ago?

Dr. BUCHMAN: I would have said the same thing five years ago, but I'm saying it louder and more acutely now. Turns out the number of patients who show up at the front desk of our emergency department ranges between 10 and 30 an hour. Peak times, patients are arriving once every two minutes. All of them have to be seen. And the front of the line that Dr. Martinez talked about, the patients who are really sick and have to be seen right now, just keeps growing.

PALCA: And if you're saying - if you're telling people about these problems louder and more often, are you getting any sense that anyone's listening?

Dr. BUCHMAN: We're getting the sense that folks are listening, but there is no one solution. The population is aging; the number of patients who have poor insurance or no insurance and are referred to the nation's teaching hospitals continues to grow. We do need to find a way to take care of all the people in a timely manner.

PALCA: Well, let's take a call from one of our listeners who's been hearing this. Maybe we can get another perspective. Let's go to Rick(ph) in Las Vegas. Rick, welcome to TALK OF THE NATION.

RICK (Caller): Hi, Joe, Doctors.

Dr. MARTINEZ: Hello.

RICK: There's a couple comments I wanted to make. The first one was that I have a friend of mine, he's also a colleague. He's an emergency room physician here in Las Vegas. And out here in these Sunbelt cities, we're experiencing like nearly explosive population growth. One of the comments he consistently makes is that one of his major problems is getting patients into what he thinks are or knows are available beds within the facility he works at. Of course, one of the big contributing factors to not being able to fill those available beds is the utter lack of nursing staff. We're having trouble just staffing our hospitals here.

PALCA: Yeah.

RICK: And...

Dr. BUCHMAN: a real issue.

PALCA: Yeah, well let me let Dr. Martinez respond to that. I mean, how big a problem is nursing?

Dr. MARTINEZ: Well, it's not just nursing. It's actually emergency physicians. We have a physician on-call specialist shortage. You know, neurosurgeons - we have less neurosurgeons now, than we had 12 years ago. And so patients who need that care - oftentimes, it's difficult to find a neurosurgeon who's available, because they're offices are packed. And they've been in surgery all day; they may not be on call. Their liability insurance has gone sky high, so they can manage it by not being on-call for emergency departments, because that's a little bit higher - it's much higher, actually - premiums.

But then nurses are a shortage, too. So all of those things have contributed to the problems that we have. Part of it's the flow issues. The question that was being raised, too, is about getting patients up to a bed. You know, it's funny. When you talk about systems, it may be that getting the patient to a bed upstairs is a matter of having additional nursing staff. It may be also be just a matter of them having a housekeeper on-call to clean that room so that it's available for the next bed.

PALCA: Yeah.

Dr. MARTINEZ: So when you look at the systems aspect of things, you may be surprised to find things such as transporters, hospital staff, nursing staff, even clerical staff, are what's keeping that bed from being staffed. It's not like there's a bed and there's a nurse. You have to have clerks; you have to have all the support staff with it. And that's become a problem for hospitals. They're running on razor-thin margins nowadays.

PALCA: But we have to let Dr. Martinez go, but briefly, sir, did - is that a problem - nursing also a problem at Barnes?

Dr. BUCHMAN: I think it's a challenge everywhere. But as Dr. Martinez mentioned, it is also a huge flow problem. It's not just a question of having a bed open, it's having the right bed. So if a patient needs critical care services, it might be possible to move an ICU patient out, but there has to be a place for that patient to move.

PALCA: Okay, well, Dr. Buchman, we'll let you go back to your patients. Thanks for joining us.

Dr. BUCHMAN: Thank you.

PALCA: Dr. Timothy Buchman is Medical Director of the Trauma Center and co-Director of the Surgical Intensive Care Unit at Barnes Jewish Hospital.

We're talking about the state of emergency care in the United States. You can send us e-mail. The address is talk@npr.org. I'm Joe Palca. It's TALK OF THE NATION from NPR News.

(Soundbite of music)

PALCA: This is TALK OF THE NATION. I'm Joe Palca, in Washington.

