Portal de Periódicos da CAPES

Saving the Safety Net

2002; Lippincott Williams & Wilkins; Volume: 19; Issue: 1 Linguagem: Inglês

10.1097/00132981-200201000-00001

1552-3624

Ruth SoRelle,

Healthcare Policy and Management

It's a chain reaction that's reaching meltdown in emergency departments around the United States and even the world. In the end, meltdown will mean that everyone — not just the uninsured — will find their health in jeopardy because EDs have become by default the nation's health care safety net. Perhaps it begins in a boardroom when bottom line managers decide to cut payments to hospitals. In reaction, hospital administrators close beds and lay off nurses and health care staff. In the middle of flu season, patients fill the already overburdened emergency department and the beds upstairs. Eventually, there are no more beds for admissions, and patients are boarded in the emergency department until one can be freed. The boarders squeeze the emergency department's ability to respond to true emergencies, and finally has to go on diversion until the squeeze is over. It's a scenario that puts some emergency departments on diversion more than once a week. It is a big problem that is unlikely to be solved soon in a nation unwilling to look for big solutions.FigureWes Fields, MD, the chairman of the board of California Emergency Physicians Medical Group, recognizes that at least 45 million Americans lack any kind of health insurance — public or private. “That group is low-income, hard-working families. They are not freeloaders, and their use of emergency departments is quite different from other kinds of patients,” he said. Dr. Fields discussed the eroding safety net and the role the emergency department plays in it during a presentation at the Scientific Assembly of the American College of Emergency Physicians in Chicago in October. Employed and Uninsured Because the uninsured are employed for the most part, they know they are responsible for their bills and, if anything, wait too long to seek care, said Dr. Fields. Looking at data from the National Center for Health Statistics, one can find that the uninsured for the most part use emergency departments with the same frequency as the rest of the U.S. population, he said. “The uninsured come less frequently than they should and tend to be sicker when they show up,” he said. As a class of payer, some try to pay their bills and others don't even make an effort, which is understandable, Dr. Fields said. “These are people who have to decide between paying the rent and paying the doctors and hospitals.” For patients who have more serious illnesses or injuries, he said, the cost of the prolonged hospital stay, the loss of work, and subsequent disability can be devastating for a family. It can result in a bankruptcy or financial disaster. Federal data show that 94 percent of all hospitalizations for the uninsured occur after an emergency department visit, he said. “That shows how crucial EMTALA [Emergency Medical Treatment and Active Labor Act] is. It's the ultimate guarantee or assurance that uninsured people without regular access can get care if they get sick or hurt badly enough. EMTALA and emergency physicians are their safety net for those major illnesses and injuries that require hospital care. The same thinking comes into play in terms of their ability to access a specialist or high-tech care. The emergency department becomes the safety net in terms of accessing specialty care and physicians.” Underpayments for Care Dr. Fields said the cost of treating the uninsured is only part of the care for which hospitals and physicians are not fully compensated. Underpayments by Medicaid and private insurers far outweigh the burden of the uninsured, he said. “The net effect of the last 10 years of managed care reform means that hospitals and emergency physicians are seeing three buckets of uncompensated care problem — the numbers of dollars lost for services to members of Medicaid programs and members of commercial insurance plans as well as the uninsured. On a proportional basis, there are just as many dollars lost from those categories as services to the uninsured.” The result is a safety net in crisis with emergency departments saturated with patients or on diversion. “There is simple arithmetic that the public and the general policymakers need to understand. This is not a crisis of access for the uninsured. You have a problem with access even if you have good insurance. “The threat to access is the result of 10 years of hospitals and emergency departments closing. There is an ugly mismatch between the hospitals' ability to provide timely emergency care, whether as a community service or to meet EMTALA requirements, and their ability after the fact to match enough revenue to pay for services that get provided,” said Dr. Fields. “Unlike the rest of the health care system, we provide the services first rather than ask how they get reimbursed.” Hospitals' abilities to cross-subsidize the care of the uninsured or underinsured from other payer classes have eroded as the federal government and private insurers have increased their ability to match the cost services to the number of services actually provided. Now, the nation is in a real problem with