Miami Herald August 9, 2004
Inside the ER: Some can pay. Some can't. Some patients can pay for emergency-room care. Others can't. That's the problem. by John Dorschner
Monday mornings are the busiest times for emergency rooms, and shortly after 11 a.m., the radio at the central nurse's station at Homestead Hospital squawked: A traffic accident victim was two minutes away. Twenty-five-year-old male. Abrasions right shoulder and face.
The radio barked numbers: Blood pressure. Pulse rate.
Paul Edwards, the head nurse, scribbled them down.
The double doors to the ER slammed open, and the blue-suited rescue team raced in with a gurney.
Dennis Salazar, a physician, rushed to the gurney and peered down. The man's face and shirt were caked with blood.
"He hit a car," said Fire Rescue.
"What?"
"Yep. Walked out of a cantina and straight into a car going down the street."
Salazar sighed. He's seen dozens of people like this. "Payday. Migrant worker. I'll bet there are a bunch of bills in his wallet. Drank all night. His insurance is what we call Mutual of Homestead.''
He meant the man had no health insurance, and Homestead Hospital would be stuck with the cost. The facility is in an impoverished area where one in every four of its ER patients don't have insurance. Another two in five have low-paying Medicaid, the government program for the poor. Only 20 percent have private insurance.
Cut, switch, to a Thursday morning at Kendall Regional Medical Center, 24 miles from Homestead in a thoroughly middle-class neighborhood, much like the national average, with 13 percent uninsured and another 13 percent on Medicaid. Fifty-six percent have private insurance.
A hospital staffer was pushing Rosey Suarez in a wheelchair into the ER. Her bare right foot was reddish and swollen. "Been bothering me for three weeks. Might have been from a fall. I decided I needed to do something. It's been getting worse. Maybe it's broken.''
She didn't know what doctor to go to, and so she chose the nearest ER. She wasn't concerned about the cost: She had good insurance, UnitedHealthcare, through the bank where she worked.
POLAR OPPOSITES
These two patients, Suarez and the unidentified man who walked into the car, represent polar opposites in the patients who are seen in America's emergency rooms, the place where all of America's healthcare woes come together.
By federal law, no person can be turned away from an American emergency room. The patient must be treated and stabilized, regardless of his or her ability to pay.
To see how the ER functions, a Herald reporter and photographer spent 12 hours each at the two hospitals, one that struggles with patients that can't pay, the other in a typical middle-class suburb. Later the hospitals provided financial information on the cost of care during the period when The Herald team visited.
As it turns out, the Rosey Suarezes of the world and their employers end up paying for all the uninsured guys who walk into cars.
''Hospitals are big Robin Hoods,'' says Jim Petkas, chief financial officer for HCA's East Florida hospital division, which includes Kendall Regional. "They take from the rich, and they give to the poor.''
Though that may seem patently unfair to the Rosey Suarezes and their employers, it seems at least on the surface to keep the system working. But for how long?
OUT OF BALANCE
''The problem is that the system is not in balance,'' says Brian Klepper, head of the Center for Practical Health Reform. "It's eroding.''
In 1989, 80 percent of all full-time workers had medical benefits, according to the U.S. Bureau of Labor Statistics. By 2003, that had shrunk to 56 percent, and experts expect that shrinkage to continue.
''This is not a sustainable business model,'' says Brian Keeley, chief executive of the nonprofit Baptist Health South Florida.
"The more we rely on private insurance, the more expensive it becomes, and the more expensive it is, the less and less people can afford it. That's particularly true in South Florida, where we have mostly mom-and-pop employers. They can't afford the premium, so they opt out.''
So far the system seems to have worked at Kendall Regional, where more patients had private insurance. It had a healthy profit of $29.6 million on net revenue of $171 million in 2003, according to state financial data.
But Homestead lost $800,000 in 2002, according to state data, and its executives say it will lose close to $11 million this year. But Homestead is part of Baptist Health, with several hospitals in the affluent southern suburbs. The system had a net return of $95 million in 2002, according to state data.
