Wednesday, Nov. 28, 2007

Assumptions about ER crowding are 'just plain wrong'

I have been an emergency physician in the San Joaquin Valley for 20 years. I have lived in Modesto since 1989 and I am the president of the California Chapter of the American College of Emergency Physicians.

Several of the answers in your article ("Q&A: Quick facts on valley health care problems," Nov. 20, Page A-12) are just plain wrong. Emergency rooms are not crowded because of uninsured and underinsured patients who use the ER because they have no other access to a doctor. Our esteemed governor has made the same assertion, but I will tell you what I told him: This is just plain false.

Most of the patients at Memorial Medical Center, where I used to work, have commercial insurance. Crowding in the ER is actually a symptom of hospital crowding. There is a shortage of nurses and hospital beds in Modesto. Admitted patients are forced to wait on ER gurneys for hours because there is no place to put them upstairs. If all ER beds are occupied, then patients in the waiting room can't be seen. That is the reason ERs are crowded.

Uninsured patients and MediCal patients often have minor problems; they are easily seen, treated and sent home. You could open a hundred new clinics for the poor, and Modesto's hospitals and ERs still will be crowded.

I also disagree with the assertion that hospital costs are high because of "cost shifting." That is HMO propaganda not borne out by the facts.

Hospital care is expensive because the "inputs" are expensive -- it costs a lot to provide care. Labor represents the largest input among hospital costs. The amount California hospitals pay in nursing salaries has soared in recent years due to a shortage of nurses and state- mandated nurse-to-patient ratios. New technologies like antisepsis antibiotics, MRI scans, arterial stents, etc., also increase costs.

The sickest and most expensive patients are the elderly, and they have Medicare insurance. So how can increased costs be attributed simply to cost shifting the care of the uninsured onto the insured?

Of course, hospitals provide some "charity care" to the uninsured (i.e., the bills aren't paid). But that is small potatoes in the hospital revenue soup, and the allegation of cost shifting is made by health plans looking for deep discounts and claiming that they are paying more than their fair share.

Actually, health plans are underfunding the system by not maintaining specialty panels and by cost shifting urgent care to hospital emergency rooms because their HMO clinics are not open 24-7.

Finally, the article asked, "Who provides health care to the uninsured and underinsured?" The provided answer ("county clinics, federally funded health centers, health care districts and public hospitals") is partially correct. It does not mention the fact that ER doctors and on-call specialists provide "free care" to uninsured patients 24 hours-a-day, seven days-a-week.

Stanislaus County does not reimburse ER doctors or on-call doctors for care provided to medically indigent adults. The county has a contract with Doctors Medical Center to provide these indigent patients with care, but providers at the county's other three hospitals get the sharp end of the stick.

Providers can apply for, and receive, about 7 cents on the dollar from Maddy Funds -- money from the state supplemented by locally collected traffic fines. Through Maddy Funds, providers get a pittance (about a third of what the low-paying MediCal program pays) for delivering life-saving care.

Salomon lives in Modesto.