The Rising Cost of Health Care

Have a discussion about health care recently?  Did rising costs come up?  Of course it did.  Emily McIsaac, an IUEM R3, discusses her perspective as an emergency medicine physician:

My mini rant

When I had that ceremonial sash (I believe it is actually called a hood), placed over my head by my father at my medical school graduation, I had little to no idea that suddenly becoming a doctor was now going to grant me the title of the health care expert and frankly I had no idea how much I didn’t know.  It is now the end of my intern year, and though I have gathered an enormous amount of clinical experience, there is still an area of medicine that I am rather ignorant about: costs.

According to a recent report released by Milliman Medical Index and published by Forbes magazine, the average health care costs for a family of four with a PPO insurance plan is over $20,000.  That is with insurance.  Imagine the costs for a family without insurance with a catastrophic health event.

As part of my residency training, the residents spend about half of their time at a county institution.  Most patients do not have insurance and only some can get on the state aid program.  At some point in my training, I quickly realized that someone was paying for patient care and it certainly was not an insurance company or likely the patient.  That CT scan I ordered was coming out of the taxpayer’s money- that doesn’t seem fair.  But it also isn’t fair that my patient can’t qualify for insurance to help pay their bill.  Or they can’t get in to see a primary care doctor regularly to control their diabetes so they are stuck coming to the emergency department for higher cost treatment.

Health care expenditures accounted for 17% of the GDP in 2008 and is estimated to rise to 19% by 2017.  It is a major concern as this level of growth is unsustainable.

What is The Affordable Health Care Act?

On March 23, 2010 President Obama signed a bill that is expected to comprehensively reconstruct the way health care insurance works in the United States.  This also includes several reforms to improve health care costs.

Recently, The Center for American Progress, held a panel discussing the Affordable Care Act.  The panel addressed the changes already made and future changes that are to be enacted soon, specifically pertaining to cost effective care.

The panel included several physicians and policymakers who were involved with drafting the bill.  The panel members extensively discussed various test areas and their success as well as future plans.  Specifically, they brought up a few terms that I feel need definition before further discussion.

Alternative Quality Contracts

Program enacted by Blue Cross and Blue Shield of Massachusetts in 2009 that took primary care providers and provided them a base fee for patient care and also provided bonuses for savings and health targets reached.  This plan suggests they reward for quality and efficiency instead of volume.

Accountable Care Organizations

Groups of hospitals and physicians made responsible for a group of Medicare patients.  In theory, the organization would be paid a flat fee per patient and its job would be to minimize patient costs.  The more money that it saves, the more money the group makes.


Transferring from a fee for service payment model to what is described as a bundled charge.  This would take a diagnosis such as congestive heart failure exacerbation and make a standard charge for the admission and recovery.  Per the panel, this is already done for many operative procedures but could also be applied to diagnosis like depression.

What does this mean for Emergency Medicine?

As the panel alluded to, a major goal of the new care plan is to decrease “unnecessary” ER visits and the rate of readmission.  The over-arching theme seems to be to place the provider and healthcare network with more responsibility in the long term care of the patient.  In order to do this, the provider/group would be financially rewarded for a healthier patient.   Not only would this include the PCP, but also the rehab sites, and nursing homes.  The plan would encourage communication between the patient’s health care resources.

In the emergency department this would hopefully mean less chronic health exacerbations or noncompliance visits, which would obviously significantly reduce patient load.  The panel also mentioned providing 24/7 primary care access through ancillary health care staff.  Traditionally, this burden has been carried by emergency departments for after hours and weekend care.  Although in theory this is a great idea, it is hard to imagine it in practice.  With the lack of primary care providers, the emergency department will still be the only option for non-ideal hours of care.   It is also unclear how emergency medicine will fit within the ACO model.

The panel did not specifically explain the intricacies of the bundled payment model, and it is hard to imagine how this will apply to emergency medicine.  Will the emergency medicine fee be an allotted amount based on the diagnosis?  Will emergency physicians be rewarded for communicating with primary care providers and working to keep patients from admission?  Since emergency medicine is a shift-based specialty based on single visits, it may take some creativity to integrate the specialty in the new system.

One more comment- during the panel, one physician cited that only 10-15% of emergency room visits are true emergencies.  It is clear that emergency departments are overused for a variety of what may seem to be primary care complaints.  I am not convinced that only 10% are true emergencies, but do agree that many can be treated with less expensive care.  Consider an uncontrolled diabetic.  Many of these patients get admitted for diabetes education and glycemic control.  What if this patient could be given fluids and insulin in the department and then sent home with follow-up the next morning this their PCP? Or their PCP could communicate with the emergency medicine physician/nurse/midlevel provider to make adjustments to their regimen that day, thus reduce another health care visit and possibly prevent future ones.

