ER Patients Lose in Specialists’ Rebellion

Seven-month-old Sydney Litzsinger was bleeding.

She’d fallen on a plastic Barbie doll bed and cut her upper lip down to the muscle.

The family rushed Sydney to the emergency room at nearby West Hills Hospital, where a doctor scrambled to find a specialist to sew up her face.

But to no avail. Every one of the specialists called refused to come in to treat the baby.

It didn’t matter that her family had insurance. Sydney was caught in a growing, and increasingly rancorous, rebellion against managed care by specialists, who are fighting what they say are low fees and late payments by refusing to care for emergency room patients, even if they are contracted to do so.

“It’s a terrible, awful problem,” said Dr. Ellis Weeker, chairman of emergency medicine at Good Samaritan Hospital in San Jose and head of a large physicians group. “And it’s rampant.”

Doctors who don’t respond to emergency room calls can do so with relative impunity, several experts said, because hospitals cannot afford to alienate them.

Hardest hit are the nation’s small and mid-size hospitals, where the supply of specialists is limited. If the trend continues, emergency room doctors warn, some trauma networks could collapse.

The problem is worse in California, where managed care is most entrenched. “It happens every day in California hospitals,” said Dr. Loren Johnson, co-chairman of an industrywide task force on the problem in this state. “I’ve had patients lose their limbs and lose their lives over failure to respond.”

To a degree, the problem is not new: It has always been difficult to persuade some specialists to respond to emergency room calls.

But hospital officials say the situation has been exacerbated since the advent of managed care, in which insurers such as health maintenance organizations hold down costs by paying doctors less and limiting access to specialists.

“Many of us now actually refuse to give out insurance information until the physician actually gets to the hospital and sees the chart for himself,” said Dr. Larry Alexander, an emergency room physician at Baylor Hospital in Dallas. “Because then he has already assumed care and he can’t [legally] leave.”

Alexander said he was working at a different hospital about 18 months ago when a woman came in after a dog had bitten off the tip of her nose.

“I called the plastic surgeon who was on call, and he said, ‘I’m not on her insurance plan, and I’m not coming in,’ ” Alexander said.

Surgery Needed After Work in ER

Sydney Litzsinger, who can no longer fully curl her lip to smile, lay for more than an hour that February evening in the emergency room at the west San Fernando Valley hospital, her wound unclosed and her tears unstoppable.

The Litzsingers had a choice, the emergency room doctor said: He could stitch up the complicated laceration himself, or they could drive Sydney more than 30 miles to Childrens Hospital, where a plastic surgeon was available.

The Litzsingers stayed at West Hills, fearing that the drive and a possible wait in Los Angeles would traumatize the baby further.

The emergency room doctor sewed the cut, but it fell open later when the stitches were removed. Now Sydney will have to undergo surgery to repair the damage.

The emergency room crisis appears to primarily involve those doctors who, like plastic surgeons, do not depend on emergency room patients to build their practices.

Among those most likely to balk at coming in are ear, nose and throat specialists; orthopedists; neurosurgeons; and plastic surgeons, said Dr. Lawrence Bonham, who heads a Santa Clara County managed care company.

Most refusals involve indigent patients or those who are on Medicaid, said Dr. Bruce Spurlock, executive vice president of the California Healthcare Assn., which represents hospitals.

But specialists are increasingly turning away from insured patients as well, he said.

Here are some recent examples:

* In San Mateo County, orthopedists resigned en masse from a large physicians group and will now come to the emergency room only if they are paid their full fees, not discounted, managed care rates.

* In New Jersey, plastic surgeons refused to come to the emergency room to treat children with lacerated faces and dog bites.

* In San Jose, ear, nose and throat specialists refused to treat a man with a dangerous abscess in his throat.

By saying no, these doctors say, they are putting managed care companies on notice.

“If we go out and work for free, the HMOs will continue to take advantage of us,” said Dr. Lawrence Pleet, a facial reconstruction specialist who practices at West Hills Hospital.

Pleet was one of four doctors who refused to care for Jacob Saitman, a 4-year-old boy who was brought to West Hills in late March after he was attacked by a relative’s dog. Jacob had facial injuries, including a puncture wound just under an eye, that required suturing by a specialist.

“I called every plastic surgeon that we had on staff,” said a source at the hospital.

But until Jacob’s parents offered to pay cash--$2,000 for a procedure that generally costs a few hundred dollars--none of the plastic or facial surgeons would come in, according to the child’s parents, pediatrician and hospital sources.

Pleet, who was substituting that night for another doctor, said he was not obligated to come in because he was not on call and was not contracted with Jacob’s managed care company.

The other doctors who refused to treat Jacob were identified by the hospital and his health plan as Lawrence Stein and Zareh Vartivarian.

