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Emergency Medicine Myths Exploded
Emergency Medicine Myths Exploded ED Care Less Than 2% of Health Care Spending
by ERIC BERGER Special Contributor to Annals News & Perspective
Coffee sobers you up. Going out in cold weather makes you sick. Too much sugar makes your kids hyperactive. Chewing gum, once swallowed, takes 7 years to digest. To be safe, wait 30 minutes after eating before swimming. Taking vitamin C, echinacea, or zinc prevents colds.
T
hese are half a dozen medical myths that much of the American population, and even more than a handful of physicians, believes. Here’s one more: Emergency medical care is expensive and inefficient. Readers of this article probably won’t be taken in by that myth, but in this respect, readers of this journal are out of step with the general public and, perhaps still more important, policymakers. Consider a Senate bill (SB 1781) introduced in October 2009, called the Reducing Emergency Department Utilization Through Coordination and Empowerment (REDUCE) Act. According to its language, the bill sought to address emergency department (ED) overuse, improve quality of care, and save taxpayers’ money by establishing pilot programs to better coordinate care for frequent ED users. “Far too many people rely on emergency room services for routine or primary care,” said US Senator Sherrod Brown (D-OH), one of the bill’s authors. ”By strategically expanding outreach services to frequent ER visitors and better coordinating their care, we can cut the associated costs to taxpayers. This initiative takes an important step toward fix18A Annals of Emergency Medicine
ing our broken health care system and improving the quality of care for communities in Ohio and across the country.” Brown is not alone in holding such beliefs. In March 2011, Health and Human Services Secretary Kathleen Sebelius joined the public radio talk program The Diane Rehm Show and responded to a small business owner in Nantucket, MA, who was concerned about paying $1,600 per month for health insurance coverage for her family of 3 under the state’s universal health insurance plan, with a $5,000 deductible because of her son’s preexisting condition. “Right now, as a taxpayer, the family from Nantucket is also paying for everyone who doesn’t have insurance who is coming through emergency room doors accessing the health care system, often in a very expensive way,” Sebelius said. In recognition of this pervasive myth about emergency care, as well as others, the American College of Emergency Physicians (ACEP) launched the “Just 2% Campaign” in April 2011. The national public education campaign seeks to promote the value of emergency medicine and to educate the public and policymakers that emergency care is less than 2% of the nation’s health care dollar. During a talk at ACEP’s Health Writer’s Conference in New York City on April 19, President Sandra Schneider, MD, a professor and chair emeritus in the Department of Emergency Medicine, University of Rochester, Rochester, NY, laid out the campaign for members of the media. “Health care spending is a huge issue in the United States, representing more than 16% of our gross domestic product. Yet, as became clear during the health care reform debate last year, there are misconceptions about the costs and efficiencies of emergency rooms,” she said. “The bottom line is this: Policymakers seeking to trim fat from the nation’s ris-
ing health care bills are looking in the wrong place if they take aim at emergency departments.” ACEP launched the campaign amid a widespread rhetoric from policymakers, public policy wonks, and some sectors of the health care industry on the need to reduce visits to the ED as a way to control increasing health care costs. This article, then, seeks to amplify this educational effort by dispelling the “too costly” myth, as well as others being bandied about by politicians and the press.
