Sentinel Emergency Departments Report Safety Net Frayed by Uninsured and Managed Care
Across the nation, emergency physicians are sounding the alarm that the healthcare safety net’s holes are enlarged to a frightening extent, overburdening emergency medical services and hospital emergency departments to a near-breaking point. The reasons are complex, but they involve the nearly 45 million uninsured people across the nation and are compounded by the budget-cutting of managed care and the consolidations of the healthcare market place.
Emergency departments act as sentinels (healthcare canaries). A breakdown in the system of providing primary care can send millions of people into these havens of last medical resort. As emergency departments close, the burden on those left, particularly the ones in the inner cities, grows, resulting in long waiting times and crowded facilities.
California was hit first and hardest: 19 emergency departments in that state have closed since 1997, while visits have increased by 1.2 million. Ambulance diversions became so common in the state’s cities that they prompted the state to hold legislative hearings.
Michael Callaham, MD, chief of the division of emergency medicine at the University of California at San Francisco, said his state’s emergency system has been hard hit because of the cutbacks required by managed care. In the first 4 months of the year 2000, he said, hospitals in San Francisco diverted ambulances during 10% to 12% of operating hours. Even in the summer, the hospitals continued to call critical care diversions frequently. “You can’t have a lean, mean system and expect to handle a flu epidemic, a disaster, or anything like that,” Callaham noted.
Across the nation, inner-city hospitals that were once the sources of health care for the nation’s medically indigent closed as Medicaid, managed care, and the mergers of hospital systems cut off their sources of income. Many fell victim to for-profit systems that increasingly focused on the bottom line rather than service to their communities. Hospitals that did not perform financially were closed.
Those that are left find themselves swamped with patients ranging from the critically ill to those needing no more than the reassurance of medical personnel. At Inova Fairfax Hospital in a Washington, DC Virginia suburb, administrators have installed call bells in the hallways because emergency patients on gurneys frequently find themselves waiting there for long periods. The decision to install the bells was a practical one, said Thom Mayer, MD, emergency department director at the northern Virginia health care facility. “The patients can let nurses and doctors know when they need us.”
According to the American Hospital Association Health Forum Annual Survey of Hospitals 1988–1998, in 1988, 4935 of the participating hospitals (94.1%) reported that they operated emergency departments. By 1998, only 3807 of participating hospitals (92.6%) reported operating emergency departments.
Opinions about the closing of emergency departments vary. The Office of the Inspector General of the US Department of Health and Human Services says that the closings have minimal effects. The inspector general reported that 38 general acute hospitals closed in 1997 and 37 closed in 1996. Of those that closed in 1997, 10 were rural and 28 were urban. The hospitals were all fairly small and saw high percentages of Medicare patients. The urban hospitals also reported high volumes of Medicaid patients. “Although residents in a few communities had to travel greater distances for hospital care, most had emergency and inpatient care available within 10 miles of the closed hospital,” claimed the report.
The distances may seem minor, but they cause considerable distress to residents of cities like Cleveland, which recently lost 2 major centers of indigent care—St Luke’s and Mount Sinai hospitals. Both hospitals were located on the city’s east side. The closing of Mount Sinai in particular strained the safety net because it was 1 of only 2 trauma centers in Cleveland.
“Our trauma census has gone up possibly as much as 50%,” said Stephen Meldon, MD, an assistant professor of emergency medicine at Case Western Reserve University Medical School and director of emergency care at MetroHealth Medical Center, the city’s public hospital.
On some nights, the hospital has 35 patients in rooms in the department and another 35 waiting outside. “Some patients leave without being seen because the wait is so long. We do not have the resources to treat everyone quickly,” Dr Meldon said.
“At some point, there are only so many resources,” noted Dr Meldon. His hospital treats the most severely injured and sickest patients needing acute care quickly, but others find themselves waiting for long periods. “We are the hospital of last resort.”
Jonathan Glauser, MD, who is now an emergency physician at the Cleveland Clinic, directed Mount Sinai’s emergency department for 15 years. He said the institution’s decline started years ago, even before a for-profit company bought the facility. “Once a hospital starts cutting costs here and there, you begin a downward spiral,” he said. That can mean that the medical records department and the cafeteria close at night. There are fewer housekeeping staff and fewer people to transport patients around the hospital. Sooner or later, the hospital cuts costs to the point where the institution can no longer be maintained adequately, physicians leave, patients follow them, and the hospitals close.
For patients on the east side of Cleveland, the journey is longer and the strain on the emergency medical services system is greater because ambulances must travel longer distances, said Dr Glauser. He wonders about the future of health care in Ohio. With the cuts in Medicare, the numbers of uninsured people, and the overall atmosphere, “it’s hard to imagine people making a profit out of a Cleveland hospital,” he noted.
Robert Williams, MD, DrPH, works with ≈50 hospitals around the nation that are staffed by his emergency physician group. During the early days of managed care, he said, the volume of patients in the emergency department stabilized. Now, however, he said his group has seen increases of 5% to 7% per year in emergency departments around the nation.