Ambulances turned away from emergency rooms, patients on gurneys in hallways: A new report out today says the U.S. emergency care system is at the breaking point. The full report is on the Web. You'll find the link to it at the NPR Web site. You'll also find its key findings and recommendations at the TALK OF THE NATION page at npr.org.

Our guest this hour is Dr. Ricardo Martinez, assistant professor of emergency medicine at Emory University in Atlanta and a reviewer of the study released today by the Institute of Medicine. You're invited to join the discussion; give us a call. Our number is 800-989-8255; that's 800-989-TALK. And our e-mail address is talk@npr.org.

And we've been talking about some of the structural problems and maybe the -those kinds of logistical things. But there's also a question of money here for solving these problems.

Dr. MARTINEZ: It's an interesting point. It's the only part of the healthcare system where you're obligated to see everyone, regardless of money. And, you know, for us in the emergency medicine, that's an ethical and moral issue that we're really happy to do. But when you look at the fact that so many patients don't need to be there, that they don't have access to care, or they have -they're uninsured and so they come for that reason, they're not really emergent.

Then what you find is you end up with these huge numbers of bills. One in three patients, on average, have no insurance and don't pay. You still got to pay, you've got to pay the lights, the overhead, all these incredible machines. Where I work, you have ultrasound machines, x-rays and everything else. So imagine if you had a restaurant and they said you have to take care of everybody who's hungry.

PALCA: Mm-hmm.

Dr. MARTINEZ: That sounds like a good, ethical thing to do. One third won't pay you, and you need to give them everything that they possibly need to be appropriately taken care of. That's where you start having the inequities of the finances. So one of the things this report calls for is a way to give subsidy to the hospitals for providing this public service. And sometimes, we have to start looking at the emergency departments as a public community service. And we have to support it just like we do fire, and police and other services in the community.

PALCA: But is the emergency room the right place to have this kind of subsidized thing, or maybe it should be just to have, you know, smaller clinics offsite, and they only get to the hospital when the little clinic decides that's what you need.

Dr. MARTINEZ: There's a lot of solutions to it, but there's no one solution to it. For example, I mean, let's just talk a little bit, even if we get a lot of patients to go to access to care, primary care, get into the doctor's office, that sort of thing, which isn't all that easy for them to do because doctors' offices are packed right now.

PALCA: Mm-hmm.

Dr. MARTINEZ: If you try to make an appointment today, tell me how many weeks for you to get in, because they're all packed. The other side of that, though, is let's talk about disaster preparedness. That emergency department is really where we go for surge capacity. A big bus crash occurs, we're thinking about the avian flu; good luck with that one, okay? We're having trouble with the regular flu...

PALCA: Mm-hmm.

Dr. MARTINEZ: ...and inhaling the burden that comes from that. So we have to step back and say this is a system that all of us benefit from, and what do we have to invest to have it there for us now and when something bigger happens? You know, I was there at the airport in Katrina trying to help out. I'm a New Orleans boy; I'm a Louisiana boy. I certainly wasn't involved in the early aspect of it, but I tell you, you learn a lot. And we were all surprised just what the surge was on the existing resources. And now everyone has a better idea there has to be an integrated system for it to really work.

Well, we have to do the same thing with emergency departments. They have to be integrated locally and they have to have the resources, the training, and the, I guess, kind of the resources they need to be able to take any surge that comes.

PALCA: Okay, let's listen to what some of our callers have to say about this. And let's go to Julia(ph) in Campo, California. Welcome to the program.

JULIA (Caller): Hi, thanks for taking my call.

PALCA: Sure.

JULIA: Just exactly what you were talking about was what concerns me. I'm a self-employed person and I don't have medical insurance, but I try to be responsible. And I pay my medical bills. I have a doctor, and I wouldn't go to the emergency room unless I really, really had to. Well, recently, I had a bad flu and I got very dehydrated and I knew I was really sick and I needed to get hydrated. And I called my doctor's office to see if I went down there, would they, you know, put a bag of fluid in me? And they said no, they didn't do that there.

And so there are no - what do you call the intermediate places, the urgent care clinics? There aren't any urgent care clinics around me at all. So I had to go to the emergency room. And I went there and they did what - you know, they hydrated me and gave me some medicine and made me not feel so sick. And they must have done some other tests, but I don't remember because I was so out of it. I was in there about five hours.

