Let me paint a picture — you have chest pain, you begin to worry that this is a real problem and head to a local emergency department (ED). You arrive to find 15 people waiting ahead of you. After being told your initial EKG was reassuring, you settle in for a two-hour wait in the lobby, wondering why there are not better options. Hearing that there is a proposal to open a freestanding ED in South Anchorage might be appealing.
As a lifelong Anchorage resident, and now an emergency department physician, I have a unique understanding of our health care access challenges, and I strongly believe that the creation of a freestanding ED in South Anchorage will delay care in critical emergencies and increase costs to health care infrastructure and patients.
Freestanding EDs are not emergency departments. Their supporters will say that they employ board-certified emergency medicine doctors, and while this is true, FSED are not equipped to definitively manage true emergencies such as trauma cases, heart attacks, strokes, and so forth. They typically do not have on-call specialists or surgical capabilities. In comparison, a traditional emergency department will have trauma surgeons, critical care physicians, OB/GYNs, anesthesiologists, internal medicine specialists, in house nearly 24 hours a day. In addition to skilled staff, traditional EDs have speciality equipment — operating rooms, endoscopy suites, cath labs, intensive care units, pediatric ICUs and neonatal ICUs not found in a freestanding ED. How can an institution lacking these services really advertise itself as an “emergency department”? The reality is that this is an expensive and well-equipped urgent care masquerading as something it’s not, with the sole purpose of providing convenient services to the well-insured of the community in an effort to siphon off high-paying patients.
Those with true life-threatening emergencies cannot be cared for at a freestanding ED and will be transferred to a larger institution at great detriment to the patient’s health and pocket book. Emergent cases are very time sensitive and, due to lack of surgical and speciality care, these patients will experience delay of diagnosis and intervention. It is not hard to imagine how this will hurt Alaskans. Back to the chest pain example: If you were to walk into our front door and have an abnormal EKG, you would be in the cath lab within minutes. If this same scenario occurred at a freestanding ED, the patient would have to be packaged, placed in an ambulance and transferred to the hospital, creating at least a one-hour delay when every minute delayed results in heart muscle dying.
The introduction of freestanding EDs into a community has been shown to increase health care costs in multiple ways. The services are simply expensive; in fact, the cost of care for the same diagnosis at a freestanding ED is at least 10 times that of an urgent care. They increase the cost to consumers by charging an additional facility fee often exceeding $1,000, justified by the presence of the CT scanner, ultrasound and labs, despite not being physically backed by a full-fledged hospital. This increase in cost will fall on patients paying higher coinsurance, but will also raise the costs to insurance companies, driving our already high premiums up further. This is not limited to those with insurance, as costs also have been shown to increase in Medicare and Medicaid beneficiaries in areas where freestanding EDs are introduced. For patients found to need hospitalization or other services, there will be expensive transport fees that would not have occurred if they had been appropriately seen at a higher level of care to begin with. Though they are often marketed as emergency departments rather than the expensive urgent cares that they are, freestanding EDs do not advertise their limitations unless demanded by legislation.
What is the solution for Anchorage?
We need a multi-pronged approach that takes into account the entire community. A large driver of ED wait times are hospitalized patients “boarding” in our department, meaning they are awaiting a bed within the hospital, but still occupying beds and taking space normally saved for new ED patients. This backup flows downstream and, as a result, our waiting rooms fill. Hospitals in Anchorage and throughout the U.S. are often too full to accommodate newly admitted patients. A primary driver of ED boarding is difficulty discharging medically complex patients to rehab or nursing care. If we want more efficient flow through our hospitals and shorter ED wait times, then we must support the creation of more discharge destinations. HCA Healthcare should consider fully staffing all of its inpatient hospital beds and then potentially expanding their current ED on site at Alaska Regional, avoiding the expensive transports and duplication of care that our already strained health care system cannot support. They should also consider reinvesting in primary care for Medicare recipients, preventing ED and hospital visits in the first place while concurrently supporting the education and retainment of our nursing and support staff, where we are facing incredible workplace shortages. A $17 million investment in a freestanding ED “for the community” may sound altruistic, but this is a self-serving, for-profit proposal that will dilute our current health system and cost Anchorage residents considerably in direct health care costs and insurance premiums.
Please join me in voicing your opposition to the Alaska Regional Hospital freestanding ED proposal by contacting Alexandria.Hicks@alaska.gov by Aug. 1.
Helen Call Adams, M.D., is a board certified emergency medicine physician in Anchorage. She is affiliated with Alaska Emergency Medical Associates at Providence Alaska Medical Center.
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