PROBLEMS IN COMMON
Despite their financial differences, the two hospitals share some basic characteristics. As with many hospitals across the nation, both Homestead and Kendall Regional have seen their numbers of ER patients climb steadily in recent years. They are frequently overcrowded.
Homestead's ER patient load has increased 30 percent in the past seven years -- to 100 a day. It is constructing a completely new hospital, costing $130 million, with an ER triple the size of the existing facility.
Kendall is even busier. Its ER visits have more than doubled in the past six years -- now averaging 150 a day -- and the hospital is planning a $110 million hospital expansion that would increase the size of its ER five-fold.
In both places, staffers superstitiously don't like to utter the ''Q-word'' when the day seems quiet because they fear they'll be instantly overloaded.
Some complain of ''granny dumping'' just before three-day holiday weekends, when relatives drop off aging relatives, particularly those on the road to Alzheimer's, so they can enjoy their days off.
In Homestead and Kendall, as almost everywhere, Monday mornings are the busiest time. Staffers theorize that some folks don't want to waste their free time, and so they wait until they're supposed to go back to work before seeking medical help. Or maybe it ''legalizes a sick call,'' as one staffer put it. Or they call their doctor on Monday morning and find they can't get an appointment for several days. Or they drink too much or get too much sun on the weekend.
Here is an inside look at what our reporting team found in the two emergency rooms:
HOMESTEAD
On this Monday morning in Homestead, the waiting room is perhaps half-full of listless people watching Bob Barker boom on The Price Is Right: "It's a new car! A Ford Explorer XLS!''
Staffers avoided the ''Q-word,'' but the day started slowly. Even so, the 14 ER beds were filled: a middle-aged woman with a severe migraine; a man with a chest pain; a HIV-positive woman with complications; a 33-year-old man with sickle cell anemia suffering from pain and dehydration; a woman in her 40s with Down's syndrome who had congenital digestive track problems; and several elderly patients who were quiet clumps in beds.
In the waiting room, Susana Sanchez, 21, was curled in a chair, her head resting on her husband's shoulder. Five-and-a-half-months pregnant, she had a sore throat and had been coughing and vomiting for three days, unable to eat. She had two kids at home, no health insurance and no regular doctor.
She came to the ER because she had no place else to go. ''I need something,'' she said softly.
Like many of the 43 million uninsured Americans, she avoided primary care because she couldn't afford it and waited until her condition worsened and she ended up in the ER, where treatment tends to be considerably more expensive. According to the Center for Studying Health System Change, the number of visits by uninsured people to physicians' offices dropped by 36.9 percent during a five-year period, 1996-2000, while their visits to ERs climbed 10.3 percent.
If Sanchez weren't pregnant, she could have been seen quickly in the ER's Fast Track Unit, which has a doctor and dentist-style chairs for less severe cases. Fast Track is quicker, but not cheaper: Though it is called an urgent care center, billing is still done as an ER visit. That means those people with insurance might find a co-pay of $100 for the ER, rather than $15 for urgent-care.
But as it is, Sanchez was both pregnant and not extremely sick by ER standards, which meant that, though she arrived at 8:30 a.m., she was still in the waiting room in the late morning.
Meanwhile, inside the unit, Salazar was examining the man who walked into the car. The hospital would not release his name, and so we will call him Cantina Guy.
Salazar ordered a ''rainbow of tests'' for him, meaning everything imaginable, including a complete blood workup and CT-scans of his head, neck and chest, searching for broken bones or ruptured organs. Since he appeared unconscious or in a deep sleep, he couldn't say where he hurt and the doctor had to guess. A nurse put a neck brace on him as a precaution. An aide went through his pockets and, as Salazar predicted, found a wad of payday cash.
The man moaned. ''Cerveza!'' he demanded. Salazar shook his head. This guy didn't need another beer.