MYTH NO. 1: EMERGENCY CARE IS TOO EXPENSIVE
A
ccording to the US Department of Health & Human Services’ Agency for Healthcare Research and Quality,1 which conducted a Medical Expenditure Panel Survey in 2008, just under 2.0% of the more than $2 trillion spent on health care annually in the United States is spent on emergency care. In 2008, according to the US government study, EDs received about 124 million total visits, at a cost of $47.3 billion. It is true that care in EDs is more expensive than in some other settings because they must be staffed 24 hours a day, 7 days a week. There are fixed costs associated with being ready for any emergency at any given time. It is therefore notable that the majority of visits to the ED in 2008 —two thirds— came after business hours on weekdays and on weekends when the majority of physicians’ offices were closed. So these emergency facilities are generally used when appropriate. There are clear reasons why the public has the perception that emergency care is too expensive and responsible for excessive costs in the health care system, said Jesse M. Pines, MD, MBA, director of the Center for Health Care Quality and an associate professor of emergency medicine at George Washington University. “Whether or not emergency care is a bargain or expensive depends upon whose perspective you take with costs,” Dr. Pines said. “From the patient’s perspective, the copays are going to be higher than for a clinic visit. It is perhaps $100 for an emergency department visit, whereas a clinic might be $20. From a patient’s perspective, then, emergency Volume , . : August
care is more expensive. And it’s also seen as more expensive from an insurer’s perspective, who looks at a bill and see the charge per service is higher in the emergency department. The cost, of course, is basically driven by a number of things. One major reason is because the focus of emergency care is ruling out the most severe diagnoses, so we do have the tendency to use more resources compared to other setting.” The annual costs of emergency care in the United States are dwarfed by several areas of waste within the health care system. A 2008 analysis2 of the health care system by the PricewaterhouseCoopers Health Research Institute identified the top 3 areas of waste in the health care system as defensive medicine (up to $210 billion annually), inefficient claims processing ($210 billion annually), and care spent on preventable conditions related to obesity ($200 billion). These are better places to look for fat to trim.
nonurgent. The report defined nonurgent conditions as those patients who could wait 2 to 24 hours for medical care. The data for the 2007 National Hospital Ambulatory Medical Care Survey,4 published last August, found that just 7.9% of visits were classified as nonurgent. So, according to CDC data, roughly 10% of patient visits to the ED were for nonurgent care during those 2 years. “The studies simply show that we don’t have that many unnecessary patients presenting in the emergency department,” said David Seaberg, MD, ACEP’s president-elect, who is dean and professor at the University of Tennessee College of Medicine, Chattanooga. “This is something that can be explained to people. When I actually sit down and talk with state legislators, it doesn’t take too long to dispel the myth.”
MYTH NO. 3: UNDOCUMENTED IMMIGRANTS CAUSE ED CROWDING
MYTH NO. 2: EDs ARE CROWDED BY PATIENTS WITH NONURGENT MEDICAL ISSUES
U
T
his is a myth that Angela Gardner, MD, heard over and over again during her 2009 to 2010 term as president of ACEP. “It really was a big issue for me, the notion most of the people in the emergency department don’t belong there,” said Dr. Gardner, an assistant professor in the Division of Emergency Medicine, Department of Surgery at the University of Texas Southwestern Medical Center in Dallas. “It was very common for me to hear that from the person you meet on the street all the way to Washington and the halls of Congress. People think that if we could just get those nonurgent patients out of the emergency department, we could pay for health care.” The reality is far from the myth, however. According to the Centers for Disease Control and Prevention 2006 National Hospital Ambulatory Medical Care Survey,3 which broke down ED visits by urgency, just 12.1% were classified as Volume , . : August
“unnecessary” costs in the ED of about $4.7 billion annually. Therefore, if policymakers succeeded in ending all unnecessary visits to the ED, which is yet another unrealistic assumption, the United States could shave about 0.2% off its medical bill. That is probably not the savings lawmakers are looking for. Some emergency physicians even have a problem with the term “nonurgent” care. “The problem with any assessment of urgency is that it’s not typically done from the patient’s perspective,” said Dr. Pines. “Surveys have shown that close to all the patients coming to the emergency department perceive their symptoms to be urgent, but this doesn’t come through in the CDC data.”
