State Urged to Intervene in Hospitals’ Urgent Care

Swamped by patients and hemorrhaging money, California emergency rooms cannot continue to guarantee quality care on demand unless the state steps in with financial help, a new report warns.

Emergency rooms are closing across California, cutting services and diverting ambulances when they run out of beds. The wait for treatment can stretch for hours, on-call medical specialists are stretched perilously thin, and paramedics are routinely forced to hold patients in ambulances until beds open up.

“The system is in crisis,” said Dr. Brian Johnston, medical director of emergency services at White Memorial Medical Center in East Los Angeles. “It’s a setup for medical errors. It’s a setup for suffering.”

The problems afflicting emergency rooms are not new, but the trend is increasingly ominous--especially in Los Angeles, according to the report, a comprehensive survey of emergency care prepared by the California Medical Assn. and obtained by The Times.

Statewide, emergency departments and the physicians who staff them reported losses topping $416 million in 1998-99, the year profiled in the report. For each of the 9.3 million patients treated in emergency rooms that year, hospitals lost an average of $46.

The epicenter of the crisis is Los Angeles County, where 64 of 78 emergency rooms lost money--a total of $95 million--in 1998-99. Martin Luther King Jr./Drew Medical Center was $9.3 million in the red, while County-USC Medical Center lost $8.7 million.

The report’s authors say the perpetual financial drain is a symptom of a system ready to collapse. “Act now,” they warn, or “ignore the warning signs and watch the system flat-line and die.”

What’s needed, they say, is a philosophical shift in the way Californians view--and fund--emergency care. As the safety net for the uninsured and destination for the critically ill and injured, emergency rooms and their staffs are as vital as police and fire departments--and should be treated as such, the authors contend.

“This is something that any civilized society should say is an obligation of government,” said Steve Thompson, a vice president of the California Medical Assn. “The state needs to declare that these are essential services for the citizens and make a commitment to them just like we do for public safety.”

Among the remedies the report prescribes is legislation that would commit the state to providing financial support to emergency rooms on an ongoing basis--a major shift in policy, and something not likely to appeal to Gov. Gray Davis.

A bill by state Sen. Joe Dunn (D-Santa Ana) would declare trauma and emergency care “an essential public service” and allocate $200 million a year to a new state fund for struggling hospitals.

Under the bill, local emergency services agencies would designate certain hospitals as “essential” community facilities. The agencies would distribute the state money based on the number of 911 patients a hospital treats, the range of specialty emergency care it provides and other criteria.

Dunn’s bill also would add $100 million annually to an existing pool of money used to compensate doctors who care for the uninsured.

“I know these are big price tags for any one proposal,” Dunn acknowledged. “But we’re all at risk with this problem--rich, poor, young and old--and it’s just getting worse and worse. We have to stop the bleeding now.”

A second bill, by Sen. Jackie Speier (D-Hillsborough), tackles the problem faced by physicians trying to bill insurance companies for care they provide in emergency rooms. It would require insurers to pay physicians directly--rather than delegating that responsibility to the patient’s medical group, an arrangement that can delay reimbursement of physicians for months.

Frustration over that issue, among other factors, is deterring specialists from serving on call in emergency rooms--leaving hospitals thinly staffed and sometimes forcing paramedics to divert to more distant facilities.

“Some hospitals have no neurosurgeons on call,” said Dr. Daniel Higgins, medical director of emergency services at St. Francis Medical Center in Lynwood. “So if you wind up at one of those and have a bleed in your brain, you have to be transferred somewhere else.”

The report comes at a time when California’s health care system is under unprecedented stress. Medical practices are going bankrupt, the state’s trauma centers are in a constant scramble for funding to stay afloat and nurses are in terribly short supply.

Los Angeles County is under particularly severe financial strain because nearly one in three of those under 65 lack health insurance--double the national rate. Many of the uninsured use emergency rooms for basic medical care because they have nowhere else to go.

With reimbursement for the uninsured an iffy prospect at best, many hospitals are choosing to simply close their emergency rooms.

Between 1990 and 1999, 50 emergency rooms closed in California. Meanwhile, emergency room visits during that period shot up from 8.4 million to 9.4 million, state statistics show.

The result is emergency rooms that are so crowded that they routinely are forced to turn away ambulances--diverting them to hospitals that may be an hour or more away.

“We’re just overwhelmed,” said Higgins at St. Francis, which has one of the busiest private emergency rooms in the county. “It’s not uncommon for one-third of the [county’s] hospitals to be closed [to new emergency patients] even in the morning. Something has to give.”

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Emergency Room Snapshot

Following are financial losses in some California counties for emergency departments in public and private hospitals:

*

Who Pays for Emergency Room Care in California

Health insurance agencies*: 43%

Medi-Cal: 19%

Medicare: 17%

Uninsured: 14%

County indigent programs: 7%

Source: California Medical Assn.

* Includes many kinds of insurance agencies, including HMOs and PPOs