Portal de Periódicos da CAPES

A Trip to Emergency Fun Land

2001; Lippincott Williams & Wilkins; Volume: 23; Issue: 3 Linguagem: Inglês

10.1097/00132981-200103000-00013

1552-3624

Edwin Leap,

Although I've never been a researcher, I've always wondered what it would be like. Because so many bad studies get such wide public attention and even cause policy overhauls (e.g., the Institute of Medicine's study on medical error), I have decided that imaginary research may be just as good as the real thing. Here's my submission, with a special dedication to Richard Bukata, MD, and Jerome Hoffman, MD, who have taught me through courses and tapes the value of good studies and the characteristics of bad ones. Go easy, boys, I'm just a beginner. Cash Up Front Study Objective: To identify alternate sources of funding to support the “safety net” of a local, rural emergency department. Methods: We reviewed financial records, both for the un-named, private, semi-rural hospital itself, and for the emergency physician group, in an attempt to improve revenues for both groups. We used four standard video poker machines, a multi-channel satellite television hookup involving pay-per-view movies, a video arcade, two fast food chains, and a company specializing in professional wrestling memorabilia. Finally, a T-shirt shop with silk screening capacity was installed to sell souvenirs of the “health care experience.”? Original plans called for use of cigarette machines, but this was felt to be mercenary in nature and a conflict of interest because smoking patients would be more inclined to seek health care. Fireworks sales were considered, but also were dropped because of concerns about patient oxygen tanks and the risk of explosion. Results: Emergency department revenues, both for the hospital and physician group, increased by 65 percent over the six-month study period. Increases were offset somewhat by the fact that many patients elected to play video poker, watch movies, or eat in the expanded “waiting room/recreational facility” rather than be seen in the emergency department. Many of these reported an overall improvement in their subjective “mood scale” brought about simply by recreating with friends. Conclusions: EMTALA forbids the apparently archaic practice of asking patients (AKA customers) to pay for services at the time they are provided. It does not, as far as we know, forbid alternate sources of revenue not related to health care itself. Emergency departments must evolve with the times. We recommend the establishment of patient recreation areas, whereby funds can be obtained from patients voluntarily, and in a manner which they find pleasant without the entanglements of private or public insurers or the difficulty of collections. A Visit to Emergency Fun Land Introduction: America's emergency departments are the cornerstone of the health care safety net for citizens. No matter what the complaint, no matter what time of day or night, anyone can be seen in the emergency department of a hospital that accepts Medicare. No patient can be forced to pay either before or after leaving, though they can be billed. In some instances, representatives of an unnamed federal agency have indicated that a sign saying, “We will bill you,” is coercive, and should not be present in emergency department waiting rooms. In spite of EMTALA and COBRA laws, the government does not provide remuneration for the “screening exams” and extensive care provided to patients under these provisions. In the emergency department described here, visionary personnel set out to create a system which would use time-honored principles of capitalism to fund the department and its staff while avoiding any changes in medical billing or pricing. Participating researchers (hard-nosed free market economists all) felt that quality of care would improve if funding improved, and that staff morale also would soar if collections began to approach billing by more than the usual 35 percent. Researchers surveyed the local community on several occasions, and tried to identify common, successful sources of revenue that did not impose significant health risks or physical danger to the populace at large. Four video poker machines were initially installed, though six more were added due to their popularity Methods: It takes money to make money. Therefore, the emergency department waiting room was expanded to twice its original size. The administration of the hospital was hesitant at first, but ultimately agreed after incriminating photographs were presented at a closed door meeting of senior department heads. Once the waiting room was of adequate size, a nearby video gaming company was contacted to provide video poker machines. Four machines were initially installed, though six more were later required due to their popularity. A suggestion was made that we re-fit the machines to dispense single 10 mg diazepam tablets, but there were concerns about the legality of this move. Subsequently, there was an attempt to re-fit them to dispense work excuses. Local industry concerns were cited, and this project was abandoned in favor of having most payouts in cash but some payouts in the form of discount tokens for emergency department care. Considering the non-payment rate of the patient population, this form of payout cost virtually nothing. Multiple video games also were placed in the waiting area, and proved to be a huge success, especially with the children of waiting parents. Warning placards were placed on those deemed too violent for children. Warning placards also were placed on children deemed too violent for contact with others. Video game tokens were distributed in exchange for completion of surveys regarding alcohol abuse, spouse abuse, immunizations, access to pediatric primary care, and HIV risk factors. These were attached to patient charts for review during the patient encounter. Two local fast food chains established sites within the waiting area. Patients were issued passes based upon their