Let’s dispel it further anyway by considering that about 10% of patient visits to the ED are nonurgent, according to the CDC data for 2006 and 2007. How much value could the health care system derive from cutting these “unnecessary costs”? First, we must set aside the possibility that some of these patients presented on a Friday night or Saturday, more than 24 hours before their primary physician’s office opened. Let us also assume every one of these patients could obtain the care they needed elsewhere, free. And let us finally make the assumption that the unnecessary patients, such as those with toothaches, racked up costs equal to those of patients with much more serious conditions. Under these assumptions, 10% of patient visits would create a bill of
ndocumented immigrants, who often hold jobs without health insurance, are perceived as overusing EDs because they cannot receive care elsewhere. But the data show this to be largely untrue. A 2007 study in Archives of Internal Medicine5 used data from the 2003 California Health Interview Survey, with 42,044 participants, to study usage of EDs and medical clinics by undocumented Mexicans and other Latinos. The study found that undocumented Mexicans had 1.6 fewer annual physician visits compared with US-born Mexicans and that other undocumented Latinos had 2.1 fewer visits compared with their US-born counterparts. The study found that both groups used the ED significantly less frequently than their US-born counterparts. “Low rates of use of health care services by Mexican immigrants and similar trends among other Latinos do not support public concern about immigrants’ overuse of the health care system,” the study authors concluded. Annals of Emergency Medicine 19A
MYTH NO. 4: HEALTH CARE REFORM WILL LEAD TO A SUBSTANTIAL REDUCTION IN COSTLY ED VISITS
T
he Patient Protection and Affordable Care Act signed by President Obama seeks to divert patients away from EDs into the offices of primary care physicians through various means, such as accountable care organizations. It remains to be seen, however, whether this will actually lead to a reduction in usage of EDs. Some previous experiences suggest it may not. The Massachusetts health care insurance reform law, enacted in 2006, requires that nearly all Massachusetts residents obtain a minimum level of health care insurance coverage. Instead of decreases, however, a 2010 report6 from the Massachusetts Division of Health Care Finance and Policy found that ED visits increased by 9% from 2004 to 2008, to about 3 million visits a year. One reason for the increase may have been that newly covered Massachusetts residents could not find a primary care physician or obtain last-minute appointments with their physician.
Dr. Gardner, ACEP’s past president, said the data do not surprise her because she has recently heard from colleagues about an increase in primary care physicians referring patients to the ED for evaluations. A hyperglycemic patient, for example, may visit a physician’s office with a blood sugar level of 400 mg/dL, Dr. Gardner said, and the quickest and easiest way to administer treatment is sending him or her to the ED, where the patient can receive fluids and be observed for several hours to determine whether admission to the hospital is necessary. “I don’t think there [are] data yet on this; it is just what I hear from emergency physicians,” she said. “I believe there will be data soon. It’s not something I’ve heard once or twice. It’s something people are talking about everywhere. It’s frustrating to hear people outside of emergency medicine say our visits will decline with expanded health care coverage. I haven’t seen any evidence for that.” Section editor: Truman J. Milling, Jr, MD Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICME conflict of interest guidelines (see www.icmje.org). The au-
A Bitter Pill Poison Control Centers Face Deep Budget Cuts
by MARYN MCKENNA Special Contributor to Annals News & Perspective
I
n 1988, the state of Louisiana wanted to save some money in its budget and stopped funding its poison control center. The next year, there were 15,000 more emergency department (ED) visits for poisonings, a 42% increase that cost an additional $1.4 million.1 In 1993, facing a budget cut, the Michigan poison control center stopped taking calls from 2 of the 3 area codes it covered. During the following 4 months, 20A Annals of Emergency Medicine
Blue Cross Blue Shield of Michigan recorded a 35% increase in outpatient visits for suspected poisonings and a 16% increase in hospitalizations.2 In 2004, the Institute of Medicine estimated that every dollar of public funding spent on a poison control center saves $10 that would otherwise have been spent on health care.3 Given those data, it would be reasonable to assume that, in an era of deep concern about federal spending, policymakers view investing in poison control as a way of saving health care funds. Reasonable, but incorrect. In fact, in March 2011, the US poison control system
