ER problems worsen, future is uncertain with new health care plan

By Caroline Young | gargoyle@flagler.edu

Eliza Jordan was waiting for her slushie in front of the Surf Station when the dehydration hit from a long day of surfing under the hot St. Augustine sun. Within seconds, the Flagler College junior was lying unconscious on the cement with a cracked skull.

When she woke up, she could not remember where she lived or her father’s phone number. The slushie vendor called an ambulance and Jordan was rushed to the Flagler Hospital Emergency Room, where her nightmare began.

“They let me lay there in dried blood for a good hour, hour and a half before they tried to clean the back of my head and hair,” Jordan said. “Then they proceeded to give me a shot to numb my head but failed to tell me they were giving me the shot on my head, right near the shattered part of my skull.”

Situations like Jordan’s are common throughout the country as ERs are overflowing with people in need of urgent care.

According to a United Press International article, the average “length of stay” in a U.S. emergency room has recently increased to four hours and seven minutes.

“After they got me in a room, I waited for a nurse for over two hours, waited for a doctor for over three, waited to get tests for over four, then didn’t hear anything for at least six,” Jordan said. “I was miserable… It was the longest most painful day I think I’ve ever had…The waiting was the worst part.”

Two years after Jordan’s head injury, she visited the ER again, but this time she had a severe kidney infection. Jordan said she was immediately taken in, but it took six hours before anybody told her anything.

“I was scared that I wasn’t going to live,” she said.

What are the issues?

“The biggest problem is invisible,” Flagler Hospital President Joe Gordy said. “It’s a capacity issue.”

Gordy said Flagler Hospital and hospitals across the country are dealing with the same issue of patients taking up ER beds who have already been admitted to the hospital but there is simply not enough room for them there.

“So now all of a sudden you don’t have 30 beds… you only have 10 beds available for the people who are showing up [in the ER],” Gordy said. “And it’s getting a little bit worse all over the place.”

Obama’s new health care law will expand health coverage to 30 million previously un-insured Americans in an effort to reduce long waiting times and to cut un-compensated care costs which come from things like ER visits.

According to an Oct. 2010 report by U.S. Senators Tom Coburn, M.D. and John Barrasso, M.D, proponents of the new health care law feel Americans without health insurance only go to the ER because they are required by federal law to receive treatment there. They think insurance expansion will decrease waiting times and tame the overflow.

On the other hand, opponents of the plan believe ER wait times will increase because there will be a shortage of primary care doctors with so many more people gaining access to health insurance.

“I think something’s got to happen,” said Stacy Hishinuma, a local ER nurse who has been working for 10 years in ERs all over the country.

She thinks the outcome of the health care plan can go either way.

“There are those that will maybe have access now to a primary care doctor . . . as opposed to using the ER for minor stuff . . . they use it now because they don’t have any other option,” she said. “But there are those that say it’s going to take longer to see a doctor so more people will come to the ER.”

In a recent national survey of ER doctors, 70 percent of those who responded said the ER is currently overcrowded at least half the week, according to Coburn and Barasso.

Locally, Gordy said the hospital is overcrowded at least one day a week.

“There’s a lot of people who don’t have anywhere else to go,” he said.

Coburn and Barasso’s report said in addition to the insurance expansion, over 16 million Americans will have enrollment in Medicaid, a governmental insurance program providing health coverage to low-income Americans, after the new health care plan comes into play. The report said patients are denied care from about half of the practicing doctors, causing them to visit the ER more often than those without insurance.

A recent report from the Center for Disease and Control Preventions reveals Medicaid patients accounting for 25 percent of the total ER visits during the year.

“That is the biggest thing I think about,” Gordy said. “People who don’t have insurance . . . doctors won’t take them in their office . . . Nobody takes Medicaid either because it’s so poor that it costs them more to file the claim than the money they [the physicians] get back.”

Hishinuma said the ER where she works has a large number of Medicaid patients who come in because they were turned away from physicians.

“For example, they have a broken arm . . . and we say, ‘Okay, we can do this today but you know you have to be followed up with an orthopedic doctor,'” she said. “That’s not something we can fix long term in the emergency department so then they call back two days later and say, ‘I called every orthopedic in town…Nobody’s going to take my Medicaid’ . . . so then the patient is stuck.”

The Congressional Budget Office predicts the health care overhaul will cause Medicaid patients to have about 68 million ER visits in a year, according to Coburn and Barasso’s report.

Gordy is concerned there are not enough primary care practitioners with some not even accepting new patients.