The problem is access to care and the efficiency of care provided.  Increasing communication and a patient centered focus will be pivotal in the change.  However, legislators must also remember that health care is a business.  People must be rewarded for the changes they make both in practice and their commitment to their patients.  The financial incentives surrounding reimbursement will have to adjust to not only be more effective but also profit enhancing.  As the panelist alluded to, this may mean more intermediate providers, electronic communication, data analysis for patient care improvement, and incentive structures to decrease costs specifically admissions.  Emergency medicine will be expected to become more involved with these changes, though the exact role remains unclear.

If you are curious about the Affordable Care Act please visit the website:

Beyond the Advocacy Track

Michael Khouli is a 2013 graduate of the Emergency Medicine/Pediatrics Residency Program here at Indiana University.  Seeking to extend the curriculum offered by IUEM through the advocacy track, Michael is developing an MPH curriculum for the residency while acquiring the Master’s in Public Health, himself.  Here’s how he got there:

“Medicine is a social science, and politics is nothing else but medicine on a large scale.”

           -Rudolf Virchow

The first time I thought about becoming a doctor, I was in Mexico.  I met a man with an obviously broken and infected hand asking for money, and I thought it seemed a relatively easy matter to treat him if only there was a physician to take care of him.  So I became a doctor.  I wanted to care for the underserved nationally and internationally, those people literally no one else would treat.  A lot of doctors probably have a similar story.  However, as I pursued my training in pediatrics and emergency medicine, I realized that many patients are underserved, not because of a lack of geographic access to a physician, but rather because of socioeconomic barriers to accessing that care effectively.  In the emergency room, I work with a disproportionate share of disenfranchised patients, serving as the healthcare safety net for America.  Rewarding as it is, I sometimes feel like the boy with his finger in the dike, dealing with the end result of a broken healthcare delivery model without having the wherewithal to address the factors that lead to preventable poor health.  I can provide medical care for the same intoxicated homeless patient for the third time this week, but I can’t provide him a home or social support to turn to instead of a bottle.  Yet many cities have initiated programs to do just that, with good results, reduced ER visits, and lower public cost overall.  Moreover, I have recognized that what really impacts our health and quality of life is not the latest antiplatelet drug or statin-de-jour.  Rather, public health initiatives often offer greater benefit at less cost, whether it has been through vaccination campaigns, potable water and sewage systems, removal of lead based paint and gasoline from the market, or adding fluoride to water supplies.  My emergency care for trauma patients matters, but legislation for stricter highway safety regulations keeps them from being trauma patients in the first place.

I chose to become a physician a decade ago to care directly for patients, unencumbered by the ambiguities and uncertainties inherent in broader healthcare policy initiatives.  Nonetheless, as I was forced to deal with the effects of those policies on my patients and myself on a daily basis, I realized that I could not simply ignore them and still do my job well.  Caring for patients requires physician advocacy and engagement in that public process.  Traditional residency training often neglects this aspect of patient care.   How do I partner with local interests in the community to establish a free clinic in an impoverished neighborhood?  How do I get funding for such a venture?  How do I establish liaisons with healthcare networks and systems in other states or countries to improve accessibility and coordination of care?  How can I understand global health to translate successes abroad to solutions at home?  How do I interpret epidemiological trends to understand and address socioeconomic and behavioral dimensions of health?  How do I engage with legislators to address these issues?  What kind of model will truly improve patient access to basic care so that their health does not deteriorate to a condition requiring emergency care?

I think many physicians, myself included, would struggle to even begin addressing such questions, and there are no easy answers.  IUEM already offers a strong and unique advocacy curriculum that offers many opportunities to understand and explore such public health issues.  To further develop such skills and interests, we are now partnering with the Fairbanks School of Public Health to offer the unique opportunity for residents to take formal MPH classes.  This program is set to launch during the next academic year.  Flexible and online classes will allow the residents to mold their curriculum within the demands of a full resident schedule.  In the ER we have ample firsthand experience of the consequences of broad public health problems.  Traditional medical training teaches us to treat those consequences.  My hope is that through our new public health curriculum, we will be able to address the deeper causes underlying those consequences to the relief of our overburdened ERs, our individual patients, and the public as a whole.  As ER physicians are increasingly asked to be all things to all patients, public health becomes a natural extension of our already broad scope of practice.


Hey everyone!

Welcome to the IUEM Advocacy Blog!  Here you’ll find updates on advocacy projects happening within the residency, links to great articles and ways that you can help advocate for some great people around Indianapolis.  Think it sounds awesome? It is!  Look how much fun the kids of the Daniel Webster Elementary School are having as a part of Sean Thompson and Michele McDaniel’s Triathlon Club!  IUEM residents came together to provide gear, train and cheer on these kids to all successfully complete a triathlon!  Stay tuned for more info on the triathlon club and many more projects.  If you’d like to contribute to the blog feel free to contact us at