Washington Post, April 26, 2004
Some Finding No Room at the ER Screening Out Non-Urgent Cases Stirs Controversy by Ceci Connolly
DENVER -- It's not the heart attacks or stabbings that alarm Norman Paradis. It's the minor maladies, the daily deluge of coughs, colds, toothaches and even hangnails that clog his emergency room.
As the provider of last resort, hospital emergency departments across America have for decades accepted thousands of truly non-urgent cases and swallowed the cost. For the most part, the patients have nowhere else to go, no insurance and no money.
That is starting to change. University of Colorado Hospital, where Paradis works, is leading the way on a controversial solution -- weeding out the people with bumps and scrapes so it can devote more time and resources to serious, life-threatening traumas and, also, to paying customers.
Officials here say its 15-month-old system of medical screening, or "triaging out," could go a long way in easing the financial strains that have forced hundreds of emergency departments to shut down in the last decade. But many in the health care profession call it a callous, greedy and shortsighted maneuver that puts a greater burden on neighboring clinics and hospitals -- all at the ultimate expense of the working poor.
Under the new policy, University hospital demands partial payment up front from non-emergency patients who seek treatment in the ER. For some, including Medicare and Medicaid beneficiaries, the fee is a small cash co-payment; insurance pays the rest. For the uninsured, however, the charge can be a few hundred dollars -- money many don't have. So they leave, toting a list of low-cost clinics in the area.
Rather than being a remedy, many argue, medical screening is a symptom of much of what ails America's health system.
"It's an incredibly mean, nasty time to be in medicine," said Mark Earnest, a general internist at University and vice president of the Colorado Coalition for the Medically Underserved. "There is not a consensus on how we are going to take care of people, and the result is everybody having to worry about their own survival."
The experiment at the Denver hospital and similar efforts in Indianapolis and Houston cut to the core of some of the thorniest problems in health care today. With about 44 million uninsured Americans, a record number of patients are flooding emergency rooms, a trend experts say is unwise from both a medical and economic perspective. ER care is both the most costly and least effective at treating the sort of chronic problems that claim the greatest number of lives each year.
In 2002, U.S. hospitals provided $22.3 billion in uncompensated care, up from $18.5 billion in 1997, according to the most recent data from the American Hospital Association. In the past, hospitals have made up some of the deficit by charging insured patients higher fees, a cost-shifting trick that in medical circles is dubbed the Robin Hood model. But that money is disappearing, too.
"We can't do everything for everyone, so what are we not going to do?" asked Paradis, who, as head of University's emergency department, implemented the screening policy in the fall of 2002. Other hospitals, clinics and private physicians find ways to limit care covertly, Paradis contends, while "we are overt. It's rational rationing."
Stop at the Financial Desk
On a recent gray Monday morning, a slow trickle of patients passed through the 11th Avenue emergency entrance of the University of Colorado Hospital. Among them were Molly Turner and Debbie, a 45-year-old woman who asked that her last name not be published because her insurer might object to her ER visit.
Both women had endured a miserable weekend: Turner afflicted with a cough, sore throat and slight wheeze, Debbie with painful hives she feared might be chickenpox. Both women were seen by the top doctor on duty, Norman Paradis. And both cases, he ruled, were "non-emergent" -- not serious enough to require immediate care.
Under the new policy, he explained to each, the next stop was the financial desk, where patients may pay to stay for treatment or leave and get a much smaller bill in the mail for the screening. From there, the two women took different paths.
Turner, 27, a mother of three who sells sod at a local farm, dropped her health insurance when the price hit $390 a month. Informed she would have to pay the hospital $250, she opted to go home and tough out what Paradis said were seasonal allergies.
"You get what you pay for," she said with a shrug afterward. "If I wanted to pay $250 I'd have had the full-blown workup. But he's telling me it's not necessary, so I'm comfortable with that."
Still, Turner was unsettled that Paradis reached his conclusion after just a brief chat and a listen through the stethoscope. "I wanted to say, 'Are you sure? You don't want to do any tests?' " she said. "But he's the doctor."
For her half-hour visit, Turner would get a $50 bill and a list of primary care clinics in the area.
The health insurance provided through the employer of Debbie's husband requires a straight 20 percent co-payment with no deductibles or up-front charges. Because she doesn't have a primary care physician, she decided to stay -- and was pleased with the service.
"I've been to emergency rooms where there are crying babies and the whole drama," she said, seated on an exam table. "I'm amazed how quiet it is."
On average, one-third of the care provided in U.S. emergency departments is "inappropriate," several studies have found. At Houston's Memorial Hermann Healthcare System, the stubbed toes, twisted ankles, leg pains, earaches and abscesses account for nearly 120,000 of the 345,000 visits each year to its eight acute care hospitals, said Tom Flanagan, vice president for emergency services. In an attempt to deal with the crowding, the hospitals instituted a triage system similar to Denver's University hospital, though there is no charge for the initial screening.
"The resources for caring for those patients are very limited," said Brent King, chairman of the emergency medicine department at the University of Texas at Houston Medical School, which is affiliated with Memorial Hermann. "Under the current market conditions, no one can stay in business if they don't somehow limit this load of patients."
