Saving the ER for real emergencies
Mauricio Hernandez’s belly was swollen like a pregnant woman’s.
Every month for four years, he’d been going to the emergency room at Los Angeles County-USC Medical Center to have his abdomen drained of fluid, the result of cirrhosis caused by years of heavy drinking.
It wasn’t exactly an emergency, but the ER was his only medical care. An illegal Mexican immigrant, Hernandez had learned that emergency rooms legally cannot turn away patients without examining and stabilizing them. He had stopped drinking, he said. But his job unloading big rigs paid little and offered no health insurance.
At each ER visit, he waited from five to 10 hours, received immediate treatment and left with no long-term plan for follow-up care. So his condition worsened, making more ER visits necessary.
Hospital officials estimate that in the first four months of 2006 alone, Hernandez’s ER visits and hospitalizations cost taxpayers $37,500.
Hernandez, 45, is among a relatively small -- but extremely costly -- group of patients known in the field as “frequent fliers.” They are chronic users of the emergency room whose care would be far less expensive, and who would probably be less sick, if they were seen regularly in a primary-care clinic.
He is an extreme example of a wider problem: About 40,000 people each year -- about 22% of ER patients -- go to the emergency room at County-USC with health problems that do not qualify as true emergencies, according to county officials. Millions of people across the country do the same thing, but the problem is especially acute in Los Angeles County, where a quarter of non-elderly adults are uninsured.
Many of these patients are homeless or working poor people. And in Los Angeles County, many are immigrants, legal and illegal. Collectively, they have strained the more than 70 emergency rooms in the county to the breaking point, helping to boost uncompensated care costs to $1.6 billion annually.
Nine ERs have closed in the last five years in L.A. County alone.
Partly to ease this strain, Gov. Arnold Schwarzenegger proposed earlier this month to ensure coverage of all legal residents of the state and illegal immigrant children. But even if his proposal passes, undocumented adults such as Hernandez would still have to depend on the county system.
Moreover, the governor proposes shifting $2 billion away from indigent healthcare -- money that counties count on -- to pay for universal health insurance, said Robert Ross, president of the California Endowment, a nonprofit foundation devoted to healthcare solutions for the poor.
Thus, what to do with people such as Hernandez “represents a part of the soft underbelly of the governor’s proposal,” Ross said. “To pencil out,” the proposal may have to require counties to train frequent fliers to refrain from overusing emergency rooms, he said.
Even before the governor’s proposal, County-USC and a private nonprofit called COPE Health Solutions were working on a potential solution. (COPE stands for Community Outreach for Prevention and Education.) They began a three-year, $250,000 pilot program to steer patients such as Hernandez into private clinics. There, they can be treated more regularly and inexpensively, and the visits cost eligible patients nothing but time.
“Our goal is to identify the 5 to 10% of our population that is driving 50 to 60% of our [ER] costs,” said Pete Delgado, County-USC’s chief executive.
The county is starting small, with 100 patients at its flagship hospital. Judging from the Hernandez case, it will not be an easy job.
Mother from heaven
Looming over Los Angeles’ Eastside, the massive Los Angeles County-USC Medical Center is sometimes known in the community as “Madre del cielo”: Mother from heaven.
Many Eastside residents are used to going to the hospital for what ails them.
“It’s like when you go into the cathedral and ask for sanctuary,” said Dr. Ed Newton, the hospital’s director of emergency services. “No matter who you are, how messed up or poor you are, you can come here and receive care.”
On L.A.'s Eastside, hospital officials say, the majority of non-elderly adults may be uninsured.
They go to the hospital for hypertension, migraine headaches, the flu, colds, insulin refills and prescriptions. Others go with conditions caused by poor diets or drug abuse. Some figure it’s the only way to get an appointment with a specialist.
Emergency room overuse is rooted, in part, in good intentions. In 1986, the U.S. Congress passed the Emergency Medical Treatment and Active Labor Act, which required emergency rooms to screen and stabilize anyone who shows up at their doors, regardless of their ability to pay. The law was intended to prevent hospitals from dumping nonpaying patients.
But as the number of uninsured people has grown, the law has turned emergency rooms into de facto clinics. Making matters worse, ERs attract nonemergency patients with insurance as well, particularly at night.
Combine that with a nationwide reduction in hospital beds and the result is crowded ERs with long waits for nearly everyone, insured or not.
