COMMENTARY ON MEDICAL CARE : When Indigents Go to Emergency Rooms, We Pay Higher Costs : We can give low-income patients better care. We can also save tax dollars, but only with a coordinated plan.
Few people can imagine going to a hospital emergency room for a common cold and waiting for eight hours or more to see a doctor. Can you imagine being unable to find a physician to remove a cast once your broken arm has healed or a physical therapist to help you rehabilitate?
While most Orange County residents receive emergency medical care only on the occasion of an emergency, what I’ve described happens repeatedly every day throughout Orange County’s local emergency rooms as our Medi-Cal recipients and indigent residents seek basic medical care.
Why? The answer is a bit complex, but one that can best be attributed to our fractured, inefficient and underfunded indigent health care delivery system.
Why is this important to the public, to taxpayers who are not indigent, on Medi-Cal or among the working poor? More important, why do we require innovation in the delivery of health care to our less-fortunate fellow residents? And how would a better system impact the majority of local residents, the taxpayers who support it?
While federal, state and county governments are responsible by law to provide medical care to various residents (including Medicare, Medi-Cal and indigent medical service), no organized system for this care exists in Orange County. At a time when more residents are out of work, uninsured and aging, government at all levels is reducing funding for the medical care of its citizens to help balance chronic budget deficits.
This non-system is extremely inefficient. It wastes taxpayer dollars and worse still, forces many to wait for care until their medical condition deteriorates into an emergency. This further drains precious resources by requiring more intensive and expensive care.
The clinics and hospitals we do have that provide preventive primary medical care are private. The county operates only two clinics that offer public health services, such as immunizations, obstetrical and other health screenings. The county sold our only public hospital to UC Irvine almost 20 years ago, but everyone still considers UCI Medical Center as a county hospital. There are also 12 community clinics, but they do not have sufficient capacity to augment all the care needs for the indigent population available at UCI Medical Center.
Employers providing health insurance pay substantially higher premiums because hospitals find it necessary to shift the costs of caring for indigent patients to their paying patients. Employee co-payments and deductibles rise, too, as employers seek to keep insurance available to employees.
Despite the cost shifting, several emergency departments have closed in recent years, and only four trauma centers remain in service. Just imagine that you are vulnerable to the point where your life hangs in the balance over the distance you must be transported for real emergency care; or that the nearest emergency room is crowded to capacity and is unable to accept you for life-saving treatment.
What can be done to shore up our inadequate county system? The state has challenged us to do just that. By October, we must show that the county government, health care providers and the community want to transform our non-system into a “County Organized Health System, or COHS.
I chair the public-private steering committee seeking to provide a solution, and believe that this effort offers us the last opportunity to fundamentally change our local health care delivery system for the benefit of all residents.
A county organized health system is a locally based entity governed by a board of directors, which is responsible for the local Medi-Cal population (over 200,000). Both Santa Barbara and San Mateo counties have successfully initiated a COHS.
In Orange County, we are trying to take this one step further and develop a COHS which incorporates the indigent and other patients whose care is the county’s responsibility. It’s an innovative solution that is within our reach.
Why is a COHS better? First, all the Medi-Cal and county medical dollars would be governed locally, under tighter cost containment, utilization and case management. This means patients would receive care at the right time--at the onset of an illness--and at the right place--a clinic, or a physician’s office. Such managed care programs have proven to be more cost effective in Santa Barbara and San Mateo counties.
Remember that one of the single greatest determinants of cost in rendering health care is the setting. Emergency rooms and trauma centers are the most expensive possible settings!
If most of our indigent patients were enrolled in a COHS, basic preventive medical care would be rendered at a more reasonable expense and more efficiently.
It is significantly less expensive to prescribe an antibiotic early than to treat a serious upper-respiratory condition later. Significant cost savings would result from less reliance on emergency rooms for basic care, leaving them instead for the real emergencies and the critically ill and injured patients.
With our local control of the COHS, we would also be free to reinvest any Medi-Cal savings into providing more clinics, increase payments to attract more providers into the system and to establish a reserve fund.
Chronic diseases such as hypertension and diabetes could be treated less expensively.
Fewer chronic and acute complications would develop. Fewer outbreaks of infectious diseases would occur.
And less morbidity and mortality would improve the health and well-being of our community.
All of this means our workplaces, schools and other common gathering places would be healthier environments. They would have more able-bodied residents ready to be gainfully employed and would help children to learn good living habits.
For workers and their employers, insurance premiums could decline as hospitals reduce the need to shift costs. Finally, we would be better utilizing our precious tax dollars to render the most efficient medical care.
