Commentary : If We Work Together, We Can Resuscitate Ailing Health Care System

The planned closure of the Fountain Valley Hospital Trauma Center is yet another symptom of the serious illness afflicting our nation’s health-care system. On an increasingly frequent basis, media attention is being focused upon the many problems of our emergency medical-care system, including emergency department overcrowding, the diversion of ambulances by hospitals, trauma center closure and incomplete backup coverage by physicians.

All of these problems result from our futile efforts to fit a square peg into a round hole--the high societal expectations of unlimited health care as a basic individual right versus the stark reality of a deficit-driven federal policy that treats health care more as a commodity.

As many as 37 million Americans are considered to be medically indigent, meaning that they have no form of health insurance. Millions more, such as those on Medi-Cal, are under-insured. In our competitive health-care environment, no organizations are competing for the poor and uninsured, who are consequently having extreme difficulty finding doctors and hospitals for their basic health needs. This is especially ironic during an era of excess hospital beds and a relative oversupply of physicians.

Because state and federal law guarantees everyone seeking emergency care a medical screening, regardless of their ability to pay, it should come as no surprise that large numbers of medically indigent people have come to emergency departments for both routine and emergent health services.

Nationally, emergency departments last year treated a record 83 million patients, with 75% of the hospitals reporting a problem with overcrowding. Because of this increased volume of indigent patients and concerns about legal liability, many specialists are reluctant to put themselves on call for emergency departments. Problems in obtaining neurosurgical backup and adequate patient reimbursement were instrumental in Fountain Valley’s decision to drop its trauma service.

During the initial year of the Orange County trauma system in 1980-81, UCI Medical Center treated an average of 12 trauma patients per month. For the 1988-89 year, the monthly average was 106 patients, with August setting the new all-time record of 140 patients. These trauma patients, along with the increasing number of critically ill ambulance and walk-in patients, have severely strained the available resources of UCI’s emergency department as well as other area centers.

This situation results in a domino effect, whereby overloaded hospitals must either go on some degree of ambulance diversion, stop receiving ambulances altogether or close permanently. These actions force ambulances to orbit the remaining open centers desperately seeking a place to take patients. This affects everyone, rich and poor alike, who may be less able to get timely and appropriate care at the closest emergency room. In fact, Fountain Valley’s decision could force the collapse of the trauma system, as the remaining centers may be unable to safely absorb the overload.

To deal with the dichotomy of health care as a right and health care as a commodity and to re-establish the integrity of our emergency medical services and trauma system, a multi-pronged approach will be needed.

Our crumbling health-care system has been put together on a piecemeal basis over the years, and no quick fix, Band-Aid-type bailout solution will suffice for the long term.

A key component of the overall solution is requiring that all Americans have some reasonable form of health insurance coverage. Of the estimated 37 million uninsured, about 25% have an annual income of more than $30,000. We need to mandate the purchase of insurance based on ability to pay and pass pending state legislation that would require some form of employer-based insurance. We must also establish financial incentives for wellness and prevention, as well as promote realistic public expectations of what the health care system can provide.

Current medico-legal problems could be partially resolved by attorneys and doctors working together to remove frivolous lawsuits from the courts and by allowing impartial boards to consider cases and compensate victims fairly based on available funds.

This would help to attenuate the practice of defensive medicine and allow physicians to significantly reduce the large number of tests ordered strictly for liability concerns. Even a 10% reduction nationally in this type of testing could save billions of dollars, which could then be reallocated to high priorities, such as trauma centers, mental health and drug abuse prevention.

As a society, we must conduct public discussion to determine how to best allocate our limited resources to benefit the greatest number of people. We must strive to simplify our complex billing and insurance system to decrease high administrative costs, which consume 22% of total health spending. This overhead is double or triple that of other major industrialized nations.

The current focus on studying the outcome of specific medical treatments will help us determine which therapies actually help patients achieve a better quality of life. This could be useful in controlling astronomical costs from the medical technology explosion, which is outpacing our nation’s apparent ability and willingness to pay for it.

By working together to raise the priority of health care on the national agenda, we can begin to resuscitate and overhaul our ailing health care system. Achieving this goal will require an unprecedented degree of vision and cooperation by people and policy-makers on the county, state and federal levels. Our own lives or our children’s lives may be riding on the outcome.