Applying Ethical Principles-Overuse of the Emergency Room in a Not-for-Profit Hospital
Introduction
Whether you are a nurse, a public health professional, a health care administrator, or in another role in the health care field, you must base your decisions on a set of ethical principles and values. Your decisions must be fair, equitable, and defensible. Each discipline has established a professional code of ethics to guide ethical behaviour. Applying Ethical Principles-Overuse of the Emergency Room in a Not-for-Profit Hospital. In this assessment, you will practice working through an ethical dilemma described in a case study. Your practice will help you develop a method for formulating ethical decisions.
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Emergency Department Repeat Admissions — A Question of Resource Use
Matt Losinski finished reading an article that provided grim details of a study of the overuse of emergency services in hospitals in central Texas. He smiled that sardonic half-smile that meant there was a strong possibility that County General Hospital (CGH) might have the same problem. Applying Ethical Principles-Overuse of the Emergency Room in a Not-for-Profit Hospital.As chief executive officer (CEO), Losinski always saw the problems of other hospitals as potential problems at CGH, a 300–bed acute care hospital in a mixed urban and suburban service area in the south-central United States. CGH was established as a county–owned hospital; however, ten years ago, the county wanted to get out of the hospital business, and the assets were donated to a not–for–profit hospital system. The new owner has continued a strong public service orientation, even though CGH no longer receives the tax subsidy it did when it was county-owned; it must look to itself for fiscal health.
The study data showed that nine residents of a central Texas community had been seen in emergency departments (EDs) a total of 2,678 times over six years. One resident had been seen in an ED 100 times yearly for the past four years. Given that an ED visit can cost $1,000 or more, the nine residents had consumed $2.7 million in resources. These high users of ED services were middle-aged, spoke English, and were split between male and female. The problem seemed like a manifestation of Wilfredo Pareto’s classic 80/20 rule to Losinski.
Losinski forwarded the article on a priority basis to Mary Scott, his chief financial officer (CFO), and asked her to see him after she read it. Scott stopped by Losinski’s office late the next day and began the conversation by asking him why he thought the article was a priority. Scott reminded Losinski that Medicaid paid 75% of costs for eligible ED users and that the cross-subsidy from privately insured and self–pay ED admissions covered most of the unpaid additional costs. Losinski had a good working relationship with Scott, but he was annoyed by her rather indifferent response. Applying Ethical Principles-Overuse of the Emergency Room in a Not-for-Profit Hospital
Losinksi wanted details on the use of the ED at CGH. He asked the administrative resident, Aniysha Patel, to gather data to identify use rates for persons repeatedly admitted to the ED. The findings that Patel gave to Losinski two weeks later were not as extreme as those reported from central Texas; however, they did show that a few persons were repeatedly admitted to the ED and accounted for hundreds of visits in the past year. The clinical details were not immediately available. However, a superficial review of the admitting diagnoses suggested that most admissions involved persons with minor, nonspecific medical problems, commonly known as the “worried well.” Although Scott was correct that Medicaid covered the majority of costs, the fact remained that over $200,000 each year was not reimbursed to CGH. Were that money available, it could go directly to the bottom line and enhance health initiatives for the community. In addition, repeated admissions to the ED contributed to crowding, treatment delays, and general dissatisfaction for other patients.
Losinski presented the data to his executive committee, which includes all vice presidents, the director of development, and the elected president of the medical staff. The responses ran the gamut from “So what?” to “Wow, this is worse than I imagined.” Losinski was bemused by the disparity of views. He had thought there would have been an almost immediate consensus that this problem needed a solution. The financial margins for CGH were already very thin, and the future for higher reimbursement was not bright. A concern echoed by several at the meeting was the requirement of the federal Emergency Medical Treatment and Active Labor Act (EMTALA) that all persons who present at an ED that receives federal reimbursement for services must be treated and stabilized. Applying Ethical Principles-Overuse of the Emergency Room in a Not-for-Profit Hospital
Losinski asked his senior management team for recommendations to address the problem of ED overuse.
