Health Care Overhaul May Mean Longer ER Waits, Crowding

CHICAGO — Emergency rooms, the only choice for patients who can't find care elsewhere, may grow even more crowded with longer wait times under the nation's new health law.

That might come as a surprise to those who thought getting 32 million more people covered by health insurance would ease ER crowding. It would seem these patients would be able to get routine health care by visiting a doctor's office, as most of the insured do.

But it's not that simple. Consider:

_There's already a shortage of front-line family physicians in some places and experts think that will get worse.

_People without insurance aren't the ones filling up the nation's emergency rooms. Far from it. The uninsured are no more likely to use ERs than people with private insurance, perhaps because they're wary of huge bills.

_The biggest users of emergency rooms by far are Medicaid recipients. And the new health insurance law will increase their ranks by about 16 million. Medicaid is the state and federal program for low-income families and the disabled. And many family doctors limit the number of Medicaid patients they take because of low government reimbursements.

_ERs are already crowded and hospitals are just now finding solutions.

Rand Corp. researcher Dr. Arthur L. Kellermann predicts this from the new law: "More people will have coverage and will be less afraid to go to the emergency department if they're sick or hurt and have nowhere else to go.... We just don't have other places in the system for these folks to go."

Kellermann and other experts point to Massachusetts, the model for federal health overhaul where a 2006 law requires insurance for almost everyone. Reports from the state find ER visits continuing to rise since the law passed – contrary to hopes of its backers who reasoned that expanding coverage would give many people access to doctors offices.

Massachusetts reported a 7 percent increase in ER visits between 2005 and 2007. A more recent estimate drawn from Boston area hospitals showed an ER visit increase of 4 percent from 2006 to 2008 – not dramatic, but still a bit ahead of national trends.

"Just because we've insured people doesn't mean they now have access," said Dr. Elijah Berg, a Boston area ER doctor. "They're coming to the emergency department because they don't have access to alternatives."

Crowding and long waits have plagued U.S. emergency departments for years. A 2009 report by the Government Accountability Office, Congress' investigative arm, found ER patients who should have been seen immediately waited nearly a half-hour.

"We're starting out with crowded conditions and anticipating things will only get worse," said American College of Emergency Physicians president Dr. Angela Gardner.

Federal stimulus money and the new health law address the primary care shortage with training for 16,000 more providers, said Health and Human Services Department spokeswoman Jessica Santillo.

But many experts say solving ER crowding is more complicated.

What's causing crowding? Imagine an emergency department with a front door and a back door.

There's crowding at both ends.

At the front door, ERs are strained by an aging population and more people with chronic illnesses like diabetes. Many ERs closed during the 1990s, leaving fewer to handle the load. The American Hospital Association's annual survey shows a 10 percent decline in emergency departments from 1991 to 2008. Meanwhile, emergency visits rose dramatically.

At the back door, ER patients ready to be admitted – in hospital lingo, ready to "go upstairs" – must compete for beds with patients scheduled for elective surgeries, which bring in more money. "If you've got 10 ER patients and 10 elective surgeries," Kellermann asked rhetorically, "which are you going to give the beds to?"

That's why easing crowding will take more than just access to primary care. It also will take hospitals that run more efficiently, moving patients through the system and getting ER patients upstairs more quickly, Kellermann said.

Ideas that work include bedside admitting, where a staffer takes a patient's insurance information as treatment starts.

That and other strategies are being tried at St. Francis Hospital and Health Centers in Indianapolis. There, the performance of nurse managers is measured by how long admitted patients wait in the emergency department for a bed upstairs.

And to stave off inappropriate ER visits, the hospitals have opened after-hours clinics staffed by primary care doctors to handle patients who can't leave work to see a doctor, said Indianapolis hospital executive Keith Jewell. ER wait times have fallen.

A Chicago hospital, too, is readying for the onslaught of ER patients. On the city's South Side, Advocate Trinity Hospital handles 40,000 emergency visits a year and is expecting more because of the new law.

Greeter Stephanie Bailey makes sure patients don't get frustrated while they're waiting. She can take their vital signs and inform staff if the patient is about to leave without treatment.

Inside the emergency department, a giant sheet of paper hangs on a wall. It's hand-lettered in orange and purple, and tracks daily progress on hospital goals: How many patients left before they were treated? How many minutes did patients stay in the ER?

On a recent day, the note said "0.0 percent" of the patients left without treatment. Someone had added a smiley face. But there was no smiley face next to the average ER length of stay for the same day – nearly four hours. The hospital's goal is three.

Comments

[rad21]

11:01 PM on 07/17/2010

Like all insurance, the costs are distributed. As in education, the poor and middle class has palmed off their healthcare duties to the SYSTEM. The middle class would rather pay the SYSTEM than care-for / address / solve many issues themselves. All this contributes to WASTE.

Between not being covered and having a high deductible and co-pays if covered, the middle class are very vulnerable. Yet like in many situations, we are our own worst enemies. We all need to SAVE the burden of healthcare and SHARE its reduced cost. Here are suggestions:

1. Preventive Care - Stop smoking. Exercise and Prevent obesity and other illness with proper diet and life style. Regular medical check-ups.

2. Care for elderly parents, uncles and aunts; thus saving hospital and nursing home costs. End-of-life care, (last few months), account for 30% to 40% of costs.

3. Help relatives manage their chronic illness which accounts for 75% of costs and responsible for 70% of deaths.

4. Dissuade relatives, neighbors and friends from making hospitals' ER the first line of care - a very expensive way to access healthcare.

5. Doctors and Hospitals have to end the 40% of over-treatment, under-treatment and in-appropriate treatment .... without further excuses of why it occurs.

6. Health industry - Insurers, Providers, Pharma, etc. need to half their overhead cost of 30+%.

We should stop blaming Govt. and take-over at grass-roots by doing the right thing, even if inconvenient.

[rad21]

10:58 PM on 07/17/2010

Another example of the making an issue when none exist. The Emergency Medical Treatment and Active Labor Act, passed in 1986, requires all hospitals to treat every patient seeking emergency care regardless of the patient's immigration status or ability to pay.

Yes ER must deliver emergency care irrespective of ones ability to pay. But most ER patients are not emergencies. And cost to care for the non-emergency patients in ER is 10 times more than seeing the patient in a physicians' office.

This article along with some congressmen and hospitals are pushing for govt. funding.

How should hospitals discourage non-emergency use of ER? With all hospitals in the area and local media (TV and print) embark of a campaign for all residents of the area to choose their own primary care provider. Charge up-front all patients seeking care in the ER. Non-emergency patients after an evaluation would be directed to their own primary doctor for prescriptions and follow-up care.

Will the hospitals do this? Why should they when they can be on the government gravy-train, while serving us with high platitudes?