PALCA: Goodness!

JULIA: And I just got the bill. And it was $2,800.

PALCA: Yeah.

JULIA: So what does a person do? I mean I was - I'm not trying to abuse the system or go every time I have a hangnail - gosh, I'm a dog trainer and I super glued dog bites before.

(Soundbite of laughter)

PALCA: Right.

JULIA: And I put a frozen bag of peas on my head when I got a concussion, but what am I supposed to do?

Dr. MARTINEZ: Yeah, well to be honest with you, I would probably think you are a person who needs to go to the emergency department. You know, we divide people in three basic categories, five total. Those that are really acutely sick and injured need to go straight to the back. There's the ones where it's kind of more minor, and you see more fast tracks developing as flow measures to try to offload those from the main ER.

And the third one is people like yourself who come in, who really are kind of in the middle there somewhere and, you know, it could be just a little bit of a flu, but it could have been appendicitis, it could have been more. So for those patients, you probably stay a little bit longer because you needed to have a full evaluation, and that takes a little bit longer to do.

The interesting thing is that a lot of the doctors' offices can't do that kind of evaluation anymore. They don't have the labs in their offices anymore. They don't have x-ray in their offices anymore. So really the hospital becomes the place for you. And so I would say you probably have the appropriate place to go to for that.

PALCA: But I want to pick up on Julia's other point, which is, okay, so she's a responsible person. She says I'm going to pay the bill, the bill comes, and it's $2,800. The next time she's going to be thinking, maybe I shouldn't tell them that I have the money to pay that, because that's a huge amount of money for, you know, re-hydration and then they send you home.

DR. MARTINEZ: Well the bill's the bill. I mean, they're not going to not send you the bill...

PALCA: Right.

Dr. MARTINEZ: ...because you don't have the insurance or because you're uninsured. I mean, that's the cost there. And I bet if you looked at the bill, there was a lot of money for the equipment and the medication and the IV and the IV fluids, which is interesting because remember everything is one use. It's very sterilized, you rarely get infections nowadays, and then that's thrown away. And so there's certain fees that make up that total $2,800 bill.

In fact, my wife, you know, had a missed appendicitis about a year and a half ago. And her CT scan was fairly expensive. But I will tell you, being an older guy, like myself, and knowing what we didn't have before, like that probably saved four or five days of evaluation and getting worse, as it were. But it is expensive.

PALCA: Yeah.

JULIA: It does...

Dr. MARTINEZ: And that's why we say that for the sicker patients, it should be used for the sicker patients. For the less sick patients, it's really an expensive burden on them. A lot of hospitals now are trying to evaluate the patients early on, and say early on, whether they have insurance or not, look, there are cheaper alternatives, and try to work with the community to get people out to cheaper alternatives. But one of the things we're finding is that a lot of those clinics are booked solid. And that's a real concern for us.

PALCA: Julia, thanks for the call. And, actually, if you stay listening to the program, we're about to talk to somebody who may be able to address some of the questions that you're wrestling with. Joining us to talk is Dr. Michael Roizen. He's Division Chair of Anesthesia, of Critical Care Medicine, and Comprehensive Pain Management at the Cleveland Clinic; and co-author of You: The Smart Patient, and You: The Owner's Manual.

Welcome, Dr. Roizen.

Dr. MICHAEL ROIZEN (Division Chair, Anesthesia, Critical Care Medicine, and Comprehensive Pain Management, Cleveland Clinic) It's good to be here, thank you.

PALCA: So you just heard this scenario that Julia, I think, mentioned. I mean, what's a patient to do?

Dr. ROIZEN: Well, you know, there are a lot of things you can do to be a smart patient, that is to get the best care for yourself. We can talk about the general issue of medical care in America, but I think - let's focus on the emergency room. The things you first should do is always call your doctor, no matter where or what time it is. And, by the way, the best time to go to the emergency room is during the Super Bowl. The worst time is an hour afterwards.