At University, Debbie's rash and Turner's allergies are precisely the sort of cases that used to jam the emergency department. In the past six months, ambulances have delivered three hangnail cases to the ER; another person made 165 visits in one year, Paradis said.
"That kind of behavior wrecks the system," he said, and used to force the hospital to divert ambulances to other hospitals hundreds of times each month. Since beginning the screening, emergency room visits have dropped 20 percent, and diversions have been almost nonexistent, Paradis said.
But the desire to redirect minor cases to more appropriate treatment facilities only goes so far. In a perversion of the system, insured patients such as Debbie are welcome to stay, no matter how trivial the problem.
"Because of her insurance, our institution will make money on her visit," Paradis said. "The charges on those cases help us treat the indigent cases."
A Doctor Comes Around
When University began screening ER patients, Kristen Nordenholz was "one of the most recalcitrant and angry" professionals on staff, as she put it. After working five years for the Indian Health Service, which provides comprehensive care for all, she found that ER triaging was "the opposite of what we are trained to do as physicians."
Yet Nordenholz has come around, in large measure because University has given doctors wide latitude in the screening process.
"Many people come just to have their fears alleviated, and they don't understand how expensive emergency medicine is," she said. Now, ER patients "are getting to see a senior doctor, usually within 20 minutes. That's not bad care."
Nurse Jeanie Murray has also come to see walk-ins in a different light. She recalled one young man who showed up for treatment of a sexually transmitted disease. Murray tried to explain that a local clinic would be better suited for his ongoing care, but the man liked the ER's round-the-clock hours.
"It made me mad," she said. "We're not here for his convenience. We're here to treat emergency medical problems."
Often, the patients Murray triages out are people who need a bit of advice about how to treat sunburn or assurance that an over-the-counter syrup should do the trick for their cough. But until those patients have alternatives, physicians elsewhere say it is risky to not give them a thorough workup.
"If we tell people don't come to the emergency department unless you're dying, that's exactly what they'll do," said Arthur Kellermann, a professor at Emory University School of Medicine and chairman of the emergency medicine department at Grady Memorial Hospital in Atlanta. "If no one else is willing to take care of that diabetic, then we are very unwise to turn that person away," because chronic conditions tend to worsen if left untreated.
"We found it offensive," said Dennis Beck, co-president of CarePoint, the physician group that staffs seven free-standing HealthOne emergency departments in the Denver area.
He and partner Stephen Hoffenberg accuse University of steering patients to neighboring hospitals, potentially violating the federal law requiring hospitals to treat every emergency regardless of ability to pay. As examples, they described cases that were turned away from University involving a man with a broken jaw, a student with an infected ear and a patient who fell down a flight of stairs and had neck pain and tingling in one arm. The pair say they are aware of more egregious cases but cannot disclose the details because of privacy laws.
The Emergency Medical Treatment and Active Labor Act, or EMTALA, leaves plenty of room for interpretation, especially on terms such as "emergency" and "treat." Cancer may be a killer, for instance, but a cancerous lump in the breast is not, by law, an emergency. Furthermore, EMTALA requires only that the patient be stabilized.
Federal and state regulators say in the past 15 months they have investigated only a few complaints against University and found one EMTALA violation, due to a billing dispute and missing paperwork, said Sharon Haney, program manager for the hospital section at the state Department of Public Health and Environment.
Shirking Responsibility?
Even if medical screening meets the letter of the law, many say that University hospital, which received nearly $28 million in federal assistance last year, is shirking its larger societal responsibilities.
"University shutting down their emergency room says to these people, 'Go somewhere else.' But the somewhere-elses are already overloaded," said Kraig Burleson, chief executive of the Inner City Health Center, a low-cost clinic.
Many in the community say they would not have an issue with triaging patients out of the ER if University could make them appointments at a more appropriate facility, as the city-funded Denver Health does.
"We do over-utilize our emergency rooms, " said Lorez Meinhold, executive director of the Colorado Consumer Health Initiative. "But a piece of paper" listing local clinics "is not access to care."
At St. Anthony's Hospital, just a short drive from University, the uncompensated care tab has nearly doubled in just two years, said Jay Picerno, chief operating officer of parent company Centura Health. Though he does not have hard statistics, doctors and nurses say part of the increase is due to the change in policy at University.
Picerno believes its ER problems stem from poor financial management, rather than too many "walking wounded," as he put it. "What are they doing with these [government] funds?"
State Rep. Debbie Stafford, Republican vice chairman of the legislature's health committee, said she has heard numerous complaints from other area hospitals and is examining ways to redistribute some of the federal money University receives to other hospitals.
The doctors and nurses at University do not argue with many of the complaints. They say they were confronted with a nearly impossible situation as uncompensated care costs rose from $31 million in 2001 to $65 million last year.
"In the ideal world, you would not want to do medical screening," Paradis said. "But when the core mission is at risk, this is an acceptable tradeoff."
- - - - - John Lacny http://www.johnlacny.com
People of the US, unite and defeat the Bush regime and all its running dogs!