Managed care has had the largest impact on the increases, Dr Williams noted. Hospitals are forced to cut deals with managed care companies, giving them less money to use in cost-shifting to offset the burden of treating the uninsured. Facilities cannot expand, and the patients stack up in the emergency department.
According to Dr Williams, the system is strained, with no help in sight. The system of financing emergency care is flawed. Only half of the patients seen in most emergency departments can pay for their care. “The only way to keep services available is to charge people who do pay twice as much. That has been eroded by managed care. Insurance companies don’t want to do that,” he said.
Patients also show up in the emergency department because the managed care system delays appointments for primary care, said Mark Hauswald, MD, an associate professor of emergency medicine at the University of New Mexico school of medicine. Recently, one of the health maintenance organizations (HMOs) in the state presented the classic case of a child with an ear infection on Friday night. The HMO wanted its subscribers to consider the money issue of rushing the child to the emergency department versus waiting until Monday to seek treatment.
“The kid is screaming because his ear hurts,” said Dr Hauswald. “The HMO wants my kid to scream in pain for 2 days. I don’t get any sleep; my wife gets no sleep. We lose time from work seeing the pediatrician during the week.” He said the case did not make its point with the subscribers, who still wanted the child seen immediately.
“We have a pretty reasonable patient population in my emergency department,” said San Francisco’s Dr Callaham. “Most have their own physicians, and they keep their appointments. I see people all the time who apologize to me. They said, ‘I know this isn’t an emergency, but I can’t get in to see my primary physician for 2 to 3 weeks.’ I know that’s true because I can’t get to see mine. It is remarkable because this primary care physician stuff is the myth of managed care.”
“The system is fragmented,” said Lewis Goldfrank, MD, head of the emergency department at Bellevue Hospital in New York City. With too many patients, doctors find it difficult to spend time talking to individuals. “There is less patient education and less doing things that do not give you an immediate reimbursement.”
Making the “Bench” Hospitable to Minority Scientists
Bills in both the US House of Representatives and the Senate seek to improve the status of basic scientists from underrepresented minorities. The Health Care Fairness Act was introduced in November 1999 by US Senator Edward Kennedy (D-Mass), who calls this bill a major step toward reducing health disparities among ethnic and racial groups in the United States.
The Senate and House versions of the bill would upgrade the Office of Research on Minority Health to the status of a center. As a center, the organization would then have the authority to make grants to scientists interested in the issues of minority health, according to a report in the Washington Fax on Health.
Administrators in the National Institutes of Health have said they support the bills. US Representative Jesse Jackson (D-Ill) introduced the House measure.
Appeals Court Says Food and Drug Administration Can Regulate Cholestin
The 10th US Circuit Court of Appeals ruled on July 24, 2000 that Cholestin, an anticholesterol agent made by Pharmanex, Inc, of Simi, California, is subject to regulation by the US Food and Drug Administration (FDA). Cholestin has been marketed as a dietary supplement and, as such, is exempt from FDA regulation.
The company says that Cholestin is a “proprietary, scientifically standardized, all-natural form of Monascus purpureus Went yeast fermented on rice, a traditional Chinese health food.” In a talk paper issued when the agency ruled that Cholestin was an unapproved drug, FDA officials said: “the FDA based its decision on the fact Cholestin contains lovastatin, an active ingredient in the approved prescription drug Mevacor used to lower levels of cholesterol levels.”
“Under the terms of the Federal Food, Drug, and Cosmetic Act, as amended by the Dietary Supplement Health and Education act of 1994, Cholestin is not a dietary supplement because lovastatin was not ‘marketed as a dietary supplement or food’ before the FDA approved Mevacor as a drug,” claimed the talk paper. If the FDA prevails, Cholestin can no longer be sold legally in the United States.
In a released statement, Truman Hunt, executive vice president and general counsel for Nu Skin Enterprises, parent company of Pharmanex, said, “The FDA’s case hinges on the nominal presence of the naturally-occurring mevinolin found in Cholestin. Mevinolin is the active ingredient found in popular cholesterol-reducing drugs. There is an extensive record showing how Cholestin is produced from a unique strain of red yeast rice, a modern version of an ancient food that naturally contains a range of healthful constituents—it is not a drug product.”
A Utah federal district court had ruled in the company’s behalf, but the 10th Circuit Court of Appeals reversed that ruling and remanded the case back to the district court. Pharmanex officials said that because the appeals court did not order Cholestin off the market, it would seek to make it available while a final ruling is sought.
Both sides intend to continue to pursue the matter in the courts. The suit goes along with a recent recommendation by an advisory panel that lovastatin in the form of Mevacor not be made an over-the-counter medication because of fears that the right people would not get the medication and that patients do not understand cholesterol well enough to self-medicate.
At the time of the July meeting when the FDA panel ruled, the irony of Cholestin being available over-the-counter was brought up. However, while admitting the paradox, the committee elected to rule on the side of safety.
- Copyright © 2000 by American Heart Association