The 7-year-old in room 12 has a BB stuck in her ear.
The man guarding a six-pack of Dr. Pepper down the hall has been hearing voices.
The toddler bouncing in a hallway crib seems to have an ear infection.
The restaurant cook around the corner might have a bone infection that could cost her an arm.
The Paradise Valley Hospital emergency room sees them all.
On and on they come, this parade of cases ranging from the serious to the silly. For every heart attack patient or victim of violence who passes through those smoky glass doors, there are two or three or four other patients who might have done just as well in a doctor’s waiting room--if they had the money or insurance coverage to go there.
Instead, they come here, to the emergency room in National City, where anyone can come and everyone is guaranteed help.
But a patient who walks in with a broken arm at Paradise Valley on an October night probably will receive a splint and some pain killer and be referred to an orthopedist’s office the next day to have the bone set. Or someone who needs surgery might have to wait 6, 8, 12 hours for nurses to finally locate a surgeon who will take the case.
The reason: A flood of uninsured and under-compensated patients has made specialists unwilling to be on standby to be called in by emergency room doctors, who cannot provide such specialized care.
So, on 14 nights this month, the emergency room will operate without physician backup in at least two key areas, orthopedics and general surgery. This has happened repeatedly over the last several months in those specialties and others.
No Place to Go
But, with no other place to turn, the sick people in this economically depressed community will keep coming to Paradise Valley.
“We’ve had a lot of discussions around here when it’s quiet, and none of us can think of an alternative,” says nurse Carolyn Sibrell as she takes a break around the high, curved counter around which all emergency room--"ER"--activity revolves. “Unfortunately, it has to end up a monumental crisis before anything gets done.”
Although this phenomenon of doctors balking at the prospect of emergency room duty is most severe at Paradise Valley and the inner-city San Diego Physicians & Surgeons Hospital, physicians say it also is beginning to show up at other hospitals in the county.
This gives San Diego the dubious distinction of having a health care delivery problem that has not hit even the beleaguered hospitals of Los Angeles’ inner city, said Dr. Brian Johnston, president of the Los Angeles Society of Emergency Physicians.
Hospital officials there have threatened to close their emergency rooms because of the uncompensated care problem, but “so far” Los Angeles-area physicians have not rebelled, Johnston said. “It hasn’t happened in Los Angeles, but the pressures are here,” he said.
At Paradise Valley, there has been talk of having to close the emergency room, but no action. Adventist Health Systems, which operates the 210-bed hospital, is trying to staunch the flow of red ink caused by uncompensated and under-compensated care--nearly $4 million last year--by negotiating with the state for higher reimbursement rates for welfare patients.
In April, the medical executive committee tried to solve the emergency room dilemma by proposing a rule that every staff doctor would have to rotate being on call for the emergency room. The rule change was placed on hold after about two dozen doctors threatened to resign from the staff, saying they would take their patients to other hospitals instead. Recently, the hospital resorted to paying some specialists for being on call.
Because these backup specialists do not work for the hospitals, their income depends on the fees they collect, which are separate from the hospital’s charges.
“Historically, you agreed to be on backup in an emergency department because they referred patients to you for follow-up care,” said Dr. Richard L. Stennes, emergency department director at Paradise Valley. “You could build a practice and see patients. The problem now is, in the hospitals with the disproportionate share (of medically indigent people), you don’t get paid. But you’ve still got to support the cost of your practice.”
Paradise Valley’s ER problems are the culmination of a series of changes in health care funding that have cut reimbursements for health care over the last several years. Private health care plans began paying discounted rates to doctors and hospitals, as did government programs such as Medicare and Medi-Cal.
Tight budgets also caused the state and counties to stiffen eligibility requirements and make other changes designed to trim the number of poor people covered under public programs.
Simultaneously, the number of Californians without health insurance increased by 50%, to 5.1 million, from 1979 to 1986, a state study found.
Among the nation’s 20 largest cities, Los Angeles and San Diego rank No. 1 and No. 2 in the percentage of adults with no health insurance. The figure is 27% in LA and 26% in San Diego, said E. Richard Brown, a UCLA public health professor who authored the state study.
Then, on Jan. 1, a new state law made hospitals and doctors denying care to emergency patients subject to $50,000 fines.
The combination of lower payments, more uninsured people using emergency rooms for primary health care, and the possibility of criminal penalties has made San Diego doctors reluctant to be on call for emergency rooms in low-income areas, Stennes said. Like other doctors, he chafes at the notion that they should be vilified for their reluctance to work without pay.
“Somehow people have the idea that doctors have just tons of money and they can provide all this care and it doesn’t cost them anything,” he said. “Well, they’re in business like any other person is in business. They run an office. They’ve got nurses and they’ve got all the expenses of running a practice.”
Take the case of Drs. Harry R. Boffman Jr. and Grady P. Anderson Jr., who are moving their orthopedics practice out of National City. Last month they ended their emergency room work at Paradise Valley, where in September five of the six patients Boffman treated were uninsured.
Alvarado Hospital Medical Center will be the doctors’ new base, because it offers a better chance of seeing insured patients whose fees will cover the costs of nurses, office staff and the $60,000 medical malpractice insurance bill they pay every year, Boffman said.
The American Medical Assn. calculates that, on average, half of a doctor’s office income goes to pay office and insurance expenses. The average U.S. doctor has $119,500 left after those expenses are paid and before taxes are deducted.