thor has stated that no such relationships exist. doi:10.1016/j.annemergmed.2011.06.007
REFERENCES 1. Department of Health & Human Services, Agency for Healthcare Research and Quality. Medical Expenditure Panel survey. 2008. Available at: http://tinyurl.com/ 489fao6. Accessed June 12, 2011. 2. The Price of Excess: Identifying Waste in Healthcare Spending. New York: Pricewaterhouse-Coopers LLP Health Research Institute; 2008. 3. Pitts SR, Niska RW, Xu J, et al. National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary. National Health Statistics Reports; No. 7. Hyattsville, MD: National Center for Health Statistics; 2008. 4. National Health Statistics Reports number 26. Available at: http://www. cdc.gov/nchs/data/nhsr/nhsr026.pdf. Published August 6, 2010. 5. Ortega AN, Fang H, Perez VH, et al. Health care access, use of services, and experiences among undocumented Mexicans and other Latinos. Arch Intern Med. 2007;167:2354-2360. 6. Massachusetts Division of Health Care Finance and Policy. Hospital inpatient and emergency department utilization trends, fiscal years 2004-2008. Available at: http://archives.lib.state.ma. us/handle/2452/50116. Accessed June 12, 2011.
narrowly escaped losing almost all of its federal funding; only last-minute bargaining reduced a proposed 93% cut to 25%.4 The system’s annual appropriation of just under $30 million will be on the block again next fiscal year, and ED personnel are wondering how long it will be until additional poisoning cases start coming through their doors. “Right now, we keep 80% of kids who have a potential poisoning out of the emergency department,” said Lewis Nelson, MD, an associate professor of emergency medicine and director of the medical toxicology fellowship at New York University’s School of Medicine. “If there is no poison center for their parents to talk to, where else are they going to go?” The United States’ 57 poison control centers receive a roughly 4-to-1 mix of state and federal money. The 2011, and threatened 2012, federal cuts arrive on top of concurrent decreases in state Volume , . : August
by ERIC BERGER Special Contributor to Annals News & Perspective
Coffee sobers you up. Going out in cold weather makes you sick. Too much sugar makes your kids hyperactive. Chewing gum, once swallowed, takes 7 years to digest. To be safe, wait 30 minutes after eating before swimming. Taking vitamin C, echinacea, or zinc prevents colds.
T
hese are half a dozen medical myths that much of the American population, and even more than a handful of physicians, believes. Here’s one more: Emergency medical care is expensive and inefficient. Readers of this article probably won’t be taken in by that myth, but in this respect, readers of this journal are out of step with the general public and, perhaps still more important, policymakers. Consider a Senate bill (SB 1781) introduced in October 2009, called the Reducing Emergency Department Utilization Through Coordination and Empowerment (REDUCE) Act. According to its language, the bill sought to address emergency department (ED) overuse, improve quality of care, and save taxpayers’ money by establishing pilot programs to better coordinate care for frequent ED users. “Far too many people rely on emergency room services for routine or primary care,” said US Senator Sherrod Brown (D-OH), one of the bill’s authors. ”By strategically expanding outreach services to frequent ER visitors and better coordinating their care, we can cut the associated costs to taxpayers. This initiative takes an important step toward fix18A Annals of Emergency Medicine
ing our broken health care system and improving the quality of care for communities in Ohio and across the country.” Brown is not alone in holding such beliefs. In March 2011, Health and Human Services Secretary Kathleen Sebelius joined the public radio talk program The Diane Rehm Show and responded to a small business owner in Nantucket, MA, who was concerned about paying $1,600 per month for health insurance coverage for her family of 3 under the state’s universal health insurance plan, with a $5,000 deductible because of her son’s preexisting condition. “Right now, as a taxpayer, the family from Nantucket is also paying for everyone who doesn’t have insurance who is coming through emergency room doors accessing the health care system, often in a very expensive way,” Sebelius said. In recognition of this pervasive myth about emergency care, as well as others, the American