So don't wait on a problem to see if it goes away. If you need it, call your doctor. If it's during the day, hopefully they will be able to get you to a place that is less expensive and more available for care. But even if your doctor doesn't come to the emergency room, and many still do, he at - he or she, at least, will call the emergency room and you get to the front of the line faster if someone calls about it.

Second, know in advance. Not all emergency rooms are equal. So, some have stroke care. And that's very important, because that first hour of care, the getting care is important. Secondly, they're required to tell the time what -from the admission of a chest pain patient to the time they get to the cath lab. Those data are available. You want to pick the emergency room that your physician likes, but also, since many physicians have many hospitals they work with, one that has those cardiac services and gets patients from the front door in.

And you want everyone that knows you to know what you want to go. So if you have a significant other, spouse, you want you and the spouse to agree where you're going, and to have that in available. Broken bones, you can go to a lot of emergency rooms. Stroke care, heart care, you want to get to specialized ones, burn care.

PALCA: But, Dr. Roizen, I mean, I hear what you're saying about preparing yourself, but how many people are organized enough to, you know, investigate all their local hospitals, look at the subspecialties, rank them by order, and then, when they're in crisis, in an emergency, decide which one is the best one to go to?

Dr. ROIZEN: Well, that's why you've got to have it done in advance, just like you're saying. I mean, we should - you shouldn't spend more time choosing your car than you do your emergency room.

(Soundbite of laughter)

Dr. ROIZEN: And that's the point: we often think everybody's equal. It's great quality in America, and it is, but everyone isn't equal.

PALCA: Dr. Martinez, you wanted to...

Dr. MARTINEZ: Well, I think some of the points he's making are really good. I think it's - there's so much information available now. The more you can do to refer yourself and get to the right place at the right time, the better off it is. One of the issues, however, is that we often get patients show up in the emergency departments I'm in who ask to go somewhere else. And what happens was, they end up in our ER because of aversion problems, which gets us back to the issues of overcrowding in the emergency departments. And when they're all over-burdened, then even your best plans may have to go awry because the system just simply can't be the safety net you want it to be to receive you as you had planned.

PALCA: Yeah. Let's take a call now, and let's go to Brandon(ph) in Portland, Oregon. Brandon, welcome to the program.

BRANDON (Caller): Thank you so very much.

PALCA: You're welcome.

BRANDON: I think a lot of what you have to say today makes a lot of sense and I recently had a challenge right along these lines. My wife and I both work long hours and our two children are in daycare for the majority of the day. And our problem is finding access to someplace after-hours to make a simple decision. We had a daughter who had an ear infection and all we needed was some simple antibiotics, but because there isn't a - it was 11:00 at night and there wasn't a nurse practitioner at one of the, you know, Wal-Marts or Rite Aids, you know, that I can go to for $75 to get a prescription filled, we were left with basically having to go to the emergency room.

But I thought a lot about where to go, because I knew the bigger hospitals would have a long wait line so we ended up pulling up the phonebook and I found a hospital in a more rural area. I'm in Portland and I've got a lot to choose from. So we ended up driving out to a town about 15 miles to another hospital and was okay because when we got there, there was only two people in the emergency room and we were able to get seen fairly quick and in and out the door. But I paid $1,000 for something that I would normally only have to pay $75 for if I could have addressed it during the day.

But because I couldn't get off work until later and couldn't address it until late in the evening time, I didn't have any other options.

PALCA: Well, Dr. Roizen, maybe you have some advice on this one.

Dr. ROIZEN: Well, what he is saying is that what we're becoming is those Wal-Mart's and the Rite Aid's and Walgreens will have those urgent care or ready care clinics so that you can do it. He was smart enough to know that that was available, but it wasn't available at the time that he wanted. That is going to be a change that happens. But it brings up another point. Not every emergency room is equipped for pediatric care. So he has a child, so you ought to know which hospitals do so you can go to them. And, again, usually you'll have a pediatrician who knows about the child in advance. And if this is not the first ear infection - and it sounds like it wasn't since he knew what to do - usually you can just call that pediatrician and get that prescription filled and then see them the next day.