presenting complaint, and could not buy food or drink if their complaint precluded oral intake. Food services personnel invented creative names for various dishes, such as “Fractured Spare Ribs” and the “Double Bacon Cardiac Burger.” Studies have suggested that patients enjoy watching educational videos in waiting areas of medical treatment facilities. Test screenings of several educational videos produced on site (“Herpes, Your Friend For Life,” “Keep Drinking or You'll Have a Seizure,” “Brush Your Children's Teeth Before They Rot Out”) failed to hold patient interest. On the other hand, first- and second-run movies did exceptionally well, most notably during the four- to five-hour waits of flu season. Movies were viewed at individual stations similar to the pay televisions in airports. “Pokemon, The Movie” was far and away the big cash cow of the project, closely followed by a form of educational video, “Nailin‘ Large Mouth Bass” and “Big Buck Highlights 2000.” Wrestling memorabilia proved to be a slow mover until a well known wrestler was injured while visiting family locally, and collector's items were contaminated with small droplets of his blood and perspiration (after appropriate HIV and hepatitis screening). T-shirts were a huge success, and silk screening was most often related to admission or discharge diagnoses. A few examples, “I'm not fat; I'm pregnant!” “Do you hear the voices, too?” “Just say no to nipple ring infections!” and my personal favorite, “I fractured my liver, and all I got was this lousy T-shirt.” Results: Wow. I mean, wow! Revenues increased by 65 percent after overhead for both the hospital and physician group. Overhead was, of course, leasing the video poker machines, video games, and satellite, as well as buying wrestling memorabilia for sale. A practically criminal markup made up the difference in gift sales and also in movie viewing. The mini-food court did not require franchising, but was simply an extension of local businesses, which shared 20 percent of their take with the visionary group of administrators, physicians, and nurses behind the project. Patient satisfaction scores, as measured by a guy named Karl who asked people if they had a good time, were really high. Really. I have the numbers somewhere, but they were much better than before when Karl wasn't asking them. Staff satisfaction, after appropriate bonus check distribution, also was really high. The initial start-up team managed to reward themselves with a trip to an undisclosed Caribbean island to start contingency bank accounts. Everyone agreed that it was much more fun and rewarding to get paid a lot of money for providing quality medical care. Somewhere along the line, people seem to have forgotten, but study participants gave a big “thumbs up” to income. Interestingly, volume decreased by 25 percent as patients elected to hang out with friends in the waiting room rather than check in. A subgroup of patients who signed in but elected not to be seen were surveyed by triage technicians. Only 15 percent could remember what their presenting complaint had been, and of them, all said they felt better anyway. Nothing, however, is perfect. Three elderly patients attempted to play advanced video games, and developed intractable vertigo from the rapid movement on the screen. One child, otherwise healthy, developed a seizure from the same game, at which point a placard was posted, “Don't have seizures or vertigo if you play this game. Management is not responsible.” One choking event occurred when a patient attempted to eat an entire “Cardiac Burger” in one bite. He was promptly resuscitated. It was fortuitous that this occurred in close proximity to emergency airway support. Five cases of gall bladder disease were precipitated by consumption of fresh fried pork skins, but this was considered a neutral event because it helped identify disease in those patients, and expedited their entry into the health care system. Wrestling memorabilia, combined with the pay-per-view movie “Batting Cage Brawl” unfortunately resulted in a very ugly amateur wrestling match between several intoxicated patrons, in which a man screaming “I'm the Pig Master!” attempted to perform an elbow drop on a police officer who had responded and slipped on french fry grease. Apparently those cans hold lots of pepper spray, which had to be aired out of the department for several hours, resulting in dozens of disgruntled patrons checking in to be evaluated for various medical disorders including boredom. When all was said and done, we also realized that we failed to identify another source of potential income in the form of a waiting room-based dating service. It's bound to happen, so why not turn it into some money? Discussion: What a resounding success! The patients who participated in our little experiment willingly gave up their money for recreation. We suspected it all along. I mean, how many patients have we all seen who said, “I can't get that prescription for amoxicillin until next week. Can you give it to me?” then promptly left to buy beer and cigarettes after discharge. Our plan cut out the song and dance of medical billing. Sure, we still billed them, but they paid up front, in a manner of speaking. No care was compromised, no care denied. In fact, everyone's mood was vastly better, as discussed in the results section. Patients were happier because their visit was fun. Staff was happier because they made more money. Some might say it was greedy or unprofessional. But those are the same people who call violent drunks customers, and who believe that socialized medicine will mean that the “government” from some unknown money tree will pay for everything, and we'll all skip down the yellow brick road arm in arm. Bottom line: More money, more happiness. And to think, I thought research would be boring. For detailed research design or for interest in a franchise of our new corporation, “Emergency Fun Land,” contact me through Emergency Medicine News, [email protected].