Sunday, June 21, 2009

Chicago Urban Health Initiative

Do you know what has been happening at the University of Chicago ER? No? Time you found out about the University of Chicago Urban Health Initiative (UHI).

Originally designed in 2005 as a community outreach program created to educate the South Side community about what healthcare options were available to them and how to decide when/when not to go to the Emergency Department. By the end of 2008, U of C still had the longest wait times in the country and the highest percentage of patients who left without being seen (something considered very bad in the emergency med world).

Surveys conducted at the U of C estimated that 40% of its 80,000 annual ER visits were non-emergent and did not require the services of the emergency department. When the economy really decided to tank, U of C decided to “up the ante,” so to speak. They announced that they were changing their method of triage by putting MDs in the triage area to asses need for emergency room resources. Those patients deemed non-emergent would be sent to a network of “20 community health centers and more than 60 UCMC doctors” as well as 2 participating local community hospitals for care. (hmmm… 30,000 patients… 60 physicians. That math does NOT work). The medical community swallowed this lump with difficulty and something doctors love to do called “watchful waiting.”

In February of 2009, on the heels of the above announcement, the University of Chicago hospital announced it was going to be firing 5% of its staff AND cutting down Emergency Room resources, mostly in terms of decreased numbers of inpatient beds available to the Emergency department. This coming from the hospital with one of the highest frequencies of ER boarding times up to 72 hours! Both the Chairman of Medicine and the Chairman of Emergency Medicine resigned to protest this announcement, causing BIG headlines. This was when I first learned about what was going on in Chicago. The protests worked. The hospital still fired staff, but they did not cut emergency room resources. As a result of the media attention, the UHI has come under severe scrutiny.

Has anyone died from these changes in routing strategies? No. Are the clinics complaining or the other hospitals involved protesting? No. The media drudged up one story of a 12-year-old boy who was bitten on the face by a pit bull and was sent to Cook County for surgery from the U of C ER… Of course, if you look at the date of the incident, it occurred before UHI became more strict and before the Feb ’09 announcement. In many ways, that makes the story of the boy worse (he’s fine, by the way), but not the fault of UHI.

The American College of Emergency Physicians (ACEP) rapidly came up with a statement condemning UHI’s policy of turning away non-emergency patients, stating that it was “dangerously close” to violating the Emergency Medical Labor and Treatment Act (EMTALA) of 1986 which states that all hospitals receiving government assistance (everyone) are required to provide treatment for all individuals seeing emergency medical care, regardless of insurance or immigration status. HOWEVER, it IS legal to transfer a patient from one emergency room to a clinic, another hospital or a government-run system. This clause was originally intended for transfer to better care (eg- a hospital without a cath lab can transfer a patient having a heart attack to a hospital with the ability to perform cardiac catheterization and open the blocked vessel). U of C is using a broader definition. This month, Representative Bobby Rush is calling upon congress to conduct an investigation into the UHI, specifically to determine if the Emergency Department is “patient dumping” under the auspices of the UHI – a practice specifically forbidden by EMTALA.

Emergency physicians I have talked to fall mostly on the side of disagreeing with UHI, but not for the reason you might expect. There is a fabulous editorial on the ACEP website by Dr. David F. Baehren (takes a while to load) that really illustrates the difficult position emergency physicians are currently in. On the one hand, our specialty was developed to treat the critically ill or injured. To provide life-saving treatment immediately without consideration to cost, insurance status, nationality, social status or anything else. What we have become is the one and only safety net for a broken medical system – a net that is stretched to breaking point. The actions at the University of Chicago may be the first rope in the safety net breaking. We, the emergency physicians, need help. Time for the other medical professions to step up and save us.

I essentially see the U of C’s UHI and an attempt to build a primary care network in South Side Chicago. I believe that such a network – a cooperative relationship where primary care physicians and clinics support our nation’s emergency rooms by increasing in number, making their presence known and encouraging appropriate utilization of medical resources can make a huge difference in our nation's healthcare. A strong network, where the Emergency Room physician can say “this stubbed toe can be treated by your clinic, I’ve called them and they will see you at 2pm.” And the clinic can say “Your shortness of breath is very concerning, We’ve called the Emergency Room and they have a bed for you and are sending an ambulance to get you.” Is what we NEED! Emergency physicians I have talked to about UHI are concerned about it because they worry that the network is too weak (only 38% of patients referred out end up going to 2 or more clinic visits). They worry about patients slipping through the cracks and about someone making a mistake.

As much as we suffer being the nation’s medical “safety net,” emergency physicians also take a certain amount of pride in our role as the dutch boy with his finger in the dam. There is fear that the changes taking place at the University of Chicago could become widespread in the wrong ways and thus leave the poor and uninsured without anywhere to receive treatment. This is a bastardization of the goals of UHI. Nevertheless, it is a valid concern that needs to be closely monitored.

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