“There’s never enough of them,” he said. “Sometimes it’s really hard to get an appointment and that’s why people wind up going to the ER.”

According to Coburn and Barasso, Massachusetts passed the health care reform in 2006, but thousands of government-funded patients with low incomes ended up using ERs at a rate one-third higher than the state’s average. The ER doctors in Massachusetts said a major reason for ER overflowing for routine care was a lack of primary doctors.

Who should have free care?

“I’ve had a patient come in because they had a wart on their hand and they were getting ready for a blind date . . . they wanted it removed before the date came,” Hishinuma said.

She thinks the main problem with wait times is people using the ER for “non-emergent” problems.

“People would come in for pregnancy tests and we’re like, ‘well you realize you can go to Planned Parenthood . . . or the grocery store,'” she said. “And they’ll go, ‘well I know but . . . here it’s free because I have Medicaid.'”

She recalls a time when a diabetic single mother was cut off from Medicaid because she started a job that exceeded the maximum income to receive the aid. Her new employer did not provide her with benefits for the first three months of her employment so she was unable to take her diabetes medication.

“She was trying to stretch it out [the Medicaid] because it was very expensive,” Hishinuma said.

The woman had put herself through school while raising her children.

“They’ll pay for these people to go and have a pregnancy test in the emergency department . . . but they’ll kick this woman [out] who is trying to better her life and who is trying to be a ‘good American,'” Hishinuma said.

Two weeks before her insurance kicked in, the woman came into the ER with diabetic ketoacidosis because her blood sugar was extremely high.

“Because she couldn’t get her medicine, she ended up in the ICU [intensive care unit] for three days, not covered by insurance, not covered by Medicaid,” Hishinuma said. “Now she’s stuck with this ICU bill in the hospital for Lord-knows-how-many thousands of dollars.”

Hishinuma said patients like this diabetic woman can be dangerously left without treatment, while others are being seen for non-emergent issues.

“I think it was the first time I realized our health care program was screwed up,” she said.

She said patients come into the ER for things like pregnancy tests and warts simply because they would rather not pay anything.

“Because of the EMTALA Act [Emergency Medical Treatment and Active Labor Act] that says we’re not allowed to turn anyone away from the emergency department, a lot of people who don’t have anywhere else to go come to the emergency department for routine care because either they don’t have insurance, or they don’t have a primary doctor or some place they can go for minor things,” Hishinuma said.

What about the future?

In an effort to keep non-emergent patients out of ERs, Flagler Hospital has started a primary care clinic where those without insurance can be treated at a low cost.

“I moved the primary care clinic into a much bigger facility,” Gordy said. “And I’m ready to expand that if we have to accept more Medicaid people to try to keep them out of the ER because that’s not the right place for them.”

Along with Flagler Hospital’s primary care unit, Gordy said the hospital has improved the transitioning of patients from the ER in to the main hospital by creating an admissions unit about a year ago. The hospital is also starting to build an observation unit to hold patients and run tests on them.

“Sometimes that requires an overnight stay . . . What we’re trying to work on right now is, ‘how can I avoid the overnight stay?’ . . . By speeding up testing,” Gordy said. “We want to build it to move people out of the ER.”

Hishinuma said hospitals are always trying to do things to reduce wait times, like take blood while patients are waiting in order to give the doctor the results as soon as he or she sees the patient and decide whether or not they need to be admitted to the hospital.

“At every hospital there are things being done to try to turn patients faster…get things done quicker to try and lessen the wait times,” Hishinuma said.

Besides Jordan’s head injury, she has been admitted to the ER four times in the last six years for a kidney infection, a cracked tailbone and torn finger muscles. She said overcrowding was always an issue in the ER.

“I think the biggest problem was and [still] is waiting to see a doctor, getting the tests and seeing the responses,” Jordan said.

Although some people fear the major expansion of Medicaid under health care reform will increase ER waiting times and problems, Gordy is not worried drastic measure will be taken anytime soon.

He does not think the House of Representatives is going to fund the Medicaid expansion, at least not on schedule with the health care plan.

“The money’s not there to fund it and the states don’t want to do it either because they don’t have any money to fund it . . . so I think that’s going to get put on hold,” Gordy said. “I don’t think the health care plan is going to have much effect on the short term for any event.”

There are rough plans statewide and nationwide to prevent an even bigger overflow of people in the ER, but Gordy said nobody currently knows exactly what to do.

“It’s all up in the air right now,” Gordy said. “We’re all just sitting and waiting to see what happens.”