County-USC’s emergency room is the country’s second-busiest, seeing close to 175,000 patients a year. A decade ago, the hospital had 1,400 beds to accommodate those patients. It currently has 750 and next year will move to a new hospital with only 600 beds.
Overwhelmed with patients, Delgado teamed with COPE to find a way of reeducating frequent fliers, defined as people who’d been to the emergency room three times in a year and had been admitted to the hospital twice.
Each of the 100 selected patients was assigned a private community clinic and a health coach. The clinic’s job was to attend to the patients’ needs, at taxpayers’ expense, whenever they showed up. The coaches’ job was to -- in some cases literally -- take patients by the hand and teach them about clinics.
That’s how Hernandez came to know Alex Lozano.
Lozano, a soft-spoken 32-year-old, had been an HIV counselor for many years when COPE hired him as a health coach.
He met Hernandez in May as the patient lay in a county hospital bed, nodding from the effects of liver toxins.
There was a better, quicker way to get healthcare, Lozano told him, but it would require changing old habits. Hernandez nodded and agreed to try.
Lozano assigned him to Clinica Oscar Romero, across the street from County-USC. Over the next six months, Lozano spent dozens of hours with Hernandez.
He went with Hernandez to his first doctor’s appointment. He arranged to have him seen by a liver specialist at another clinic, then went with him there. He trained him to use his various medications.
Hernandez, nodding often, seemed to understand. He had been through the emergency room dozens of times, but no one had spoken to him like that.
Hernandez couldn’t read or write, so Lozano wrote the numbers of the buses he needed to take to get tests.
At Oscar Romero, “it took him a long time to understand that he still had to go through the line,” Lozano said. “He was unaware that there was a waiting list to be seen.”
Hernandez showed signs of rebelling and heading back to his old ER habit. But the clinic’s wait times were only two hours, compared to eight at County-USC. That cured him.
Lozano’s caseload grew to 29 frequent fliers, each with issues well beyond their health. Like Hernandez, many couldn’t read or write. Some were single mothers. Some were homeless, some worked part time. Many were illegal immigrants, who couldn’t take time off work to visit a clinic during the day.
From his small cubicle at the clinic, Lozano grew familiar with enormous national issues: not just the woes of lacking health insurance but the lives of poor -- but working -- Mexican immigrants.
He realized that part of his clients’ emergency-room overuse was rooted in cultural attitudes from working-class Mexico. A certain stoicism allowed people to tolerate exhausting waits in the emergency room instead of looking for other options. County-USC resembled the massive Seguro Social hospitals in Mexico, where long waits in uncomfortable chairs in crowded rooms were the price for care.
“It happens a lot in Mexico and South America, where people are in that big long line and they’re used to it,” he said.
Lack of insurance, machismo and a fear of doctors conspired to keep people from tending to ailments until they were too painful to bear. People would go to herbalists or witch doctors or ask friends to get medicine for them in Tijuana.
In L.A.'s Eastside immigrant enclaves, where English is rare and education levels low, Lozano saw that old habits were reinforced by friends and family who reported successful experiences at County-USC.
“They know they won’t have to pay, but they won’t be turned away,” Lozano said.
It was a victory -- albeit a small one.
In September, after four months in the program, Hernandez twice used the clinic for minor ailments -- a strained back and a lacerated finger -- that previously would have sent him to the emergency room.
Since then, Lozano has cut back their meetings to once a month, but he still must instruct Hernandez on how to refill his prescriptions by phone.
Hernandez’s reeducation has amounted to a huge public investment in only one person and raises the question of how it can be replicated countywide. Nevertheless, the county and COPE are so encouraged by their experiment that they are seeking money to expand it to include 1,000 patients.
“It’s a herculean task, but the efforts are worth it,” said Jim Lott, a vice president of the Hospital Assn. of Southern California. “When we move it out to the rest of the community, we’ll get the economies of scale.”
By now, Hernandez has stopped going to the ER.
His stomach is slowly becoming smaller. A specialist has determined that he doesn’t need a transplant.
Hernandez goes to the clinic so often that he’s learned the names of nurses and clerks and takes them tamales. He visited six times in the three weeks before Christmas.
The cost of his care over the last seven months has been cut almost in half, to $19,500, COPE officials estimate.
Every so often, Hernandez will jokingly threaten to go back to the county’s emergency room.
“Go ahead,” Lozano tells him. “Wait 13 hours for a visit.”