Guest Editorial: ACEP Attacks Rebuttal as “Deliberate Misreading” (04/27/2011)

By David Stern, MD, CPC

You may have read my editorial from two weeks ago titled “American College of Emergency Physicians Attacks Urgent Care.” The editorial was in response to a TIME Magazine editorial written by two emergency physicians who were writing in support of ACEP’s campaign to discourage the efforts of payors to educate the public on all of their options for medical care – efforts they claim devalue emergency departments.

Now ACEP is directing its attacks directly on my editorial by anonymously posting comments stating “this blog post is a deliberate misreading of both the TIME article and ACEP’s position. ACEP never attacked urgent care centers or said anything about them.”

Exactly! The editorial did not mention urgent care. Instead, the editorial suggested that patients’ only option for after-hours care is the hospital emergency department. I replied to ACEP that “ignoring urgent care in the conversation is an ‘attack’ by omission.” Imagine a discussion of healthcare that did not mention physicians or hospitals. Preposterous?

Yes, the TIME editorial has no direct attack on urgent care. Instead, the public is encouraged to use the ER for minor problems (specifically a young woman with a urinary tract infection). ACEP is well aware that these are the very kinds of cases that overload hospital ERs and have created a national crisis with average ER waits of 4 hours.

Does ACEP back away from the assertion that the only viable choice for after-hours care is the emergency department? Does ACEP backtrack and mention the proper place of urgent care? No, ACEP continues on its blind crusade: “Considering that two-thirds of all emergency visits occur after normal business hours, most of these patients have no place to turn for care other than the ER." What nonsense! “Normal business hours?” What about normal urgent care hours? ACEP completely ignores the elephant in the room. Most urgent cares are open 30-50 hours beyond "normal business hours," and typical urgent care hours of operation cover the vast majority of hours for unnecessary ED visits. ACEP is doing a disservice to emergency physicians and the American public by suggesting to the American public that their only viable option after-hours is the hospital ED. What about the 8,500 urgent care centers in the USA?

In addition, ACEP states that, “the percentage of non-urgent patients actually has declined for 3 years to less than 8 percent in 2007.” Seriously! Quote this number to any emergency medicine physician, and she will tell you that the only ED with less than 8% non-urgent patients exists only in fantasyland.

So where does ACEP get this ridiculously misleading number? It comes from the completely non-standardized opinion of the triage nurses, who select for each patient visit from the following list:

ER Triage List
In their attack on my editorial, ACEP is quick to point out that even "these [nonurgent] patients require medical treatment in 2 to 24 hours." Do they take their readers to be idiots? "Nonurgent" is the lowest possible category. Per this ACEP logic, every single ED patient needs treatment within 24 hours. Thus, ACEP may essentially claim that there is zero inappropriate ED use.

Another proof of the sanitized saying, "Statistics don't misinform, but misinformers use statistics."

Yes, these categories have definitions, but most triage nurses have essentially no training on how these categories are to be used. In real life, ED triage nurses can use the "semiurgent" and "nonurgent" categories for any patient who could have been seen in an urgent care center instead of the hospital ED — almost one-third of ED patients.

Using better classifications, the state of Connecticut reported in 2010 that "from FY 2006 to 2009, approximately 47% of ED non-admits were for non-urgent visits, [which] did not need immediate medical care within 12 hours"1. Even hospitals in wealthy neighborhoods had a 37% rate for non-urgent visits. An additional 30% of ER visits were for injuries, many of which were certainly minor injuries, which also could have been treated in urgent care centers.

Next, ACEP tries to exempt emergency medicine costs from the discussion for reducing the costs of healthcare reform. ACEP brands efforts to reduce waste in emergency medicine and to reduce unnecessary ED visits as "counterproductive." Really? The average cost of an office-based visit is $199 compared with $922 for emergency department (ED) visits2. Getting even a fifth of these patients out of the emergency department and into urgent care centers would result in at least a $20-billion reduction in the nation's healthcare costs. Is it really "counterproductive" to look at methods to accomplish these massive savings?

Interestingly, the TIME editorial noted the low "marginal cost" of seeing patients for minor problems in the ER, but the anonymous ACEP representative now admits that ER "individual [patient] bills are high." The anonymous ACEP representative now defends these hefty bills because they help cover the cost of treating patients who don't pay their ER bills. My response was, "Will a patient really be happy that a substantial portion of their bill is essentially a forced charitable contribution to the hospital to help cover its cost? Why not reduce the cost of staffing ERs by moving most of those unnecessary visits to a site that is designed to care for non-emergency injuries and illnesses — the neighborhood urgent care center? If there aren't enough urgent care centers in some neighborhoods, maybe the answer is not encouraging more patients to seek care in the ER. Maybe the answer is policies that encourage urgent care centers to open in these neighborhoods."

If ACEP was serious about serving the American public, they would engage in a program to educate the public on what types of problems do not require a visit to the hospital ED. Instead, they disingenuously suggest that virtually every patient who visits a hospital ED is in the right place for medical care.

If ACEP continues to obfuscate the facts and if ACEP continues to disparage discussion of reducing expenses for emergency department care, then maybe ACEP should be relegated to the sidelines of the discussion of healthcare reform.

Am I "deliberately misleading," or is ACEP self-interestedly misinforming? Don't just take my word for it – read the ACEP responses (linked above) and judge for yourself.

1. Greci, Laurie K.Issue Brief: Profile of Emergency Department Visits Not Requiring Inpatient Admission to a Connecticut Acute Care Hospital Fiscal Year 2006-2009. December 2010. Office of Health Care Access, Hartford, CT.

2. Machlin, S., and Chowdhury, S. Expenses and Characteristics of Physician Visits in Different Ambulatory Care Settings, 2008. Statistical Brief #318. March 2011. Agency for Healthcare Research and Quality, Rockville, MD.