the right patient to the right place at the right time. “That’s a laudable goal. In fact, that is a goal that I have pushed for many, many years.” But this model has also driven a lot of what we see today, which is a surplus of resources at the top end of the scale, he said. For example, approximately two-thirds of physicians work in the tertiary, urban environment. Specialists and specialized interventions are increasingly concentrated there. At the other extreme, about 32-35 percent of emergency medicine physicians are non-board certified, and they are more likely to be in smaller hospitals in rural and suburban areas—facilities that have far fewer resources.

Martinez said that the intent of the regionalization model is to identify a certain number of patients in the EMS environment and move them to higher-level facilities. But he said this raises two structural questions. First, does this help a narrow group of patients or a broad group of patients? He would argue that the system helps a small number of emergency care patients quite a lot. However, he estimates that 95-98 percent of emergency care patients get no benefit from this system. While he is a strong believer in having the trauma system focus on those who need it most, the question becomes: what about all these other patients? “We are not focused on those patients right now,” he said.

Second, does this model help or hurt the facilities that participate in regionalized systems? He said he works with 150 emergency departments and many of them are suffering because of what he called a “one-way valve.” Because they have no way to work with the top-end facilities (through telemedicine or other means), a significant number of patients are transferred out. “In fact,” he said, “there are a lot of hospitals where their transfer rates are actually higher than their admission rates.” However, these hospitals only make money on admissions, and “so what is happening is they are dying off.” All those patients who are sick are transferred up, he said, not just for trauma, but often for evaluations, second opinions, and that type of thing. It is really a huge economic shift. “So what’s happening is, we are actually killing the access to care for [a] percentage of the population.”

Martinez asked whether this model is sustainable. Does it help everyone? Does it help just a little bit? “This is what we are putting in the marketplace of ideas.” It is a great idea to get the right patient to the right place at the right time. But the model has been “out there in the market for 30 years. Who is picking it up? Who is saying, ‘This works for me. This is great. I want this’?”

Martinez concluded that if you can’t change the market, and you can’t change the basic funding issues, “maybe what you need to do is change the model, so that all the other players see the benefit.” We are talking about emergency care coordination and emergency care patients, “yet we have been focusing [only] on a small part of that. Maybe we are missing a bigger opportunity.”

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