Emergency uncertainty under Obamacare
Emergency physicians who staff the last line of defense for health care are feeling quite a bit of angst regarding the current health care crisis and the feeling our voices aren't being heard.
As I briefly explained when Rep. Kevin McCarthy called on me at the Aug. 26 town hall meeting at Cal State Bakersfield -- that was me in the bright pink shirt, the first person he called on -- most of the patients we see either have no insurance or rely on MediCal. Compensation for many of these patients is a very low, deeply discounted rate.
But no matter how serious the condition they present with, from an earache, to a gunshot wound to the head, or a non-compliant diabetic with overwhelming sepsis and multi-organ failure requiring central lines and intubation for ventilatory support, we receive the same capitated or deeply discounted rate as our reimbursement while assuming a huge liability risk for their care.
Typically, these are the patients that have "government-sponsored insurance," or no insurance at all, and are typically the ones who can't get in to see a primary care physician or clinic doctor. The PCP, if he participates in the MediCal program, usually doesn't see these patients. Instead, he has a "mid-level provider" seeing these folks en masse because the reimbursement doesn't pay for his overhead, thus he must see a huge volume of patients to cover expenses.
As fewer providers agree to accept these inferior reimbursements, they quit participating in the program. Fewer providers, more crowded clinics, delayed or missed appointments mean the patients are sicker, meds aren't refilled, and they end up on our doorstep in the emergency department seeking care. These providers/clinics can and do refuse to see patients based on ability to pay -- however, with the federally unfunded mandate of the Emergency Medical Treatment and Active Labor Act (EMTALA), we cannot refuse anyone based on ability to pay.
Our badge of honor in emergency medicine is that we never deny anyone health care based on their ability to pay. We are the only ones who day or night see anyone and provide health care; we're just seeking compensation for this care.
These are the types of patients who President Obama envisions by nationalizing health insurance for the masses, so that even the 46 million patients with no insurance will have the type of coverage that reimburses those of us on the front line 15 to 20 cents on the dollar for our time, expertise and significant liability risk. This nationalized health care is insurance in name only. We are their PCP's. These patients will continue to use the ED as their care provider as they become frustrated over the limited access to care that's on the horizon if this model is at all similar to the current Medi-Cal system.
Due to budget cuts, when the governor of California releases prisoners onto the health care scene, where do you think they will end up? At our emergency departments.
There are no provisions in HR 3200 for providing health benefits for illegal aliens. But rest assured, when any undocumented individual from any country comes to our ED, we will see and treat them to the best of our ability and not get reimbursed for their care -- another example of the free care we provide every day in emergency departments across the country, thanks to EMTALA.
Tort reform should be a key part of this legislation. Every patient we see is a possible improvised explosive device waiting to blow up in our faces, today, tomorrow or next week. The risk on every patient we see for a possible bad outcome is real and the possibility of a certified letter from a malpractice attorney using the "restrospectivescope" to second-guess our care hovers over our heads daily. All for free or a deeply discounted rate; a rate that we often have to chase down. Will the government-sponsored health plan also be named in the suit?
Colleagues often argue that this is a business. Well, it is a business that is rapidly going bankrupt. Continuing to discount our services, cutting back our fees, will ultimately lead to fewer motivated folks going to medical schools. Fewer physicians, so even more patients will end up in the ED's across the country.
As KMC gets into the black by closing beds in the ED, leading to lengthy waiting room stays, where do you think those patients end up? Other community ED's. Their black is everyone else's red. KMC receives government subsidies to see the very patients they are turning away. DSH funds (for disproportionate share hospitals) go to safety net hospitals that see a higher, disproportionate number of the uninsured or low-income patients. In fact, all the local emergency departments are seeing these patients; we should also be eligible for similar funding.
So now we can trust the government to establish national health care and run it successfully, just as they have with the Postal Service, the VA or the health care seen on Native American reservations? Go ask any veteran or Native American about their health care and the limitless delays they face every day under government supervision. Where does the average Joe sign up for the same plan as the senators and congressman in Washington, D.C.?
In the recent stimulus packages, the banking industry was given a lifeline. Emergency departments have been given an anchor. What's obvious is that Wall Street, trial attorneys, HMO's and the insurance industry clearly have more powerful lobbies than those of us in Emergency Medicine.
Over 80 hospitals and 50 emergency departments have closed in California over the past 10 years, squeezing the vise of health care on those of us at the end of the health care food chain. Access to medical care is at a breaking point, and we in emergency medicine are at the fracture site.
We are your safety net, and it's full of holes.
Les Burson is a doctor of osteopathic medicine and president of Pinnacle Emergency Physicians of Bakersfield.
