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ER's Feel Pressure of Increasing Number of Uninsured

June 22, 2009
Friday, May 22, 2009 ERs feel pressure of increasing number of uninsured Denver Business Journal - by Bob Mook More people are showing up at emergency rooms in Colorado and nationwide, having little choice after losing jobs and their health coverage. The trend is symptomatic of several problems in the health care system that are driving up the costs of insurance premiums for employers, and is at the crux of the debate on health care reform. When people show up at an emergency room (ER), doctors and nurses are obliged to care for them whether or not they can pay. Emergency care is expensive, but many ER patients who lack coverage can pay very little of what’s charged. The costs are ultimately passed back to those who can pay — including employers who pay the bulk of their workers’ insurance premiums. Debbie Welle-Powell, vice president of payer strategies and legislative affairs at Exempla Healthcare, which operates three hospitals in the Denver area, estimates that 22 percent of the patients who visit Exempla’s ERs have no insurance. Welle-Powell pegged the average ER visit at $700. But the cost of an emergency-room visit can quickly climb to $10,000 if CT scans and other expensive tests are needed. Although Exempla gives uninsured patients a discount of up to 60 percent on medical services and flexible repayment schedules, most of the costs go uncompensated. “We get back about 8 cents on the dollar,” Welle-Powell said. “It represents about $15 million in billed charges for us.” EDs also deal with a fair number of patients on the federal Medicaid program who lack family doctors. That’s because reimbursements from the government program are so low that doctors either limit the number of Medicaid patients they see or refuse to serve them. While a handful of community health centers in the state specialize in Medicaid patients, the waiting lists for appointments can be long. As a result, the EDs are flooded with people who choose them as the provider of first resort. “A lot of times when someone walks in, they say their primary care provider is the ER,” said Polly Anderson, policy director of the Colorado Community Health Network, a nonprofit that represents 14 community health centers in Colorado. But to maintain their own fiscal health, hospitals pass the costs back to the private sector. “It has to be covered somewhere,” Welle-Powell said. “That’s what’s made health insurance less affordable to employers.” Crisis hits home Nowhere in the Denver area is the ER dilemma more apparent than at Denver Health, a safety-net hospital largely subsidized by federal dollars and local government. In April, Denver Health’s emergency and urgent-care units treated between 250 and 450 patients a day. About 6 percent of the children and 23 percent of the adults who go to Denver Health’s ER are admitted to the hospital, said Dr. Vince Markovchic, director of emergency medicine there. Overall, about 60 percent of the patients in the hospital were admitted through the ER. “The reason these numbers are so high is that these people have absolutely nowhere else to go,” Markovchic said. “They have no doctor to call for advice. They have no doctor who can see them in the office. A lot of them have lost their insurance recently. And that’s why [patient volume] has gone up so dramatically.” A physician for 39 years, Markovchic said demand on emergency care is growing in Colorado and nationwide. “Back in 1970, emergency rooms were exactly that — two little rooms in hospitals,” he said. Health insurers at that time wouldn’t pay for what’s now regarded in the industry as “outpatient” care. “They would tend to pay for emergency-room visits, but they wouldn’t pay for office visits,” he said. “And, guess what? Patients figured that out pretty quick. Rather than paying cash up front for the office visits, they started showing up at emergency rooms.” Markovchic cites statistics that show the number of patient visits to ERs nationwide was 120 million last year. “It’s going up probably 7 to 10 percent a year,” he said. “And again, a lot of that has to do with access to care.” The growth of patient volume is directly linked to the lack of access to care, Markovchic said. He added that about 50 percent of the patients coming to the hospital have no insurance — compared with 45 percent last year. “The reason it’s not higher is because trauma patients who are brought in by the ambulances are more likely to be insured,” he said. “If you walk in here, you’re much more likely to be in here because you have no insurance.” Meeting the challenge The financial realities, combined with growing patient traffic, have forced local hospitals to adapt new approaches and technology designed to help medical professionals operate efficiently while giving better care. To accommodate the heavy traffic, Denver Health’s ER and urgent-care units have become well-oiled machines, capable of handling a high volume of patients without diverting patients to other hospitals. Markovchic credits the advent of electronic medical records (EMR) of patients who’ve been to the hospital before for helping doctors and nurses move patients along faster. “Within a minute or two, we can pull up the old medical records and old EKGs, discharge summaries and X-ray reports,” Markovchic said. “Hopefully that means we’ll do fewer tests.” Dr. Adam Hill, assistant medical director for the emergency department at Denver’s Saint Joseph Hospital, said the hospital is “busy all the time” but hasn’t experienced a sharp upturn in patient volume in the last six months. Hill credits EMR and a new approach to handling patients for helping the emergency department operate more smoothly. He said the objective is to get patients out of the triage as quickly as possible and ask them for their basic medical information as they’re waiting to be examined. “We see 80 percent of our patients in less than 30 minutes,” Hill said. The hospital also has set up a special triage for cardiac patients that gets them to undergo an EKG and see a doctor within 10 minutes to establish whether they’re having a heart attack. bmook@bizjournals.com | 303-803-9221