High-cost emergency rooms reflect a health care system
out of control.
The middle of Linda Regan's evening shift looks like this:
Thirty beds in various cramped rooms at Johns Hopkins
emergency department in East Baltimore are filled; one
man dressed in a hospital robe sits up on a gurney parked
in the hallway; more than 30 other people sit in the
low-ceilinged waiting room, hoping a bed becomes available.
It is 10:15 p.m. "We're a dumping ground," says Regan, an
assistant professor in emergency medicine at the School of
Medicine, and a regular physician on the nighttime
Some patients walk out because of the wait. Those who remain present a spectrum of complaints. One woman is suicidal because her teenage son has run away. A cancer patient suffers from swelling on his face and throat. An HIV-infected 17-year-old girl has swelling and pain inside, likely the result of encounters with eight males over the course of two days. Regan has to keep them all straight, ensuring that interns, med students, and nurses are properly directed in giving treatment as she and a small handful of doctors handle the crush.
Emergency care has been in crisis for at least the last decade, a phenomenon largely — and perhaps wrongly — attributed to the fact that one in seven Americans, about 46 million in all, lacks health insurance and relies on packed emergency rooms for health care. It's one of the most expensive medical options available, and many patients come in with complex and costly problems because of generally poor health. Other factors drive up the price of emergency care: Doctors, generally unaware of a patient's medical history (and always unaware of their lack of health insurance), often prescribe expensive diagnostic tests to make sure they aren't overlooking more serious problems. Although private-practice health care providers can deny treatment to uninsured patients, federal law requires emergency physicians to treat everyone. Many patients can't pay their bills, leaving hospitals to absorb the costs.
About a quarter of the people who show up in the Johns Hopkins East Baltimore emergency department are what the medical industry calls "self-payers," compared to 6 percent of patients elsewhere in the hospital. "The emergency department is becoming a substitute for a doctor's visit," says Ronald R. Peterson, president of Johns Hopkins Hospital and Health System. "There's an extended role for the emergency department, which is a relatively expensive department to run overall."
But uninsured patients aren't the major reason behind a 36 percent increase in emergency room visits nationwide in the past decade or why Johns Hopkins Hospital's East Baltimore emergency room has seen nearly 57,000 patients in the past year. The other 75 percent of emergency room visitors — patients with insurance — often clog a system that takes people in through the emergency room, then admits them and moves them upstairs to a hospital bed. Often, hospitals are too full to accommodate emergency patients who need to stay. Tonight, for example, as Regan tries to find room for an elderly woman with a severely swollen leg, a charge nurse complains: "We can't get anybody back here because we can't get anybody out of here."
James Scheulen, chief administrative officer of Johns Hopkins Department of Emergency Medicine, says a clogged emergency system, if not managed effectively, can negatively affect the quality of care hospitals can give. "Because hospitals have to keep filling beds to near capacity to remain financially viable, we often have nowhere to send people who are really sick once we're done with them," he says. "At times at Hopkins Hospital, we have 110 percent of capacity, which means we have these backlogs."
Nationwide, many hospitals have closed in recent years, leaving fewer emergency rooms and fewer beds. At the other end of the equation, the numbers of family physicians — who could treat minor medical matters that shouldn't send a patient to the hospital — are dwindling, as are doctors who will treat Medicaid patients. "Primary care practices are all booked up," says Scheulen. To maximize their schedules, doctors fill up all appointment spaces, leaving them with little room to fit in people with sudden illnesses or injuries. "So even when people do have doctors, [the physicians] often don't know [the patients] well enough to help them over the phone. They'll send them to the emergency room for an ankle sprain or a cough that turns out to be a respiratory infection. The result is we get squeezed from both ends," he adds.
A constantly revolving door reflects more than just an insurance crisis, Scheulen says. "As much money as we have wrapped up in health care in this country, there is still a fundamental issue of the system's capacity." That, coupled with the desire of some people to get immediate care no matter what, can drive up costs.
What's more, some Americans' desire for instant solutions
to problems factors into the equation. "When I give
lectures, I put a picture of McDonald's in my slide show,"
Scheulen says. "If I could find a way to give drive-through
health care, I would. It's what people want. They expect
immediate care, whether they need it or not, and here we
are in the emergency department — open 24 hours a day
and accessible, a one-stop-and-shop opportunity."
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