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1 in 5 ED Patients Referred By Primary Care Doctors

Cheryl Clark, for HealthLeaders Media, May 29, 2012

"Either they see the patient, and say, this is beyond what I can do in my private office, with limited resources, or they talk to the patient on the phone and say I'm concerned about your symptoms," Sama said.

"Or they know the patient has complex problems with subtle symptoms that can mean grievous issues, and they send them to us because we can do the diagnostic testing rapidly, or call on a colleague or specialist to get more detail."

It's true that many physicians across the country are not willing to see Medicaid patients or those with no insurance. Additionally, some physicians' schedules require appointments booked months in advance, as they intersperse office visit care with time on call or performing procedures.

Simply having more physicians in primary care settings willing to see patients in all income brackets and levels of insurance will help, Sama says, but it won't solve the problem.

Sama is the senior vice president for emergency services at North Shore Long Island Jewish Health System.

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3 comments on "1 in 5 ED Patients Referred By Primary Care Doctors"


John T. Skowronski, MD, FACEP (6/6/2012 at 6:23 PM)
Excellent comments. In my community, most PCP's are very uncomfortable with anything that might be emergent. I'm sure this is based on genuine concern, mixed with malpractice risk and the fact that PCP's don't see many urgent patients, so they feel ill-equipped. In addition, getting a CT or MRI for an acute headache, or other similar tests, can be a significant delay for PCP's. In addition, pre-certification costs them time and money and the perception is that the ED can get any test at any time without these hassles. Also, even simple tests such as CXR's have new regulations, so a number of PCP's in my community can't perform this basic test. I can't tell you have many cases of "bronchitis" have turned out to be CHF. Finally, the ultimate insult to ED medicine in this scenario is payment. Naturally, patients that can't pay for a lot of tests wind up being referred to the ED. But, even worse, denials for care in insured patients are rife, even when the PCP refers the patient for care. What "prudent layperson" would NOT go to the ED after being referred by their primary caregiver? Unfortunately, this is a constant fight with payors, based on retrospective reviews and final diagnoses.

Daniel Woodard, MD (6/2/2012 at 5:26 PM)
As a board certified emergency physician with over 30 years of experience in ER, urgent care and primary care, I would like to offer a comment. First, ER docs tend to be of mixed mind on this question. If I had a dime for every colleague that complained about "ER abuse" by patients who were not sick enough to be "genuine emergencies" I would have retired long ago. At the same time, of course, hospitals see ambulatory patients as a revenue source and don't want to suggest they should go elsewhere. Why not consider what is best for the patient? These patients were all discharged from the ER, so unless they had critical outpatient procedures we can assume that most could have been taken care of in a primary care setting and were certainly stable enough that, if needed, they could have been safely transferred to a hospital. The primary care physician does not have instant access to CT or even labs, but he has two diagnostic tools that are even more powerful. First, the physician knows the patient and is already familiar with his/her complete history, medications, reaction to pain, and all the other thousand details that make up a complete patient, and if the patient is new, there is time to do a careful history and physical, something that is virtually impossible in the ER. Equally important, the physician has already established rapport and trust. There is little need to do medically unnecessary (but highly profitable) tests because if the patient has a complication he/she can easily be seen again. For an ER doc the sheer efficiency of primary care has to be seen to be believed. And in my experience, most patients would rather be seen by a doctor they know, and avoid having to either go through their life story or get a $500-$1000 bill. So the survey seems focused on two reasons to go to the ER. One is real, the inability to get to see a primary care physician without a two month wait. There is a simple solution to this; train more primary care providers and ask them to keep a few spots open each day for walk-ins, like they did when I was a kid. The situation we have [INVALID]d, in which it is impossible to see a primary provider when you are acutely ill, is simply absurd. Given the chance to see a doctor they know today, for a fraction of the cost of the ER, Second, many patients have the perception that ED care is necessary when it is not. Obviously some cases are equivocal and need the ER, but to say that every single patient might be having a silent MI and needs troponin levels is the mark of someone who does not know how to do a proper history and physical. Finally, there is the perception that the ER actually provides better care. When the patient is unstable with a dramatic but obvious diagnosis and requires immediate respiratory support, thrombolysis, surgical consultation, etc. then the ER is essential. But this isn't most patients, even at a trauma center. Confronted with complex histories that take more than 30 seconds to understand the ER is woefully ineffective, as I've seen more than once when bringing family members there. If we want the best care for all our patients we have to get beyond petty turf battles and actually look at the evidence. And that means looking objectively and with an open mind, not with the object of proving our own importance.

Bret Ginther MD (6/2/2012 at 12:00 PM)
Interesting article and my experience as an ED physician resonates with the numbers referenced in the article. One aspect of this referral sequence that has not been appreciated anywhere I can see is WHO is doing the referral. Most patients will readily volunteer that they were sent by "my doctor." But more often than not their referrals are by whoever picked up the phone at the doctor's office and based on variable if questionable medical input or decision-making. Asking your patient who referred them often reveals the contact specifics. This is significant because often the person least knowledgeable to make medical decisions is directing patient care and inevitable incurring resource utilization that the actual doctor may have felt unnecessary. I would never discourage appropriate ED referrals but ideally the care should be discussed doctor to doctor so the acute concern and approach to evaluation can be coordinated between the parties most capable in coordinating the care plan.