College of Emergency Physicians (ACEP) launched the “Just 2% Campaign” in April 2011. The national public education campaign seeks to promote the value of emergency medicine and to educate the public and policymakers that emergency care is less than 2% of the nation’s health care dollar. During a talk at ACEP’s Health Writer’s Conference in New York City on April 19, President Sandra Schneider, MD, a professor and chair emeritus in the Department of Emergency Medicine, University of Rochester, Rochester, NY, laid out the campaign for members of the media. “Health care spending is a huge issue in the United States, representing more than 16% of our gross domestic product. Yet, as became clear during the health care reform debate last year, there are misconceptions about the costs and efficiencies of emergency rooms,” she said. “The bottom line is this: Policymakers seeking to trim fat from the nation’s ris-
ing health care bills are looking in the wrong place if they take aim at emergency departments.” ACEP launched the campaign amid a widespread rhetoric from policymakers, public policy wonks, and some sectors of the health care industry on the need to reduce visits to the ED as a way to control increasing health care costs. This article, then, seeks to amplify this educational effort by dispelling the “too costly” myth, as well as others being bandied about by politicians and the press.
MYTH NO. 1: EMERGENCY CARE IS TOO EXPENSIVE
A
ccording to the US Department of Health & Human Services’ Agency for Healthcare Research and Quality,1 which conducted a Medical Expenditure Panel Survey in 2008, just under 2.0% of the more than $2 trillion spent on health care annually in the United States is spent on emergency care. In 2008, according to the US government study, EDs received about 124 million total visits, at a cost of $47.3 billion. It is true that care in EDs is more expensive than in some other settings because they must be staffed 24 hours a day, 7 days a week. There are fixed costs associated with being ready for any emergency at any given time. It is therefore notable that the majority of visits to the ED in 2008 —two thirds— came after business hours on weekdays and on weekends when the majority of physicians’ offices were closed. So these emergency facilities are generally used when appropriate. There are clear reasons why the public has the perception that emergency care is too expensive and responsible for excessive costs in the health care system, said Jesse M. Pines, MD, MBA, director of the Center for Health Care Quality and an associate professor of emergency medicine at George Washington University. “Whether or not emergency care is a bargain or expensive depends upon whose perspective you take with costs,” Dr. Pines said. “From the patient’s perspective, the copays are going to be higher than for a clinic visit. It is perhaps $100 for an emergency department visit, whereas a clinic might be $20. From a patient’s perspective, then, emergency Volume , . : August
care is more expensive. And it’s also seen as more expensive from an insurer’s perspective, who looks at a bill and see the charge per service is higher in the emergency department. The cost, of course, is basically driven by a number of things. One major reason is because the focus of emergency care is ruling out the most severe diagnoses, so we do have the tendency to use more resources compared to other setting.” The annual costs of emergency care in the United States are dwarfed by several areas of waste within the health care system. A 2008 analysis2 of the health care system by the PricewaterhouseCoopers Health Research Institute identified the top 3 areas of waste in the health care system as defensive medicine (up to $210 billion annually), inefficient claims processing ($210 billion annually), and care spent on preventable conditions related to obesity ($200 billion). These are better places to look for fat to trim.
nonurgent. The report defined nonurgent conditions as those patients who could wait 2 to 24 hours for medical care. The data for the 2007 National Hospital Ambulatory Medical Care Survey,4 published last August, found that just 7.9% of visits were classified as nonurgent. So, according to CDC data, roughly 10% of patient visits to the ED were for nonurgent care during those 2 years. “The studies simply show that we don’t have that many unnecessary patients presenting in the emergency department,” said David Seaberg, MD, ACEP’s president-elect, who is dean and professor at the University of Tennessee College of Medicine, Chattanooga. “This is something that can be explained to people. When I actually sit down and talk with state legislators, it doesn’t take too long to dispel the myth.”
