This commentary is by Ben Smith, an emergency doctor and director of the emergency department at Central Vermont Medical Center in Berlin. He lives in Duxbury.
As an emergency doctor and the director of a small Vermont emergency department, I am glad to see some of Vermont’s health policy thinkers embracing investment in outpatient services like primary care, mental health, home health, and in the social determinants of health.
The hallways of emergency departments nationwide, including here in Vermont, are a vivid, gut-punch tutorial in the social determinants of health and the paucity of outpatient care. These investments are desperately needed, as are major investments in nursing home care.
Worth questioning, though, is the notion that any of these investments can be made simply by reallocating money from emergency and hospital care, which is often characterized as “avoidable” and “low-value.” Although there is data to suggest the magnitude of the so-called avoidable care problem, supposedly on the order of 30% of emergency and inpatient stays, this data is startlingly divorced from the following realities on the ground:
- First, emergency departments and hospitals are the safety net for the most vulnerable — the elderly, those with poverty, mental illness, disability, substance abuse, homelessness, neurodivergence, geographic isolation, transportation difficulties, and domestic violence — and both health equity and basic safety currently depend on viable, functioning emergency departments and hospitals.
- Second, the statistics on so-called avoidability completely fail to account for the granular realities of people’s lives (when one’s grandfather, for instance, needs a hospital admission for vomiting and diarrhea — usually a benign, self-limited condition — because he is too weak to stand, and needs the help of two to four people in cleaning every 15 minutes). That admission is “avoidable” only in the eyes of someone distanced from the bedside by many layers of spreadsheets.
- Third, 66% of all Americans over the age of 75 will visit an emergency department this year, and we know that the elderly require more extensive testing, longer stays, and more hands-on care. This is not a systemic failure — it’s simply the reality of our demographics and the aging human body, and it bears asking whether the health policy apparatus has wrapped its head around the amount of work required to ethically care for this population.
- Fourth, even as I write, we are consistently overwhelmed and under-resourced, to the point that everyone’s quality of care is right now affected.
- Fifth, this resource crisis, largely the result of under-investment in the frontline workforce, has roots long preceding Covid-19 and the tripledemic, and will not end with them.
To intentionally divest from emergency and acute care, as has been repeatedly suggested, before robust outpatient systems are fully built and demonstrably functional would be a profound failure of health quality and equity, mimicking the tragic failures that have already accompanied psychiatric deinstitutionalization.
We are actually living with a version of this already, as resource constraints have contributed to chronic hospital undercapacity, the warehousing of admitted patients — both psychiatric and medical — in emergency departments (a phenomenon known as “boarding”), and the poor-quality care that’s data-proven to follow.
The big question, then, is precisely how to fund the building of outpatient systems adequate to the task at hand without jeopardizing quality, safety and equity in the meantime. And it’s hard to see how that won’t require more money deployed to the front lines — both outpatient and inpatient — not less.
Although this may be a shocking contention to some, there are robust economic theories to explain why health care labor costs increase faster than inflation, and we need to think seriously about disaggregating labor from the debate over health costs if we wish the system to survive intact.
A final note, on our impoverished notion of “value”: Emergency departments have been characterized as “low-value” and “the endgame of bad policy.” But I wonder if we feel the same way when we show up at 3 a.m. to find a highly trained team, with many years of sacrifice and education, ready to diagnose and treat our condition, and resuscitate us if it should come to that; a secretary, to register us in the computer, and answer the phone calls of our loved ones; a radiology tech, to administer our CAT scan; a lab technician to run our blood work; a housekeeper to clean and ready our room; and a security guard to keep us safe from the violent, intoxicated patient in the next bed.
I mean, how much should that cost? Have we actually reckoned with the societal value, security and equity that emergency departments and hospitals provide?
I plead with the policymakers and administrators to reconsider their notion of “value,” and to use gentler language when speaking of those of your neighbors who continue to show up for work — in the midst of inadequate resources, increasing moral trauma, pandemic risk, and workplace violence — day after day, night after night, to care for us all.
