On a recent Saturday night, all 36 beds at San Diego’s Hillcrest emergency room are full and three patients lie on gurneys in the corridor just outside.
A doctor perches on a stool next to one of the hallway beds and stitches a gaping knee wound while the patient, grimacing, holds a mobile phone above him for extra illumination. Others in the hallway watch curiously, including a young child clutching the hand of a woman lying on a bed nearby.
“There’s nothing more appalling than being treated in a hallway bed,” said James Dunford, medical director for the city of San Diego’s emergency medical services system. The emergency room is “the canary in the coal mine” for what patients can expect from U.S. health care over the next few years, he said.
ERs, the front line of modern medical care, are crumbling nationwide just as patient visits promise to surge with the 2014 rollout of the Affordable Care Act adding 25 million newly insured patients over time. ER doctors say they expect these people, seeking the everyday care they couldn’t get before, to flood a system already so overcrowded that some hospitals are unable to accept ambulances for days at a time.
“There’s a shortage of all types of doctors now, and it will only get worse with many Baby Boomer doctors retiring as the Baby Boomers age,” said Darria Long Gillespie, a doctor at Beth Israel Deaconess Medical Center in Boston.
Health reform was envisioned as easing pressures on ERs by providing the uninsured with coverage to see primary care doctors. That would mean more preventative care that would reduce health emergencies and allow the newly insured to see doctors rather than get care in emergency departments.
Policy makers, however, largely haven’t dealt with a major barrier to this plan: a dearth of primary care doctors, many of whom aren’t accepting new Medicaid patients, set to make up more than a third of the newly insured, partly because of the program’s low reimbursement rates.
The result: “They’ll end up in the ER,” Gillespie said in a telephone interview.
Studies in the Annals of Emergency Medicine over the past two years suggest the fears are well-founded. A 2011 report by researchers at Harvard Medical School found that ER utilization in Massachusetts rose in all 11 hospitals they studied after the state began implementing its 2006 health-care overhaul act. A 2012 study found that Medicaid patents are twice as likely to use the ER as those with private insurance.
Nationwide, about 20 percent of U.S. adults report at least one emergency room visit a year, and 7 percent report two or more visits, according to a study of 2011 data released May 30 by the Centers for Disease Control and Prevention.
“Health planners and states should start preparing for an increase in ER visits,” as a result of the U.S. health law, said Peter Smulowitz, the Harvard researcher who led the 2011 study, in a phone interview. “There will be higher demand.”
What the newly insured will find isn’t pretty, according to surveys by the Chicago-based American Hospital Association. Two decades of hospital closures have thinned the number of ERs in the U.S. by about 650, leaving more than half of the remaining ERs reporting that they regularly operate at or over capacity.
The overcrowding “we see now is going to pale in comparison” once the health-care overhaul kicks in fully, said Ryan Stanton, director of emergency medicine at UK Healthcare Good Samaritan Hospital in Lexington, Kentucky.
“We’re about to get a perfect storm that will lead to decreased access,” Stanton said in a telephone interview. “The current dialogue on medicine isn’t addressing this.”
The fallout for patients at the most crowded ERs includes longer stays, higher costs and a 5 percent jump in mortality risk, according to a study involving almost 1 million ER visits published in the Annals of Emergency Medicine in December.
Closed to Ambulances
In some cases, patients can’t even get access to ERs. In January, San Diego’s Hillcrest ER was so overwhelmed it closed to ambulance traffic for about 100 hours, according to data supplied by University of California, San Diego Health System. In February, the ER blocked ambulances for about 50 hours.
While the reasons behind the ambulance shutdowns are complex, they’re underpinned by a basic fact highlighted by Dunford: Seven hospitals in San Diego’s city limits have closed since 1984, leaving Hillcrest “taking care of everything.” That includes psychiatric patients, who tend to need longer and more complex supervision.
Nationally, more than one in four ER departments have closed in the past two decades, according to a May 2011 study on ERs in non-rural areas in the Journal of the American Medical Association. Sixty-six percent of the ERs were shuttered because the hospital itself closed and, for the remaining 34 percent, the ER was closed while the hospital stayed open.
Rise in Visits
The closures are happening even as ER visits in the U.S. rise, climbing about 30 percent to 123 million annual visits in the decade from 1998 through 2008, according to the study.
Compensation is also lagging. Medical centers received about 90 cents in 2010 for every $1 spent by hospitals caring for Medicare and Medicaid patients, according to a 2012 American Hospital Association report.
While hospitals in well-to-do areas can offset that shortfall with higher-profit care for insured patients, safety-net hospitals that serve a large number of low-income patients often can’t, said Jesse Pines, an associate professor of emergency medicine and health policy at George Washington University in Washington.
“The number of ERs is shrinking, hospitals are closing in some of the poorest areas, and the overall number of ER visits are increasing year over year,” Pine said in a telephone interview. “It’s a serious issue.”
Two hospitals closed in Pennsylvania in the past year, according to the state’s Health Care Cost Containment Council. Included in that list was Marian Community Hospital in Carbondale, a facility licensed for 70 beds.
Now the closest ER is a small hospital about nine miles away in Peckville, Pennsylvania, and another larger, non-profit hospital about 15 miles away in Honesdale, called Wayne Memorial. Wayne has seen ER use jump at least 10 percent from the 20,000 visits that would be normal in a year, according to David Hoff, the hospital’s president and chief executive officer.
Steve Durkin, executive director of the Greater Carbondale YMCA, said he’s worried that seniors and less advantaged younger people who use his facility won’t be able to get to Wayne in the event of an emergency even if they are insured.
“I miss it,” he said of the former Marian Hospital, in a telephone interview. “It’s a problem when you have to travel half an hour to get help. We have lots of seniors here. For them, that’s a hike.”
Long waits are also prompting dangerous frustration. An estimated 1.6 million emergency department visits resulted in people leaving against medical advice in 2010, according to the federal government’s Agency for Healthcare Research and Quality. Some return later by ambulance when their health deteriorates.
“It’s a crisis,” said Arthur Kellermann, an analyst at Rand Corp., a Santa Monica, California-based research group, in a telephone interview. “We’re turning a blind eye to the most glaring, most dangerous public-health issue today.”
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