“The reimbursement has been going down, down, down, and expenses of malpractice and supplies are going up, up, up. It’s just reached a point that you can’t afford to practice,” Boffman said of their National City office, which closes at the end of October.
No Financial Cushion
When the huge majority of patients are not covered by private insurance, there is no financial cushion for a medical practice, he said.
“If we see a Medi-Cal patient, we get 35 cents on the dollar,” Boffman said. “We’re in the 50% tax bracket, so we’re left with half of 35 cents. It costs us 50% of that for office overhead, so we’re left with half of half of 35 cents. That doesn’t leave us with anything.”
Expressed differently, Hoffman and Anderson take home about $90 in after-tax income for each $1,000 billed to Medi-Cal.
All these dollars and cents translate at Paradise Valley into an emergency room that reminds Dr. William O’Riordan of the days when his idle MASH unit in Vietnam would go out into the countryside to treat sick Vietnamese.
“We would see everything imaginable,” said O’Riordan, the hospital’s chief of staff, during a 3 to 11 p.m. shift recently. “It reminds me so much, because there was no other health care available.”
In addition to the usual assortment of broken arms and cut fingers an ER might expect, the Paradise Valley unit sees the products of a health care system that can’t cope.
Like the Medi-Cal mother whose feverish, tonsillitis-stricken toddler got sick more often than the one-doctor-visit-per-month rule could take into account.
Or the child who cut himself in a fall and needed stitches.
O’Riordan points to a sheet of paper at the bottom of the stack of paper work involving that case.
“We don’t look at this ever before we treat,” he said. “But mom is unemployed, has no insurance, nothing else. We never question that. We always take care of it. But after a period of time and things adding up--I don’t know how we’re going to pay the nurses. I don’t know how we’re going to pay the doctors.”
And, while the cases can be routine, emergency doctors also see many patients whose health care has consisted primarily of hoping their sickness will go away. When they do arrive at the emergency room, their minor symptoms have become major problems difficult to treat.
“I mean, they’re sick, " O’Riordan said. “These elderly people, especially, wait till the last minute to come in, especially if they don’t have any insurance.”
Hurt by Doctor Shortage
Although he and others insist that emergency patients get the best care possible, they acknowledge that the doctor shortage does indeed affect their ability to provide care.
Stopping in her routine of shuttling patients from room to room as more arrive, head nurse Betty Hallett recalls the night she spent eight hours on the phone trying to find an orthopedist to treat a man with an open fracture of the finger.
“It’s a big deal if you get an infection in the bone. You can end up losing the extremity. But we had no orthopedic doctor on call,” Hallett said. “I called every hospital in San Diego. I called as far as Fallbrook, over an eight-hour period.
“Finally out of frustration I called Balboa (Naval Hospital) and said, ‘Look, is there any way we can send you this patient?’ and they suggested maybe calling the VA. And he finally did go to the VA.”
On this night, the ER also sees three elderly suspected “MI"--myocardial infarction, or heart attack--patients. All will need the electronic monitors and close tending of the hospital’s intensive care unit. But by 8:30 p.m. those 10 beds and the 21 in the post-intensive care unit are all full. Thus begins a nightly ritual in ER.
“We’re going to have to hold for beds again,” O’Riordan announces to the staff. “They’re going to try to move Bed 5 in ICU out.”
Dr. O, as he is known to his co-workers, then makes a quick trip to the intensive care unit in search of other patients who might be moved. But, even if he finds one, it’s no easy matter.
“The nursing supervisor contacts each and every physician of the (ICU) patients and asks if they can be moved,” nurse Sibrell says. “And we have like a double block here, where there’s no ICU and no PICU, post-intensive care. That means we have to move two people.
“We have to move the PICU down to the (regular nursing) floor and then we have to clean that bed and then move the person from ICU into it, and then clean that bed. So we’re talking hours delay to get people moved. And so there tends to be this backlog of critical-care patients in the ER.”
Indeed, by the time the shift ends, a private-duty nurse has had to be called in, for about $25 an hour, to sit with with one critically ill man.
“They’ll probably be here another 12 hours,” head nurse Hallett says.
Why not just add more critical-care beds to the hospital?
“It’s an extraordinarily expensive level of care, and Medi-Cal does not reimburse you any more if you have intensive care or if you’re on a regular unit,” administrator Fred Harder explained in an interview later. “Hospitals just cannot afford to have more intensive care beds. Almost everything boils down to money one way or another.”
Stennes, whose firm Associated Emergency Physicians contracts to staff the Paradise Valley ER with emergency doctors, also complains about the fees his emergency room physicians collect, although they appear to be in better shape than backup specialists because they don’t have office expenses to pay.
Emergency doctors at Paradise Valley collected 22 cents on the dollar billed during the first three months of this year, Stennes said. The firm guarantees them $50 an hour for being there, which rises as fees are collected--if they are.
Dr. O worries that this low collection rate could eventually affect the Stennes firm’s ability to attract physicians to staff the ER itself. He notes that higher fee-collection rates at other hospitals mean that emergency doctors can expect to earn $80 to $100 an hour elsewhere.
“What’s going to happen is what’s already happened with the backup staff,” he muses. “There’s no way on an incentive basis that, if you’re in dollar-to-dollar competition, that you can compete. You eventually lose people. Even though they may be happy as larks, as our doctors are, they get better offers and they move on.”