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Uninsured Put a Strain on Hospitals
By Reed Abelson, The
New York Times
December 8, 2008
Dr. Vincent Markovchick, head of emergency services at Denver Health, told of encountering patients who have lost insurance.
As increasing numbers of the unemployed and uninsured turn to the nation’s emergency rooms as a medical last resort, doctors warn that the centers — many already overburdened — could have even more trouble handling the heart attacks, broken bones and other traumas that define their core mission.
Dr. Melissa Hippely, a resident at Denver Health, examined Matthew Armijo last week. Mr. Armijo, who was laid off in August, arrived at the urgent care center with abdominal pain.
Even before the recession became evident, many emergency rooms around the country were already overcrowded, with dangerously long waits for some patients and the frequent need to redirect ambulances to other hospitals.
“We have no capacity now,” said Dr. Angela F. Gardner, the president-elect of the American College of Emergency Physicians, which represents 27,000 emergency doctors. “There’s no way we have room for any more people to come to the table.”
In a report to be released Tuesday, her group warns that the nation’s system of emergency rooms is in “serious condition.” Dr. Gardner argues that any public discussion of overhauling the current health system must include the nation’s emergency departments.
The number of patients coming to emergency departments has been steadily increasing. Helping push up that volume have been the growing ranks of the uninsured, because emergency rooms are legally obliged to see all patients who enter their doors, regardless of their ability to pay. But even insured patients who have no quick access to regular doctors are also showing up — among them older people, who represent the fastest growing population of emergency room visitors.
So far, there are no firm figures on the recent influx. But even two years ago, when a government survey found that the annual volume of visits to emergency departments had reached 120 million — a third higher than a decade earlier — doctors considered many emergency rooms overburdened.
Now the recession, whose full impact is yet to be seen, threatens to make conditions even worse, emergency doctors say. Hospitals are absorbing increasing amounts in unpaid medical bills, and some are already experiencing much higher numbers of patients without insurance.
For example, Denver Health, a public hospital system, had a 19 percent increase in emergency visits by uninsured patients in November — to 3,325, up from 2,792 a year earlier.
“Virtually every time I work a nine-hour shift, I encounter a couple of patients who have never been here before because they’ve just lost their insurance,” said Dr. Vincent J. Markovchick, the director of the hospital’s emergency medical services.
They include patients like Matthew Armijo, 29, who was laid off from his client services job at a technology company in August and could continue his health insurance only through October. He showed up at Denver Health’s urgent care center, a part of the emergency department, suffering from increasing abdominal pain. Mr. Armijo said he went there because he would not have to pay anything.
Denver Health expects the amount of care it delivers for which it will never be paid to grow to more than $300 million this year, compared with $276 million in 2007.
Some patients are people who have delayed seeking medical care as long as they can, like those who arrive during an asthma attack after deferring treatment.
“I am definitely seeing patients coming in presenting worse in their illness because they are further along,” said Dr. Katherine A. Bakes, the director of the program’s emergency services for children.
Other doctors around the country also report treating people who seem to have no other option. One emergency room doctor in Iowa, Dr. Thomas E. Benzoni, said he recently saw a mother come in with her two children for what he thought was routine care. When he asked her why she had not gone to her family doctor, she said she did not have health insurance.
“I don’t know what else she was supposed to do,” Dr. Benzoni said.
The increase is not affecting all emergency rooms. Some emergency physicians, in fact, said there had actually been a recent decline in visits. A report by the American Hospital Association for July, August and September found a slight overall decrease in hospital traffic, including emergency visits, as some people apparently sought to avoid spending money on anything they did not deem absolutely essential.
But as the recession continues, many officials of the college of emergency doctors predict it is only a matter of time until the rising number of uninsured and the delays in getting primary care create a crisis.
“I think we’re seeing the tip,” said Dr. Nicholas J. Jouriles, the group’s current president. Patients, he said, will have no choice but to come to the emergency department when they have no money or insurance. “They will get turned away elsewhere,” he said.
One of the doctors’ major concerns is the long waits by patients requiring a hospital bed. The doctors group, surveying its members last year, learned of at least 200 deaths related to the practice of “boarding” — in which patients on stretchers line the corridors until they can be moved into a bed.
“Crowding is a national public health problem,” said Dr. Jesse M. Pines, an emergency physician in Philadelphia.
Patients forced to wait for hours on end for a bed clearly suffer.
“It was pure hell,” recalled Robert Roth, whose 90-year-old mother, Kato, last year spent 36 hours at the emergency department of a Queens hospital, near her home in Jackson Heights, waiting for a room after going to the emergency room in the middle of the night. Mrs. Roth, who had a recent series of falls, said she had been hearing music in her ears, and both her son and the doctor he called were worried about a possible stroke.
After the first five hours of waiting, she became increasingly disoriented and delusional. Mr. Roth was unable to stay with her during the entire wait. After he left and returned, he said, the hospital staff told him they had no idea where she was. She turned up in an empty room off the emergency department, and her physical and mental condition had clearly deteriorated, Mr. Roth said. She believed that she had been kidnapped.
When she had to go several weeks later to another emergency department in Manhattan, she endured a 20-hour wait for a room, again becoming disoriented after several hours, forcing her to be sedated.
The emergency staffs “just seemed overwhelmed, overwhelmed,” said Mr. Roth, who wondered why emergency departments could not handle the elderly in a special fashion.
Dr. Ann S. O’Malley is a physician and senior researcher for the Center for Studying Health System Change, a nonprofit group in Washington that has studied emergency services in different communities. While some hospitals have taken steps to reduce crowding and move patients more efficiently from the emergency department into rooms, Dr. O’Malley said, others have responded by expanding their facilities — attracting more patients.
“Emergency departments,” she said, “are a kind of barometer of the general health of the rest of the system.”
Dr. Eric J. Lavonas, an emergency physician in Denver, said: “The nation’s emergency rooms are the end of the line. We will strain and stretch and bulge under the weight.”
Dr. Gardner, of the emergency doctors’ group, said the question now is whether the emergency room safety net will break — how often people with heart attacks will not be able to get care in time to be saved. Her group’s report, she said, is meant to alert people to the precarious nature of the system.
“What they don’t understand,” she said, “is that the system is fundamentally flawed and will fail.”
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