Posted: January 4, 2010

James Dudley MD
Emergency Medicine,
Riverside Tappahannock Hospital
 
Chairman of the Riverside Medical Group Board of Directors, Dudley is also service line chief of the Tappahannock Division of Riverside Medical Group and a member of the Medical Staff of Riverside Walter Reed Hospital in Gloucester. He is the local medical examiner for the commonwealth of Virginia, board member and past president of the Virginia College of Emergency Physicians, and chief medical adviser for the Virginia Association of Volunteer Rescue Squads. He served four years as a member of the Governor’s EMS Advisory Board for the Commonwealth of Virginia. He is a graduate of the Univeristy of Virginia, Eastern Virginia Medical School and Virginia Commonwealth University and did a family practice residency at Riverside Regional Medical Center.
 
What is one aspect of the current system that works well and shouldn’t be changed?

From the view of an emergency department doctor working in the trenches, the best part is that we are given the honor of taking care of people who need our help, regardless of their insurance status, position in society, ability to pay, and are allowed to do so with the sole focus of providing for them in the best manner we can.
 
From the health system perspective, [the best part is] we are able to offer emergency care as one of our core services and we are able to do this in spite of the often-negative financial impact the ED has on our bottom line. We do this, of course, by charging more from our paying customers to make up for the 25 percent who pay nothing yet receive the same services.
 
What is the biggest problem with the current system in need of change?

As an American society, we have never answered the fundamental question if health care is a right or a privilege. On the one hand, we have 45 million to 50 million uninsured and many more underinsured. On the other hand, we have a federal law that requires that any emergency department that participates with the programs of CMS, provide a medical screening exam and stabilization for any emergency medical condition, regardless of the ability to pay, and further requires that if an emergency department is unable to provide such stabilization, that we will arrange for a transfer to a hospital that can provide such.
 
Culturally we have become a society with tremendous, often unrealistic, expectations of the health care system. We want it perfect every time and we want it now. We want answers to questions without regard to cost. This contributes to doing more and more testing with less and less return on the dollar spent.
From a state level, we have huge budget issues to manage … given the uppopularity of raising taxes to cover the costs of services provided in the Medicaid program.
 
As a health system, we are obligated to provide services to all and then try to manage the expenses and revenue in a way that keeps us solvent. Accordingly, we become experts in just-in-time inventory management and struggle to manage our staffing models to manage our costs yet still provide first-rate services.
This leads to thinner and thinner margins as we get better and better at this type of operation. The downside of this is that we have no surge capacity and our safety-net function, as we contemplate pandemic response and manmade and natural-disaster response, becomes more and more tenuous.
 
As doctors, working in the trenches, we look after people who are the working poor, uninsured, who are charged full price, while the uninsured are offered deep discounts on services. We are faced with social problems that we do not have the tools or resources to manage. We are faced with homelessness, addiction, mental health issues, and can offer those individuals little more than a meal and a pat on the back.