MYTH NO. 3: UNDOCUMENTED IMMIGRANTS CAUSE ED CROWDING
MYTH NO. 2: EDs ARE CROWDED BY PATIENTS WITH NONURGENT MEDICAL ISSUES
U
T
his is a myth that Angela Gardner, MD, heard over and over again during her 2009 to 2010 term as president of ACEP. “It really was a big issue for me, the notion most of the people in the emergency department don’t belong there,” said Dr. Gardner, an assistant professor in the Division of Emergency Medicine, Department of Surgery at the University of Texas Southwestern Medical Center in Dallas. “It was very common for me to hear that from the person you meet on the street all the way to Washington and the halls of Congress. People think that if we could just get those nonurgent patients out of the emergency department, we could pay for health care.” The reality is far from the myth, however. According to the Centers for Disease Control and Prevention 2006 National Hospital Ambulatory Medical Care Survey,3 which broke down ED visits by urgency, just 12.1% were classified as Volume , . : August
“unnecessary” costs in the ED of about $4.7 billion annually. Therefore, if policymakers succeeded in ending all unnecessary visits to the ED, which is yet another unrealistic assumption, the United States could shave about 0.2% off its medical bill. That is probably not the savings lawmakers are looking for. Some emergency physicians even have a problem with the term “nonurgent” care. “The problem with any assessment of urgency is that it’s not typically done from the patient’s perspective,” said Dr. Pines. “Surveys have shown that close to all the patients coming to the emergency department perceive their symptoms to be urgent, but this doesn’t come through in the CDC data.”
Let’s dispel it further anyway by considering that about 10% of patient visits to the ED are nonurgent, according to the CDC data for 2006 and 2007. How much value could the health care system derive from cutting these “unnecessary costs”? First, we must set aside the possibility that some of these patients presented on a Friday night or Saturday, more than 24 hours before their primary physician’s office opened. Let us also assume every one of these patients could obtain the care they needed elsewhere, free. And let us finally make the assumption that the unnecessary patients, such as those with toothaches, racked up costs equal to those of patients with much more serious conditions. Under these assumptions, 10% of patient visits would create a bill of
ndocumented immigrants, who often hold jobs without health insurance, are perceived as overusing EDs because they cannot receive care elsewhere. But the data show this to be largely untrue. A 2007 study in Archives of Internal Medicine5 used data from the 2003 California Health Interview Survey, with 42,044 participants, to study usage of EDs and medical clinics by undocumented Mexicans and other Latinos. The study found that undocumented Mexicans had 1.6 fewer annual physician visits compared with US-born Mexicans and that other undocumented Latinos had 2.1 fewer visits compared with their US-born counterparts. The study found that both groups used the ED significantly less frequently than their US-born counterparts. “Low rates of use of health care services by Mexican immigrants and similar trends among other Latinos do not support public concern about immigrants’ overuse of the health care system,” the study authors concluded. Annals of Emergency Medicine 19A
MYTH NO. 4: HEALTH CARE REFORM WILL LEAD TO A SUBSTANTIAL REDUCTION IN COSTLY ED VISITS
T
he Patient Protection and Affordable Care Act signed by President Obama seeks to divert patients away from EDs into the offices of primary care physicians through various means, such as accountable care organizations. It remains to be seen, however, whether this will actually lead to a reduction in usage of EDs. Some previous experiences suggest it may not. The Massachusetts health care insurance reform law, enacted in 2006, requires that nearly all Massachusetts residents obtain a minimum level of health care insurance coverage. Instead of decreases, however, a 2010 report6 from the Massachusetts Division of Health Care Finance and Policy found that ED visits increased by 9% from 2004 to 2008, to about 3 million visits a year. One reason for the increase may have been that newly covered Massachusetts residents could not find a primary care physician or obtain last-minute appointments with their physician.
