That being said, sometimes the system itself fails the patient. Through inefficiency, poor communication and administrative roadblocks and hurdles, sometimes getting the right care can seem impossible. And, unfortunately, when this happens, many people end up in the emergency department. Yes, the emergency department, where we are specifically trained to treat life threatening acute conditions such as heart attacks, strokes, and major injuries or trauma. We also manage many conditions which are non-life threatening but still acute, from minor injuries and illnesses to symptoms which COULD represent life threatening conditions. We are NOT the people to see for that chronic condition you've had but you just haven't had a chance to make an appointment to see your doctor, no matter how tedious that may seem. Sometimes, however, patients come to us because they don't know where else to go.
Case in point, I recently had a middle aged patient come to the emergency department (key word being "emergency") with a non-acute surgical condition. He (I'm going to alternate pronouns to further obscure the patient) knew his diagnosis and knew he needed surgery at some point. Easy, right? No. He called his primary care provider (PCP) but the PCP would no longer see the patient because he didn't accept his current state funded health insurance. The PCP's suggestion was to go to the emergency department. Okay, so I have the patient, I just need to give her the name of a surgeon. I called the two different surgical groups that we had on call, and neither accepted her insurance. Okay. I asked Case Management to get involved and was told to just tell the patient to call the number on his insurance card. I thought that it wouldn't be that simple, so I took it upon myself to make the calls for the patient. After getting bounced around a couple of times, I spoke to someone who seemed to understand the the patient simply needed the name and contact info of a general surgeon who was in the plan's network.
The first name I was given was one our hospital's surgeon whom I knew did not do general surgery, only specialty surgery. I knew this, but was ASSURED by the insurance plan that he was on their list for general surgery. Okay, I thought, maybe the surgeon did some general surgery too. I called his office and was told, "no," only specialty care.
I called back, got bounced around again, and got another representative and explained what had happened so far. I was told that that surgeon was listed as general surgery, but there must have been a mistake. Okay, so let's try some other names.
The next name was someone that I had never heard of, but was given my hospital's contact info for the surgeon's info. I've been with my hospital for nearly 10 years, I'm pretty sure I know who practices here and I said as much. The next surgeon was the same thing, I was given our hospital's main contact info, but I knew that these surgeons did not perform surgeries at our hospital. I looked them both up while I was on the phone with the representative and learned that they were both specialists, and neither did general surgical cases (and neither worked out of my hospital). The next name I was given was, as I learned by looking the name up while on the phone with the representative, was a plastic surgeon.
I FINALLY found a commonality between the names that I had been given, and looked up and found some general surgeons that DID take the patient's insurance. This took some knowledge of how practice groups work or are associated, and wouldn't have been intuitive to the lay person.
I don't know how anyone can think this is helpful or efficient. Fortunately, I had the time to make these calls, but in all, it took about 2hrs total. No wonder it's easier for patients to "just go to the emergency department." Until these administrative barriers get removed, and we make it easier for patients to get prompt appointments, we're never going to reduce unnecessary emergency department visits.
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