The California Chapter of the American College of Emergency Physicians
Emergency Departments in US
1998-1998 loss of 1,128 ERs
Number of ED visits increased 15% since
1990
By 1998 1 out of 5 people had at least
one ED visit
Emergency Departments in California
310 hospitals with EDs in California -
1999
(OSHPOD data,
excluding standby EDs)
Serving nearly 10 million Californians
per year
3000 Emergency Physicians + several
thousand on-call back up physicians
ERs are safety net for health care system
Federal law requires emergency treatment
for all patients. No
market place dynamics.
1999
1990
Comprehensive
9
7
Basic
301
332
Stand-By
47
68
Total
357
407
Hospitals & ER Closures in California
Decreased Number of ERs:
12% decline in number of EDs from 1990 –1999
407 to 357
19 closed since 1995; 9 in 1999/2000
LA:
20% of all hospitals in past 20 years
Increased ER Utilization:
8.4 to 9.4 million : 1990
– 1999
Increased urgent and critical visits
1990-1999
58% to 65%
Decreased non-urgent visits by 6%
ER Overcrowding & Ambulance Diversion
WHY are ERs OVERCROWDED?
1. Decreased
Capacity (hospitals closed)
2. Increased
Volume (more patients)
3. Multifactorial
Causes: increased
complexity of patients, in-patient hospital bed shortage, nursing
shortage, on-call specialist shortage, increased need for transfers
Bypass/ Diversion
Definition:
Ambulance can’t go to closest ER;
must “shop” for ER that has a bed
Suspension of Diversion, Round Robin
Diversion = when all area ERs are full, they all must
accept any patient, regardless of capability
Bypass/ Diversion – November 2000
San Diego: 12/20
hospitals on bypass more than 20% of the month
Grossmont 38%; Kaiser 35%; Alvarado 35%; Sharp Chula Vista 30%;
UCSD 28%; Mercy 23%
Orange County: Nearly
double total bypass hours from 1999 – 2000
Nov 2000 Mean = 53 hours;
Nov 1999 Mean = 27 hours
FVHMC and Mission Hospital = 19% of Nov on diversion
Sacramento: Nov
2000 nearly double diversion than previous months
Round Robin Hours Nov, 2000 = 150+;
Jan – Oct = 56-76 hours
UCDMC = 42% of Nov on diversion
Los Angeles: Nov 2000 Data
72 hospitals total
33 > 20% of month on bypass = > 144 hours = 46% of
hospitals
6 > 50% bypass = >375 hours
47 > 100 hours of bypass = 14%of the month = 65% of
hospitals
Alameda County: incomplete data, not available
Patient Consequences
Preventable Deaths & Disabilities
AT LEAST 5 KNOWN DEATHS IN WAITING ROOMS
BECAUSE OF NO BED IN THE ED
Patients waiting for respirators
ICU
patients held in ER for days
Long waiting room times
Prolonged pain and suffering
Patient Dissatisfaction
Violence in the ED
On Call Specialist Crisis
Definition:
the doctor you need for your emergency is not available
Survey Results:
Serious problem for 60% of hospitals
Hospital payments for on call services:
$100 million/ year (informal hospital data)
Insurance Status does not matter
The Impact
System: ER closures & transfers: “domino effect”
Patients: preventable
deaths and disabilities
Financial Murder:
Why are ERs Going Broke?
$400 million losses/year in uncompensated care
$317 millon hospital/ $100 million physician
1. Unfunded
Federal Mandate to see and treat all patients
(COBRA/ EMTALA)
< 2% of health care dollar
2.