The day was just getting started. Shortly after 11 a.m., an ambulance crew rushed in an elderly man with high blood pressure. ''I don't have a place for him,'' said Edwards, the head nurse. He asked Clifford Cook, 33, the sickle-cell patient, to slide from his bed to a chair. Cook obliged, even moving his IV stand himself.
Moments later, another ambulance crew brought an elderly man from a nursing home, where he was reported to be disoriented and lethargic. A nurse walked up to him with a chart. "Sir, do you know your height and weight?''
''Yes!'' said the man with an amazed expression, as if he couldn't imagine who wouldn't know such basic information. Then he lapsed into silence.
Shortly after 1:30 p.m., Cantina Man was wheeled back from radiology. Apparently, he awoke during the tests, because basic personal information was now on the chart. Under social security number, someone had written: 777-77-7777. Meaning he didn't have one. Illegal alien.
Salazar shook his head when he examined the blood work. His alcohol level was 409.8. The doctor translated: "Forty percent of his blood is alcohol.''
A nurse said she didn't believe humans could live with that level. Salazar shrugged. The guy seemed to be sleeping peacefully.
Trained in Costa Rica, a veteran of ERs in Oklahoma, Salazar has come to embrace Homestead. "I love it here. This is a very unique little hospital. This is still in the United States, but it's frontier medicine.''
New cases kept coming through the ambulance bay. In the waiting room, Sanchez, the pregnant mother, was wrapped in a blanket, snoozing, oblivious to Dr. Phil, who was introducing his next guest: "She has gone from a Size 20 to . . .''
At 3:30 p.m., the radio blared that Fire Rescue was on its way with a woman from a halfway house for the developmentally disabled. She had been smashed in the head with a bat by another resident.
Edwards, the charge nurse, groaned. Head injuries meant neurosurgeons. Because of enormous malpractice insurance premiums, most neurosurgeons don't want to risk serving in ERs.
Edwards raced toward the ambulance bay. Halfway down the corridor, the doors swung open and the rescue team pulled in a gurney.
''No!'' said Edwards, holding up his hand. "We can't handle neurosurgery cases!''
Salazar was right behind him. ''She's in,'' he said. Meaning under federal law, they had to treat her.
But how? She was huge, her arms and legs thrashing wildly. Her head was smeared with blood. Edwards ran to the medicine cabinet, which opened at the touch of his finger. He pulled out several vials. "Chemical restraints. This stuff will knock out a horse.''
At 3:42 p.m., the radio squawked again. Elderly woman, hypertension.
''Bring extra oxygen,'' the nurse snapped over the microphone. "We don't have a bed right now.''
Within moments, an elderly red-headed woman was wheeled in. Edwards took her pulse and blood pressure. She was not nearly as serious as other cases. He helped her into a wheelchair and an aide pushed her toward the waiting room.
''I don't want to wait for hours,'' she shouted. Like many people, she assumed that arriving by ambulance would move her to the head of the line, but that's not the way the system works. ''We treat the worst first,'' said Edwards.
''Where are my smokes?'' the red-head asked as she was wheeled away. "I want a cigarette.''
The retarded woman continued to thrash wildly. The injection that ''would knock out a horse'' had done nothing. Two security guards, two nurses, a paramedic, a physician's assistant and a doctor wrestled to tie her down with straps.
''Restraints quadruple the amount of paperwork,'' Edwards said as he ran back to the medicine chest for more drugs.
At 4:05 p.m., the waiting room was packed. Oprah was expressing open-mouth shock to something a television guest had just said. After seven and a half hours in the waiting room, Susana Sanchez, the 21-year-old pregnant woman, and her husband worked up the courage to complain loudly to the waiting room receptionist. The receptionist asked Edwards to speak directly to them.
''There are no beds available,'' the nurse told the couple. ''I'm sorry. You're next on the list.'' He didn't add that the list was always shifting.
He trudged back to ER, head down, exhausted. He began his day at 7 a.m. and was on duty till 7 p.m. before he could retreat to the 38-foot sailboat where he lived. ''One day you save someone's life, and you see that in their eyes and that makes up for a whole bad year,'' he said.