Dr. Jerome Vener treated Jacob after his parents signed a promissory note requiring them to bring $2,000 in cash to his office by noon the next day.

Vener was among those who failed to respond to Sydney Litzsinger, said Sydney’s mother, Alison, and the child’s pediatrician, Dr. Charles Goodman. It is unclear how many doctors were phoned in Sydney’s case, but her family recalls listening to the hospital staff make six calls.

‘You Think You’re Safe’

Neither Vener nor Stein would comment.

Vartivarian said he did not come in to treat Jacob because it was Palm Sunday and he wanted to spend time with his family. He was not on call that night, Vartivarian said, though his contract with the child’s managed care company did require emergency room response. He said that had he known others had refused, he would have attended Jacob.

“You think you have insurance,” said Alison Litzsinger, Sydney’s mother. “You think you’re safe. But if you can’t get a doctor to go in and do the surgery, then you have nothing.”

The failure of specialists to respond to emergency room calls strikes at the heart of the emergency system, a delicately patched together network that relies as much on relationships and the cultural history of the practice of medicine as it does on high-tech equipment and hospitals.

In the past, young specialists relied on emergency room referrals to build their practices, said Dr. Johnson, who is working on the issue for the American College of Emergency Physicians, both in California and nationwide.

The hospital was the center of the medical community in an area, and doctors felt a kinship to one another and a sense of responsibility to the institution.

Now, the patients are assigned to specialists by managed care companies, and the emergency room is not the vital source of patients that it once was. As a result, doctors are less willing to sign up, and many find excuses not to come in even when it is mandatory.

And although several studies have shown that doctors have not lost income under managed care, they’re able to make the same money only by seeing more patients. A trip to the emergency room takes up valuable time.

“The physicians have a moral dilemma,” said Jim Lott, executive vice president of the Healthcare Assn. of Southern California. “That moral dilemma is what they pledged to do when they became a physician and what they can afford to do in order to maintain a viable income and living.”

According to the American Medical Assn., the average income for doctors rose 0.3% in 1997 to $199,600. By contrast, the average income for a person in the United States that year was $25,598.

Pay is a greater issue at public hospitals where doctors make far less than the physician average. That, coupled with dissatisfaction with managed care, led about 800 Los Angeles County physicians who are not medical residents to unionize last week.

In the West Hills hospital cases, the monetary concerns were heightened by the shaky financial condition of the physicians group under contract to pay for the children’s health care.

Maxicare, which covered Sydney Litzsinger, and Blue Shield, which covered Jacob Saitman, had contracted with a middleman, Pasadena-based Huntington Provider Group, to provide the care.

Such companies pay doctors and hospitals out of monthly fees provided by the plans, and form the foundation of managed care in California.

They also, however, are the most vulnerable to the financial strains besetting managed care. Last month, Huntington announced plans to close on Aug. 31 the division that covered the two children.

In February and March, when the children were injured, the division was slow in making payments, according to several area doctors.

Huntington, which denies that it was behind in payments, said doctors are under contract to respond to emergency room calls at all times. The company reimbursed the Saitmans the full $2,000, even though it exceeded normal rates.

“It’s just appalling,” said Alan Puzarne, vice president and chief executive for the Southern Region of Blue Shield, which is investigating Jacob’s case. “I can’t even fathom [the doctors] doing this.”

Maxicare would not comment, but sources said the company had pressed Huntington to repair Sydney’s wound. The provider group initially denied the request, said Goodman and a Huntington spokesman.

Hospitals also have contracts with physicians, and any doctor who is on call is required to respond or find a substitute.

Arguments Focus on Wording of Call-Ins

But enforcement is weak, in part because hospitals depend on specialists for much of their business.

At West Hills, none of the doctors who refused to treat Sydney or Jacob has been disciplined, said Jim Sherman, hospital president.

He said the doctors did not breach their agreements with the hospital because of the wording that the emergency room staff used when phoning them.

“They were called as providers for [Huntington], not as members of the hospital’s panel,” Sherman said.

Emergency room sources and the children’s parents dispute that claim, and experts in trauma care say that emergency physicians do not typically make such distinctions when phoning for help.

A state inquiry found no violations of law by the hospital, because both children eventually received treatment.

Emergency room refusals put hospitals in a particular bind, because they are legally required to provide emergency care. Without a full-service emergency room, a hospital risks losing accreditation.

To overcome the problem, some hospitals have begun paying doctors up to $1,000 per day just for being on call.

Others have agreed to supplement payments by managed-care companies and Medicaid.

“The on-call issue is the biggest and most critical” affecting emergency care, Johnson said. “If you lose your on-call system, emergency departments will have to close.”