Dr. Gardner, ACEP’s past president, said the data do not surprise her because she has recently heard from colleagues about an increase in primary care physicians referring patients to the ED for evaluations. A hyperglycemic patient, for example, may visit a physician’s office with a blood sugar level of 400 mg/dL, Dr. Gardner said, and the quickest and easiest way to administer treatment is sending him or her to the ED, where the patient can receive fluids and be observed for several hours to determine whether admission to the hospital is necessary. “I don’t think there [are] data yet on this; it is just what I hear from emergency physicians,” she said. “I believe there will be data soon. It’s not something I’ve heard once or twice. It’s something people are talking about everywhere. It’s frustrating to hear people outside of emergency medicine say our visits will decline with expanded health care coverage. I haven’t seen any evidence for that.” Section editor: Truman J. Milling, Jr, MD Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICME conflict of interest guidelines (see www.icmje.org). The au-
A Bitter Pill Poison Control Centers Face Deep Budget Cuts
by MARYN MCKENNA Special Contributor to Annals News & Perspective
I
n 1988, the state of Louisiana wanted to save some money in its budget and stopped funding its poison control center. The next year, there were 15,000 more emergency department (ED) visits for poisonings, a 42% increase that cost an additional $1.4 million.1 In 1993, facing a budget cut, the Michigan poison control center stopped taking calls from 2 of the 3 area codes it covered. During the following 4 months, 20A Annals of Emergency Medicine
Blue Cross Blue Shield of Michigan recorded a 35% increase in outpatient visits for suspected poisonings and a 16% increase in hospitalizations.2 In 2004, the Institute of Medicine estimated that every dollar of public funding spent on a poison control center saves $10 that would otherwise have been spent on health care.3 Given those data, it would be reasonable to assume that, in an era of deep concern about federal spending, policymakers view investing in poison control as a way of saving health care funds. Reasonable, but incorrect. In fact, in March 2011, the US poison control system
thor has stated that no such relationships exist. doi:10.1016/j.annemergmed.2011.06.007
REFERENCES 1. Department of Health & Human Services, Agency for Healthcare Research and Quality. Medical Expenditure Panel survey. 2008. Available at: http://tinyurl.com/ 489fao6. Accessed June 12, 2011. 2. The Price of Excess: Identifying Waste in Healthcare Spending. New York: Pricewaterhouse-Coopers LLP Health Research Institute; 2008. 3. Pitts SR, Niska RW, Xu J, et al. National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary. National Health Statistics Reports; No. 7. Hyattsville, MD: National Center for Health Statistics; 2008. 4. National Health Statistics Reports number 26. Available at: http://www. cdc.gov/nchs/data/nhsr/nhsr026.pdf. Published August 6, 2010. 5. Ortega AN, Fang H, Perez VH, et al. Health care access, use of services, and experiences among undocumented Mexicans and other Latinos. Arch Intern Med. 2007;167:2354-2360. 6. Massachusetts Division of Health Care Finance and Policy. Hospital inpatient and emergency department utilization trends, fiscal years 2004-2008. Available at: http://archives.lib.state.ma. us/handle/2452/50116. Accessed June 12, 2011.
narrowly escaped losing almost all of its federal funding; only last-minute bargaining reduced a proposed 93% cut to 25%.4 The system’s annual appropriation of just under $30 million will be on the block again next fiscal year, and ED personnel are wondering how long it will be until additional poisoning cases start coming through their doors. “Right now, we keep 80% of kids who have a potential poisoning out of the emergency department,” said Lewis Nelson, MD, an associate professor of emergency medicine and director of the medical toxicology fellowship at New York University’s School of Medicine. “If there is no poison center for their parents to talk to, where else are they going to go?” The United States’ 57 poison control centers receive a roughly 4-to-1 mix of state and federal money. The 2011, and threatened 2012, federal cuts arrive on top of concurrent decreases in state Volume , . : August