Increased Uninsured
22% Californians; > 7 million
70,000 more uninsured per month
EMS fund does not meet cost of delivering care
3. No
Pay/ Underpayment by HMO
No incentive to pay
30,000 unpaid claims to DHS in 3 years
$112 million/ year loss from commercial HMO
23% payment by Medi-Cal HMO IF paid at all
4. Under
funding of System
California is 47th for Medicare reimbursement
Medi-Cal Managed Care Saga
Under funded
No pay, slow pay, low pay
Fraud and abuse to provider
Court Room Experience
DHS Appeals Process
Unfair Payment Practices- Down Coding
Examples
28 yo F with Tylenol overdose
Bill = $325; Paid $20.90
10 month old with Febrile Seizure
Bill = $223; Paid $20.90
38 yo with kidney stone
Bill = $231; Paid $16.77
84 yo with acute heart attack
Bill = $288.75; Paid $70
Unconscious patient need life support
Bill = $740.25; Paid $117.32
SOURCES
ER Overcrowding Spreads into Crisis
Territory. LA Times. May
14, 2001. Jane Allen
Emergency Room Demand outstrips supply;
patients potentially at risk.
Center for studying health system change.
May 9, 2001
Emergency Room Diversions:
A symptom of hospitals under stress.
Center for studying health system change.
May 2001.
US Emergency Health Safety Net
Unraveling. New York
Times. Alan Elsner. May
9, 2001
Trend Watch AHA March 2001, Vol 3 No 1
As ER visits climb, hospitals react. The
Philadelphia Inquirer. March
16, 2001
Valley ERs packed, but not by flu.
The Fresno Bee. Barbara Anderson. March
2001.
Patients bypassing primary doctors for
emergency care. AMNews. Leigh Page. Feb 12, 2001
Struggling to Stay Aflota, Save lives in
ERs Chaos. Jan 22, 2001. Mark Morocco.
Doctors say emergency rooms ailing.
Statewide loss put at $400 million per year.
San Diego Union Tribune. Cheryl Clark. January 19, 2001
State Urged to Intervene in Hospitals’
Urgent Care. LA Times. Jan 18, 2001.
3rd page.
Jennifer Warren.
Hospitals divert patients to other
emergency rooms. San Diego Union Tribune.
Cheryl Clark Jan
15, 2001
New trauma center eases little burden.
Emergency rooms still rack up costs.
Kathy
Robertson. Sacramento
Business Journal. Jan 5,
2001
Emergency rooms struggle with crowding
ambulances sometimes directed away from the nearest hospital. USA Today. Julie
Appleby. Jan 4, 2001
Sutter swats frustrated doctors on their
way out. Sacramento
Business Journal.
Kathy Roberson.
January 5, 2001
Emergency room crisis worsening.
Boston Globe. Dec 25, 2000.
Larry Tye.
Emergency Crews Worry as Hospitals Say
“No Vacancy”. New
York Times.
December 17, 2000. Carey Goldberg.
ER Crisis.USA Today. Feb 4, 2000.
Front Page. Julie Appleby.
The saga of general hospital: a real life
soap opera. EMN. Anne Scheck. Feb 2000.
Critical Condition. Time. Daniel
Eisenberg. Jan 31, 2000.
EMS Commission Report. Jan 26, 2000. Issues
impacting Hospital Diversion and EMS Systems.
www.emsa.ca.gov/hospcrwdrpt.htm
Overcrowding in the Nation’s Emergency
Departments: Complex
Causes and Disturbing
Effects. Derlet
and Richards. Annals of
Emergency Medicine. Jan
2000; 35:1.
LA Times.
Page 3. Feb 15,
2000. Treating an
Emergency Care Crisis. Miguel
Bustillo.
LA Times.
Jun 1, 1999. ER
Patients Lose In Specialists’ Rebellion
USA Today.
Feb 4, 2000. Page
6. Deaths lead to debate
in California Laws aimed at hospital closure, consolidations.
Julie Appleby.
AMNews. Geri Aston. Feb
21, 2000. Medicare HMO
Spending.
Irvin and Fox.
Annals of Emergency Medicine. March 2000; 35:3: 287.
Reimbursement
Impact of Medicaid Managed Care Organizations Replacing
Standard Medicaid
Health Care Financing Administration Form 64 and 2082 – 1998
(Medicaid
reimbursement)
Kaiser Commission on Medicaid and the
Uninsured 1998
Closing Time.
California leads the nation in hospital closures.
Nurse Week. May 17, 1999.
On Call Task Force Survey 1999:
California Medical Association, California Healthcare
Association, and California Chapter of the American College of
Emergency Physicians
