Tuesday, April 3, 2007

Govrnment reform - The Media, Congress, and The ER Crisis

Read the papers, view TV, listen to Congress hearings, and you’ll learn America has an ER crisis.

ER crisis signs are:

• Eight hours waiting to be seen in overcrowded ERs.
• ER ambulances diverting every minute with no room in the inn.
• ERs and trauma centers closing from monies lost treating the uninsured.
• Concerns about ERs not being ready should a terrorist attack come.
• Intoxicated people, the mentally ill, the homeless, and immigrants piling up and clogging ER entry ways.

All true enough. Our ER “system” may well be at the “breaking point.” Critics snicker when the word “system” is used in referring to any aspect of U.S. health care. If only, critics assert, we had a government-run system for all, surely at last we’d have a real “system” for handling all health care “crises.”

Critics fail to mention the “ER crisis” partly stems from federal doing. In1986, Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA) to ensure public access to ER services regardless of ability to pay. By offering this “universal” access to ERs through federal law, the government helped create the ER crisis.

EMTALA means hospitals must accept all comers with an “emergency” – a cough, headache, hangnail, boil, burn, pain, constipation, loose stools, heart arrest, ruptured disc, drug abuse, household beatings, alcohol overdose, gunshot wound, mental distress, stabbing, car wrecks, HIV, psychosis, personality problems, or any other complaint, real or imagined, which a person knows or thinks may require medical attention.

EMTALA applies “only” to “participating hospitals” accepting payment from HHS (Department of Health and Human Services), and CMS (Centers of Medicare and Medicaid). EMTALA, in other words, forces all hospitals to accept who enter ER doors, for if hospitals don’t accept federal payment, they’re out of business. Run a hospital, and you live or die by EMTALA – or you close your ER or trauma center doors, as hundreds of hospitals have done, more than 70 in California alone since 1990. EMTALA, in effect, obligates hospitals to treat all ER patients but don’t pay for care.

EMTALA shows unforeseen consequences of a government effort to protect the public.

To repeat these consequences:

• overcrowded emergency rooms (nearly all ERs say they can’t cope with the present load of 115 million visitors each year),
• long waiting times (the average waiting time at Massachusetts General Hospital, a premier teaching center, is 5 ½ hours),
• diverted ambulances (on average one every minute for a busy ER),

Unfortunately, the consequences of this federal protection are:

• financially overburdened hospitals forced to close ERs ( hospitals say unpaid ER visits with subsequent hospitalizations make up as much as 50% of bad debt),
• difficulties obtaining specialty coverage (73% of hospitals say they don’t have adequate ER specialist coverage.)

Just a word, if I may, about hospital’s hard times in obtaining cover by specialists, such as neurosurgeons, neurologists, cardiologists, or orthopedic surgeons. In my just released book, Innovation-Driven Health Care (Jones and Bartlett, 2007), Stefani Daniels, managing partner of Phoenix Medical Management, a consulting firm devoted to case management for hospitals, writes a case study entitled “Emergency Rooms, Hospitals, and Innovation.”

Daniels describes how a 2003 EMTALA revision has intensified specialist shortages. EMTALA now permits specialists covering ERs to be on call at more than one hospital and to schedule surgeries during on-call hours. This revision allows doctors to opt out of being on call for the ER.

A study by the American College of Emergency Physicians, underwritten by the Robert Wood Johnson Foundation, found two-thirds of hospitals report inadequate specialist coverage. This lack of coverage has many fathers: EMTALA changes, no or low pay to physicians covering ERs, sky-high malpractice rates, doctors balking at disrupting their private lives to care for non-paying patients in ERs, and doctor options to earn more income in their own outpatient facilities or specialty hospitals.

Hospitals are innovating by hiring full-time specialists, who have the security of full-time employment, malpractice coverage, and regular hours, while the hospital gains predictable coverage, quicker consultants’ response, and shorter hospital stays.


One can argue what IMTALA, universal ER coverage in America, portends. Brian S. Gould, MD, a seasoned health care executive who has traveled the world consulting for various national health systems, including those in Europe, and who is senior vice-president for Navimedix, a health communications firm, observes, “In America when you’re hit crossing the street, you’re taken to the hospitals and receive the finest care in the world. In Italy, they call that universal coverage. In the U.S, we call it being uninsured.”

Not quite. In America, universal care implies full cradle to grave care. Whatever you call it, I doubt full coverage and more federal funds will relieve ER pressures. When someone else is paying for it, you’ll always know where to go. You’ll go someplace with the word “emergency” on its doors, you’ll go someplace you know is always open, you’ll go where 911 or your doctor directs you. If you’re an illegal immigrant, who account for 25% of ER visits, you may have no other choice. Superimposing universal care on the present system is unlikely to relieve ER pressures.


1. Kowalczyk, Liz, At the ER, The Stay Can Reach 8 Hours: Loss of Beds at Major Bay State Hospitals is Blamed, Boston Globe, March 25, 2008.
2. Institute of Medicine, Hospital-Based Care at the Breaking Point, June 14, 2006.
3. Babula, Joelle, Hospitals Work to Solve Emergency Room Crisis, Las Vegas Review Journal, August 25, 2000.
4. Reece, Richard L, Innovation-Driven Care: 34 Key Concepts for Transformation (Jones and Bartlett, 2007), Chapter 14 – From Independent Specialty Practice to Hospital Employment, Case Study, by Stefani Daniels, Emergency Rooms, Hospitals, and Innovation.”

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