Money will be lost in health care. This is true no matter how we describe it.

By | December 3, 2018

Does anyone in medicine, particularly emergency medicine, understand why we lose money? Why we have to push those metrics so hard to capture every dime?

I mean, we’re constantly reminded that satisfaction scores, and time-stamps and time to door, time to needle, time to discharge, reduced “left without being seen” scores are connected to the money we make.

Medicine now is far less about the wonder of the body, the ravages of disease, the delight of the diagnosis and the thrill of healing.

Medicine, now, is clicks and time-stamps, clipboards and strategies, through-put, input, out-put, put-out, burned out.

I don’t know about all of the house of medicine. But I do know this.  When we, in the emergency departments of the U.S., see everyone at all hours, regardless of payment, then money will be lost.  This is true no matter how we describe it, no matter how we twist the truth to cover up reality with good feelings.

And thus, patients who actually do have a payer source will be squeezed tighter.  And every metric will be ratcheted down to try and make up for the very unrealistic ideas that we can:

  1. see everyone, anytime, regardless of the validity or reasonableness of their complaint.
  2. see everyone, anytime, regardless of the fact that many of their problems are social dysfunction, medical non-compliance with things already done to them for free, drug seeking or the desperate need for a work excuse
  3. see everyone, anytime, regardless of whether or not we will make any money for the transaction
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No matter what you do with the rules and time expectations, the satisfaction scores, the consulting schemes, the computer programs or anything else, eventually you’re faced with the reality that you’re giving away care.  Sometimes to those who really need it. Often to those who don’t.

Worse, this occurs in fixed spaces, in hospitals where there is no more money for staff or space.  In a setting where there is no fixed number of patients and no fixed end to the need (or desire) for resources.

When reality meets business (and political) theory, then frustration and anger develop. Patients get angry because of cost (in money or time), or because they were told “no.” (I’m just joking there. Who gets told no in an age of customer satisfaction?)

Physicians and nurses get frustrated because the game is fixed. It cannot be won.  Do better?  More is expected.  Do worse?  More is expected, but the threat of firing looms.  So that a new group of physicians and nurses can try, for a while, to continue to do the impossible.

And administrators become frustrated, and angry.  Because however hard we try to make it work, it can’t.  Eventually, something breaks.

This can’t go on.

But we just keep on pretending it will.


Edwin Leap is an emergency physician who blogs at and is the author of the Practice Test and Life in Emergistan

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