Shortly before 5 p.m., after a patient was transferred to a room upstairs, Susana Sanchez was finally brought in and put on a gurney beside the nurse's station.
Cantina Guy, sitting on the side of his bed, stared at her. Then he looked around the room, soaking in the reality that he had woken up in a hospital.
The doctor came over and saw the results of his CT-scan tests had arrived. No broken bones, no damaged organs. ''We need to do a road test,'' Salazar said. "See if he can walk, eat, let him go.''
A meal was ordered, and a physician's assistant stitched up the cuts on his face.
At 6:45 p.m., in the waiting room, an elderly guy, teeth clenched, insisted on seeing the charge nurse. ''This is ridiculous. My wife was a nurse for 50 years. She worked here for 30 years. She had diverticulitis eight months ago.'' The same pain had returned. "I want a gurney where she can lie down. She's been here four hours.''
Edwards said he was sorry, but he had no gurney for her.
''This has been very good for a Monday,'' Salazar said abstractly, looking around the crowded room. He meant that it wasn't too busy. His shift was over.
But the day kept getting worse. A young tattooed man, slumped in a wheelchair, was brought in. A drug overdose, he had a team of a half-dozen suctioning his stomach, giving him injections, putting him on a respirator. Then a huge man suffering from shortness of breath arrived in a wheel chair. He looked to be in his mid-30s, but as soon as the late-shift physician, Craig Travis, saw the chest X-ray he had a bad verdict: congestive heart failure.
The patient was occupying Bed 2, where Cantina Guy had spent most of the day. Cantina Guy was now in a chair beside the bed, wolfing down a tray of food. ''He's good to go,'' said a nurse, but he had no shirt, which had been cut off him when he arrived. An aide went to a storeroom, where charity clothing was stored.
The place was so busy that two ambulance crews waited an hour just to get their gurneys back: No ER beds were available for the patients on the gurneys to be moved to.
Finally, when that patient seemed to be stabilized, Travis sat down beside the pregnant Sanchez. ''On a scale of one to 10, how is your pain?'' he asked. She said a three or four.
He checked the results of her tests. Everything seemed normal. Apparently she was suffering from a simple flu bug. The ultra-sound showed she was having a boy. She beamed when she heard the news, and her husband squeezed her hand.
''Go see your doctor,'' a nurse advised her. She nodded, but she had no doctor.
Shortly before 10 p.m., with a new T-shirt, Cantina Guy turned to a nurse. ''Me voy,'' he said. ''I'm going.'' He wandered out the double doors that led to the ambulance bay.
In his 12 hours, he had cost the hospital more than $3,500, plus hundreds more for the ER physician and the radiologist who studied his X-ray and CT-scans.
Cantina Guy had no idea of the expense. He might have qualified for charity care, but he never talked to the hospital people who take insurance data. He never even received a bill. When the hospital attempted to reach him later, at the address he had given, the letter was returned as undeliverable.
KENDALL REGIONAL
In marked contrast to Homestead, Kendall Regional Medical Center has a much larger ER operation that sprawls over perhaps three times the space of Homestead's.
''People really hate to wait,'' says Freda Arzadon, the hospital's ER director. She had structured the flow so that people rarely had to spend more than 15 or 20 minutes in the front waiting room before they were called in. The seriously ill moved straight to a bed while others were sent to a corridor with a long row of chairs that functioned as a second waiting room.
The average time from entry to leaving at Kendall is three and a half hours, compared to three hours, 45 minutes at Homestead, according to the two hospitals.
Kendall Regional is in a middle-class, largely Hispanic neighborhood, and compared to the high drama of Homestead, its rhythm on this Thursday morning seemed steady.
In Section A, where the seriously ill are taken, most were elderly patients who lay quietly in their beds: a liver problem, congestive heart failure, chest pain, someone who passed out at home and was ''feeling very weak,'' a cancer patient with "swelling in the extremities.''
The one oddity was an armed guard outside a glass-enclosed room. A prisoner inside had suffered a seizure.
