Emergency Rooms

COVER: "If This Is An Emergency, Please Go To Your Nearest Emergency Room"

Guy Clifton M.D. — Thu, 10 Apr 2008 11:07:00 -0400

You may have seen the reports this week, on a recent journal article that the crowding we keep hearing about in emergency rooms is not the uninsured poor after all. That doesn't mean that the uininsured aren't going to the emergency room because, all too often, they don't have anywhere else to go. But everyone else is going too. After all, if you call your doctor at night or on weekend, doesn't the voicemail prompt caution you: "If this is an emergency, please go to the nearest emergency room"?

The number of people who visited U.S. emergency departments began to surge in about 1996, and visits have not decreased since then. From 1992 to 2002, the U.S. experienced a 23 percent increase in emergency room visits -- at the same time as the number of emergency rooms dropped by 15 percent. The population, meanwhile, grew by roughly 10 percent.

We've known for some time that emergency room overcrowding is not driven by the uninsured. The recent survey, in fact, found that the uninsured are less likely to visit emergency rooms than either Medicare or Medicaid patients, probably because ER care is expensive and they try to avoid the expense if they can. Communities with the highest emergency room use are not those with the highest uninsured rates but those where people have to wait the longest time for an appintment at a clinic or doctor's office.

The real driver of emergency room overusage as the authors of the Annals paper have found is...everyone. Look around the ER and you'll see Medicare patients, Medicaid patients, privately insured patients, and of course the uninsured. The percentages of these groups visiting ERs has scarcely changed over the decade. It's just that the total visits by all of them have increased out of proportion to the population increase (and remember we have fewer ERs for them to go to).

The people whose reliance on emergency rooms increased was those who actually did have a usual source of care in a physician's office -- but who couldn't necessarily get in when they needed to -- or wanted to. The uninsured go to the emergency room for care when they have no other option. (And yes, of course we need to address their needs through comprehensive health reform, ERs are not the right place for basic care economically or medically.) The insured, however, turn to the ER for convenience or because, like the uninsured, they may have fewer choices than they used to have. If you have a regular doctor, have you ever called his or her office after 5 pm or on Saturday or Sunday? The answering machine usually says, "If you think you have an emergency, go to your nearest emergency room."

The emergency room is a barometer of our whole system's problems. ER overcrowding is the result of an entire nation that is displaced from regular medical care. The emergency room has become the default provider. Can you imagine a less efficient way of delivering health care?

COST: Dealing With Financial Crises in Our Trauma System

Guy Clifton M.D. — Tue, 01 Apr 2008 21:07:00 -0400

Increasing financial strains are pushing Level I and II trauma centers to the point of breaking, according to a recent article on Grady Memorial Hospital— the only Level I trauma center serving Northern Georgia, which loses over $40 million a year on trauma care. The problem is simple: the trauma services rendered to the uninsured are uncompensated, and the revenue generated from treating the insured is not enough to cover the deficit. The solution is clear: we must cover all Americans to financially stabilize our trauma care services in this country.

In 2004, over 112,000 Americans died from unintentional injuries—such as car crashes and falls—and another 17,357 were victims of homicide. A 2003 survey in JAMA of trauma centers in the U.S. found that only 453 hospitals or about 10 percent of all hospitals were classified as a Level I or Level II trauma center and thus qualified to treat these life-threatening injuries on a 24/7 basis. While many hospitals carry designations that qualify them to treat patients with lesser injuries—such as broken legs and concussions—the Level I and II hospitals are a key community resource, and thus their peril warrants our serious concern.

Emergency care in the US is governed by the Emergency Medical Treatment and Active Labor Act (EMTALA). This legislation requires hospitals and doctors to treat patients judged to have a life threatening emergency, regardless of their ability to pay. Practically and ethically it could hardly be any other way. We all look alike covered in blood on a stretcher.

EMTALA means that trauma hospitals admit and treat all members of their community. In communities with a high percentage of uninsured, trauma hospitals lose money because the revenues from treatment of insured patients are not enough to offset the losses from the care of uninsured patients and the hospitals become financially unstable.

The predominant means of stabilizing the trauma system in states with a high percentage of uninsured is to provide dedicated funding for trauma care, as Georgia is now considering including $10 fee on auto registrations that would generate about $74 million a year. The financing of trauma care is complicated by the fact that about 20 percent of Level I and II trauma centers are public hospitals, and often are also academic teaching hospitals such as Grady Memorial Hospital.

Over the last decade, federal funds that supplement local funding of public hospitals have progressively declined. The budget submitted by President George W. Bush proposes to cut $25 billion in "disproportionate share" payments to hospitals serving predominantly poor patients and cut $23 billion more to teaching hospitals. These hospitals are already losing money, yet required by law (and a sense of what's right) to treat uninsured patients.

As long as there are 47 million uninsured in the United States, maintaining a stable trauma system will be a constant struggle. Coverage for all Americans is ultimately the only means of stablizing the financial staus of key emergency hospitals in the U.S. and thus stabilizing the system of emergency care.

QUALITY: Ambulance Diversions are Tip of Emergency Care Iceberg

Guy Clifton M.D. — Wed, 26 Mar 2008 18:24:00 -0400

What happens when your local emergency room is full? For a troubling number of Americans, the ambulance is put on diversion and forced to seek the nearest hospital with open beds. These diversions were the focus of a recent article in Seattle Times and, more importantly, are a warning of the troubling times ahead for our over-burdened health care system.

The Seattle paper told the story of Sara Nakagawa, who had complications 10 days after gall bladder surgery. She waited in an ER for six or seven hours,without being seen, went home and dialed 911. The ambulance then spent 20 minutes parked near her home trying to find a place that would take her. Later, the same thing happened to her 12-year-old stepson in the midst of an acute diabetic crisis.

Ambulance diversion was rare before 1999, but it has since become increasingly prevalent and dangerous. Every minute, one ambulance is diverted from a U.S. hospital, according to a 2006 study in the Annals of Emergency Medicine. A study of New York City hospitals found that periods of ambulance diversion were associated with a 47 percent increase in the mortality rates for heart attacks.

While the effects of ambulance diversion are increasingly apparent, the origins of our current crisis are systematic and date back to the 1990s with the rise of managed care and the Balanced Budget Act of 1997. The calculus of managed care led many hospitals to cut beds, while the budget law meant that the federal government reduced its payments meant to partly reimburse hospitals for treating the uninsured (care that occurred largely in emergency rooms). This one-two punch left hospitals with too few beds and too little money to face an increased demand for emergency services, resulting in the overcrowding of emergency rooms and the diversion of ambulances seen today.

The U.S. has been in the midst of a hospital building boom, but the evidence is that it has focused on high-margin operations such as back surgery, orthopedic surgery, and heart surgery and not on the kinds of services needed by patients with emergency medical conditions, which are less profitable for hospitals.

The nation's emergency services system in most communities is a patchwork of ambulance services all working in isolation taking patients to a group of hospitals that don't talk to each other.Coordination of services is not only crucial to curbing ambulance diversion, but, more broadly, it is a principle for reforming our health care system as a whole. Electronic medical records, medical homes, and host of other reforms have the potential to ensure that individuals have access to the right care when they need it, making sure their primary care physician manage their heartburn and their the ER can manage heart attack.