Emergency Care in
California
Overwhelmed, Underfunded and in Peril
The California Chapter of the American College of Emergency Physicians
Emergency Departments in California
- Demographics
- 520 hospitals in California
- Serving 10 million patients/ year
- 3000 Emergency Physicians
- ERs are safety net for health care system
- Emergency Physicians must care for all patients. No market place dynamics.
Hospitals & ER Closures
ER Overcrowding & Ambulance Diversion
- WHY are ERs OVERCROWDED?
- 1. Decreased Capacity (hospitals closed)
- 2. Increased Volume (more patients)
- Increased Use of ERs:
- 89 million – 100 million: 1992 – 1998
- 70,000 additional uninsured per month =
840,000/year
- Bypass/ Diversion – Definition:
- Ambulance can’t go to closest ER; must "shop" for ER that
has a bed
- Suspension of Diversion = when all area ERs are full, they all must accept any patient,
regardless of capability
- Bypass/ Diversion - Statistics
- Los Angeles: 60 out of 81 ERs in LA; Harbor 73%; MLK 50% (12/99)
- San Diego: 30% of the time one San Diego; 15% of time overall county (12/99)
- Riverside: Wait for 30 minutes outside ER for bed
- Orange County 2/28 hospitals with problem
- 31%, 18% of time on bypass (2/00)
ER Overcrowding & Ambulance Diversion
- Patient Consequences
- Preventable Deaths & Disabilities
- 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
- Insurance Status does not matter
- How did this happen?
- The Impact
- System: ER closures & transfers: "domino effect"
- Patients: preventable deaths and disabilities
Financial Murder: Why are ERs Going Broke?
- 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 dwindles each year
- 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 was 49th, now 50th for Medicare
reimbursement
- Per Capita Medicare Expenditure: $2600 vs $3500 ave
- Medicaid Capitation Rate: $85 vs $130
- Commercial Capitation Rate: 30% lower National
Medi-Cal Managed Care Saga
- Under funded
- No pay, slow pay, low pay
- 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
Solutions
- 1. SB 1177 Perata
- 2. State Budget Act.
- Medi-Cal pay its fair share
- 3. Medi-Cal Managed Care
- Eliminate subcontractors/ "brokers" of Emergency Care
- 4. Maddy EMS Fund
- Increase funding of indigent care
Sources
USA Today. Feb 4, 2000. Front Page. ER
Crisis. Julie Appleby.
EMS Commission Report. Jan 26, 2000. Issues impacting Hospital Diversion and EMS
Systems. www.emsa.ca.gov/hospcrwdrpt.htm
Derlet and Richards. Annals of Emergency Medicine. Jan
2000; 35:1. Overcrowding in the Nation’s Emergency Departments: Complex Causes and
Disturbing Effects.
LA Times. Page 3. Feb 15, 2000. Treating an Emergency Care Crisis. Miguel Bustillo.
LA Times. Jun 1, 1999. ER Patients Lose In Specialists’s 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
On Call Task Force Survey 1999: California Medical Association, California Healthcare
Association, and California Chapter of the American College of Emergency Physicians
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