So there are ways of, quote, "being smart about it," if you will, and he was, obviously, knowledgeable. But it is true; you need a physician in advance. And that's another thing. In that bag that we have, say, you should have prepared in advance to go in case a disaster happens to you, all of the medicines and your insurance card. And a lot of insurance companies require you to call just to get clearance. Many of them don't even have someone on call after hours, but if you leave a voice message before you're actually seen in the emergency room, then they cover your costs of visiting the emergency room. So there's some tricks that you can do there to be a smart patient, too.

PALCA: Okay. Brandon, thanks very much for your call.

We're talking about the crisis in emergency rooms in the United States and you're listening to TALK OF THE NATION from NPR News.

Okay, let's take another call now and go to Greg(ph) in Spokane, Washington. Greg, welcome to the program.

GREG (Caller): Well, thank you very much. It was interesting to - I'm a community emergency room physician in the northwest and it's interesting to hear the view of the physicians that are in university settings and large urban areas.

One of the things that was striking to me was we didn't really talk about one of the big reasons for overcrowding in our emergency departments is that the way that medical care - in office medical care has changed over the last 10 or 15 years is you can no longer see your physician, your internist or family physician if you're sick, you can only see them if you're well, because there's so much of an emphasis on preventative care, which is a good thing. But doctors don't keep slots open in their offices to see somebody that they know that may have, you know, a relatively minor problem. They're doing complete physicals and health maintenance. And so you call their office and they say, well, you need to go to the emergency room or you need to go to urgent care.

The second issue that I wanted to just sort of revisit is that with the growing number of people who are elderly and people who are on Medicare - and I don't want to belabor the fact of you know Medicare is, you know, going down the tubes and reimbursement is terrible - but older people are just, unfortunately, more complicated. And as the pressures on physicians and hospitals continue to mount with declining reimbursement and a planned decrease of five percent for all professional services in January of 2007, more and more physicians are going to be less and less willing to see new Medicare patients in their office. And the only option, especially for an elderly person, similar to a small child, is to go to the emergency department…

PALCA: Okay.

GREG: And longer waits, longer stays in the emergency department, bigger work-ups and bigger bills.

PALCA: Greg, thanks for that. That's an interesting point of view and maybe Dr. Martinez can - I mean, it sounds like what he's saying is that there's a problem not just at the emergency room, but in advance before you get there.

Dr. MARTINEZ: Absolutely. I mean, we are an America's safety net and things fall through the cracks, but they come to us. And, you know, that's exactly right. The issue of primary care, and it's not just primary care for wellness. Remember, a lot of people who do a lot of self-care - diabetes, congestive heart failure, asthma, people with cardiac problems, they do a lot of self-care - but they need their medications checked, if they start to have problems they need to be seen by a physician. And so getting in acutely when those occur -those can't wait for two or three weeks - is a problem, because a lot of the primary care is full right now.

Another point he makes is elderly care. We are getting an older, more intense population. Those people can have a little nausea and it may be a heart attack, so it's a little harder for the doctors to work them up in their office sometimes. They prefer to have them in the ER, so we have that burden going for that growing population. But the other point he makes I think people need to look at, for some reason the federal government has decided one way to save money is to start making cuts to the payments. So now, for the next five years, it's going to be a 26 percent decrease in reimbursement. How's that going to help?

PALCA: Yeah. Dr. Roizen, I just, I want to talk to you briefly before the end of this segment. What do you think should be done in the hospital ER's? Is there a problem obviously obvious that needs to be solved to you?

Dr. ROIZEN: Well, yeah, but there's - while there is a problem in the structure, clearly you and we, individually, can do a lot about it. So, for example, one of the things you said, you should if you have a heart condition, you should have a copy of your electrocardiogram with you.

Dr. MARTINEZ: That's a great thing to have.

Dr. ROIZEN: Whether that's in that bag or whether that's in your wallet. You should know what medicines you take. And then there are a lot of things we can do. We're using - right now, when you look at the medical care costs in America, 20 - something over 16 percent of it is going - that's $225 billion this year - is going for just diabetes Type II, a totally preventable illness, a genetic disease…

PALCA: Dr. Roizen, I'm sorry, we're almost out of time so I apologize for cutting you off a little bit there, but I'm afraid we have to move on. I'd like to thank you for joining us today. Dr. Michael Roizen is Division Chair of Anesthesia, Critical Care Medicine and Comprehensive Pain Management at the Cleveland Clinic and co-author of You, the Smart Patient.