resources. “We are really struggling now to cover the direct cost of the services provided,” he said. The solution has to be pragmatic, at least for now, said Dr. Fields. “Everyone understands this is an essential public service. If everyone knows how important access to emergency services is and if everyone wants it available when they need it, we need to figure out as a society how we are going to pay for it.” EPs as Advocates The problem is complicated by the fact that emergency services are provided up front, while most other services are “pay-as-you-go.” To get the message across, he said, the American College of Emergency Physicians and its members need to become advocates, collecting the needed data, communicating the problem to the public and decision-makers, and advocating a solution. As advocates, emergency physicians need to gather other groups with the same interests. “It's important for the college to get out in front of expanding coverage at the margins,” he said. One solution might be expanding the State Children's Health Insurance Plans to cover parents and others at the margins. Just getting the eligible children covered by allowing them to be enrolled when they show up at hospitals might go a long way to ensuring access for youngsters, he said. “We also need to find a way to make sure these safety net facilities that provide disproportionate amounts of uncompensated care get their costs covered,” Dr. Fields said. “This can make the difference between a hospital staying open or closed or between an emergency department staying open or closed. If we can't insure everyone and operate emergency departments, the next best thing is to at least figure out how to pay for the system so that an essential public service gets delivered in a reliable way. “Basically, I think if the safety net is at risk and we can't insure everyone, the college members need to be in front at the state level to find creative solutions to generate new revenues for the emergency system, some mechanisms before or after the fact to earmark new money to flow as directly as possible to the places where it is needed the most seriously.” It may vary by state, he said. In California, a bill sponsored by the California Medical Association as well as the California College of Emergency Physicians pushed to put $300 million more into a fund for emergency medical services. Maximum Response The nation is currently concerned with disaster preparedness, said Susan Nedza, MD, an emergency physician at Elmhurst Memorial Hospital in Illinois and the EMS medical consultant to the state of Illinois Department of Public Health. The emergency department is as much a part of that as the fire and police departments and the emergency medical services, she said. Yet emergency departments have to be ready to respond to any emergency, but no one is willing to pay for that standby time. “It is not covered in reimbursements,” she said. However, every person wants to be assured that his emergency will get the maximum response, Dr. Nedza said. Yet without a method of taking care of those costs, she said, such services may not be available. Charlotte Yeh, MD, an emergency physician in Boston and a former chairwoman of the ACEP task force on health care for the uninsured, also expressed concern about maintaining the viability of the emergency department as a key component of the safety net. “This is as much a crisis as bioterrorism,” she said. “Those are sporadic and real threats [while] the threat of diversion and boarding is day-to-day right now. “As we are spending money on preparedness for bioterrorism, some of that money should go to rebuilding the infrastructure so we can rebuild our day-to-day capacity,” said Dr. Yeh. Improving emergency departments' ability to care for patients while collecting data and monitoring the systems' status are critical so that “we can identify trends earlier than we do now.” Most individuals do not recognize that the health care industry is not a drain on the economy but instead contributes to it by employing large numbers of people and using supplies, for instance. In cutting such services and the payment for them, the nation has been shortsighted, she said. Payments are figured based on a steady use of health care facilities, but that is not reality. Often, the need for health care will spike with illnesses such as the flu or sudden physical disasters. “The health care system should be modeled the way that many businesses with varying demands are,” she said. “That has never been applied to health care.” The problems in Massachusetts where diversions are a daily occurrence are so dire that Dr. Yeh worries about making it through the next year. “We are hoping for a mild flu season like last year,” she said. She has been part of a task force trying to quantify the problem of diversion and boarding in hospitals in her state and propose solutions for the long and short-term. “As I see it, the crisis with boarding inpatients and the crisis of diversion and the access to care for the sickest affects all Americans. We thought it only affected the uninsured. Because of our failure to address it, it is now affecting middle America — it's affecting you and me. I'd hate for it to come to a crisis because of some big event.”