''He comes in on a regular basis,'' said Ruth Taylor, the head nurse for the section. A bullet was lodged in his brain -- impossible to remove by operation -- and it periodically caused seizures.
Rosey Suarez, the bank employee with the swollen foot, had come because she figured it was the easiest way to get treated. "It's hard to see a doctor. My gynecologist didn't even have an appointment for me for three months.''
She was taken to the back waiting area, had an X-ray taken and then was told to wait for the results. They showed no broken bones, and she was told to see a podiatrist for further tests.
Suarez is part of the fastest growing segment of ER patients -- those with private insurance. According to the Center for Studying Health System Change, ER visits by those with private insurance increased 24.3 percent between 1996 and 2001 - more than twice the increase of those with no insurance and those with Medicare.
Many experts theorize the reason is that primary-care physicians, squeezed by low-rates from managed care plans, are so overloaded that patients have to wait days or even weeks before they can get in to see their doctors.
In Kidsville, the ER section devoted to children, two nurses guess that between 10 and 30 percent of the patients don't belong there. They've come because they have no regular doctor or because their doctor can't see them right away.
On this Thursday morning, Evelyn Castro, a slender 13-year-old, was curled up in a Kidsville bed, a plastic bedpan beside her. Her sister, Michelle Yepes, had brought her. Castro was on Medicaid and, like many people with government insurance, had no regular doctor. That's why, when she had been vomiting for more than a day, she was brought to the ER. Doctors ordered a broad range of tests.
In a nearby bed was listless Nelson Ruiz, 12, with his parents, Nelson and Beatriz, sitting in plastic chairs beside him. He, too, was a Medicaid patient. For several days, he had a severe pain in his stomach and hadn't eaten. Doctors thought it might be appendicitis, or something more complicated, or simply an upset stomach. They ordered blood tests and a CT-scan.
In another section, Alex Polo, 20, lay on a gurney, grimacing. He had just been in a motorcycle accident, and his hands and knees were scraped up. A nurse was applying an antibiotic cream and -- as gentle as the nurse was trying to be, the touches sent spasms of pain through Polo.
Polo, an employee of the Collection car dealership, was scheduled next to have a CT-scan, to see if he had damaged organs.
At a desk area nearby, two doctors talked about how threats of lawsuits lead to more tests. Contrary to what she had learned in medical school, said B.J. O'Sullivan, "in the real world you do everything on everybody.''
''If he walks in the door,'' said Richard Mason, another physician, "he's going to get a CT-scan.''
Kendall Regional's CT-scan machine cost $1.1 million, with installation. It gets used for virtually everything, at least partly because physicians fear that if they don't use it, that decision might later haunt them in court.
''That one-in-a-thousand chance the CT-scan would show something could mean a $10 million lawsuit,'' said Ruslan Ivanov, an ER physician born in Russia. "The American people don't accept room for error. In the end, the whole society pays for it.
"We waste a lot of money. If we could remove this burden of liability, care would be much cheaper. The Czech Republic spends about $400 per capita [a year] for healthcare, and America spends about $4,000, and Americans don't live any longer.''
Polo, the motorcyclist, didn't hear what Ivanov said, but he decided that a CT-scan was something he didn't want and couldn't afford, because he didn't have insurance.
When his hands and knees were covered with ointment and bandaged, he decided he had had enough.
His shirt had been cut off after the accident, and he was dressed in one of those flimsy hospital gowns open in the back. With a hand behind him, holding the gown shut, he hobbled out of the emergency room.
He ended up with gross charges of $2,042 for the day. If he had coverage, his insurance probably would have paid about $500 at highly discounted rates. As it is, he has made two monthly payments of $100 each.
HCA reported that 13 of the 15 uninsured patients who used the ER on that Thursday made no payments at all in the four months since they were treated. That means, in the ''Robin Hood'' tradition that hospital executives talk about, their bills will be made up by the higher costs charged to those with insurance.
- - - - - John Lacny http://www.johnlacny.com
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