When we come back from a short break, we'll talk more about hospitals and emergency rooms in this country, plus our regular Wednesday feature: the Political Junkie. There's good news for the White House this week, bad news for local Democrats, and bloggers boo Hillary.

I'm Joe Palca. It's TALK OF THE NATION from NPR News.

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PALCA: We're talking with Dr. Ricardo Martinez, assistant professor of emergency medicine at Emory University, about hospitals in America and the problems they're facing, especially in the emergency rooms. And the discussion is focused on a report that came out today from the Institute of Medicine and we're taking your calls. And let's take another call now and go to Joe(ph). Joe, welcome to the program. Joe in Memphis, welcome.

JOE (Caller): Hi, Joe, how are you? Enjoy the program. Your guests are right on target. I have extensive experience in running an emergency department, as well as disaster medicine, and I think the - much of what we see with the system actually backs up all the way into the street. The issue of diverting ambulances to other facilities - and part of my concern is the tremendous and so far somewhat untested concern regarding our ability to ramp up in the event of a major medical disaster of some sort.

I think we saw many problems in Katrina and I think that was probably just the tip of the iceberg to the issues we will see in the event of a major biological terrorist attack or simple pandemic from the flu. Our system is already operating in disaster mode and there's not much left to allow us to expand for further demand.

PALCA: So that's - I mean, we've been talking about that, Joe, but maybe I can ask Dr. Martinez. So people see the problem, politicians see the problem, administrators see the problem, doctors see the problem. Who has to do something to change the problem?

Dr. MARTINEZ: Well, it's a good point, because it's a shared problem with shared solutions. One of the things we were talking about before the show started was September 10th, 2001, US News and World Report had this headline cover story, Emergency Department in Crises. And, of course, that was quickly overshadowed because we shifted our focus to terrorism and what happened on September 11th. If you look at what we invest now as a country, in terms of emergency preparedness, in terms of the medical side, it's about four percent of all that money that's now come down the pike. And the joke we say in emergency medicine is we're homeless in the homeland, because no one's focused on the fact that if something happens, someone may get hurt, and we are going to have to go to that system and build that.

So we have to shift our focus now and get all these players aligned on what the vision should be, which is a non-fragmented (unintelligible) but a coordinated system that has regionalized and accountable; having the right incentives and the right finances and the right people to do it.

PALCA: But the report looks at all this, looks at the playing field and says, okay, Congress has a role, insurers have a role, doctors have a role, hospitals themselves have a role; how do you coordinate all this? And I know the report also says we need more commissions and committees, but that's - the Institute of Medicine always says we need more institutes, you know, commissions and committees. So, I mean, how do you coordinate it?

Dr. MARTINEZ: Well, remember, one of the largest payers is the federal government, so they certainly have a role in this. And the incentives are going the wrong way. They're actually cutting things, not putting money to invest into it right now. And even the NAH puts a very small amount of money into emergency services, emergency preparedness; so they've got to grab their piece of the pie. No one can solve that but them. The hospital systems have to make sure that they know that these department patients are not the emergency department patients but the hospital patients and the community patients. And thirdly, we have to really look at the idea of supporting the emergency departments as a public service just like we do fire and police, where we look at their readiness and their ability to serve.

So there are several things, different groups - and I think the report does a good job of dividing those up with what different groups have to do.

PALCA: Well, maybe we'll have to have you back in five years and see whether this report had the same - had as much effect as that headline in US News and World Report did five years ago.

Dr. MARTINEZ: Well, I hope we start paying attention. I've got small children and I've got a wife who got sick last year, and this is a very important issue for us, every time in the emergency department, on either side of that door.

PALCA: Okay. Thanks very much. Dr. Ricardo Martinez…

Dr. MARTINEZ: Thank you.

PALCA: …oh, you're welcome, is assistant professor of emergency medicine at Emory University and Executive Vice-President of Medical Affairs at the Schumacher Group. He joined us here in Studio 3A.

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