Emergency rooms face crisis

Dr. Amorette Miller doesn't know if the patient she's treating in the emergency room has insurance.

She doesn't know how the hospital where she works - Helen Keller in Sheffield - will get reimbursed for the services she and others are providing.

What Miller knows at the moment is that the patient needs treatment.

"Most of the time, a patient won't even mention his insurance status," she said. "But the key there is, when we do an intervention and ask the patient if he has a family doctor and he says 'no,' and he's young and healthy or older and healthy, we often hear they just don't see a need to have a family physician."

Emergency rooms at local hospitals are often the health-care option of choice for people Miller describes as those who are otherwise healthy but lack either a family physician or insurance to cover regular physician visits. The result: an often overcrowded emergency room.

A new study by the University of Michigan reveals that people who lack insurance may not be the only ones in crowded emergency rooms. Researchers say the overcrowding is more complicated, and widely repeated perceptions about the uninsured and emergency care may be rooted more in assumption than in solid fact.

"The crisis in emergency medicine and the problems of the growing uninsured population have been conflated," Dr. Manya Newton, lead author of the study and an emergency room physician, said in a news release about the study. "The rise in ER use has much more to do with the aging of the population, the increase in chronic diseases and the decrease in available primary care than with the uninsured. Policies based on false assumptions risk diverting energy and money from confronting the true drivers of emergency department crowding."

Alabama and the Shoals have not been immune to the causes Newton lists.

According to census data, more than 12 percent of the state's population is 65 or older. In the Shoals, more than 15 percent of the population is in that age group.

Compounding the age issue is the fact that Alabama ranks in the top five on several chronic disease lists, including obesity, heart disease and diabetes.

Perhaps of most concern to ER doctors is the fact that fewer and fewer medical students are opting for family medicine as their specialty. And this fall, statistics from medical schools across the country revealed that enrollment was down by 6 percent.

"Primary care physicians see the gamut, from cardiology patients to endocrinology. It's across the board," Miller said. "We refer to primary care physicians as do specialists, so what we're seeing now is a bottleneck there."

An additional component to emergency medicine in the United States is that hospitals with an emergency room can't pick and choose the patients they see. It's a law designed, in part, to ensure that an emergency patient gets the most appropriate care as quickly as possible without regard to his ability to pay.

In Alabama, the law has been tweaked somewhat.

"The state requires that if you have a hospital other than a psychiatric or rehabilitation facility, you've got to have an ER," said Carl Bailey, chief executive officer at Eliza Coffee Memorial Hospital in Florence.

Unfortunately, he said, the state's track record for reimbursements on its Medicare and Medicaid patients is not good, and it's a situation which often forces hospitals to operate their facilities at a loss.

The question is, then, how long can these facilities do this and still give appropriate, up-to-date care?

"It sounds cold and heartless to turn people away," Bailey said. "But it sounds even more cold and heartless to close a community hospital. Our number of uninsured patients is up this year by 1 percent, but 1 percent translates to $7.5 million over the course of the year. That's probably $1.5 million to the bottom line in a negative impact."

Clinics in outlying rural areas of Lauderdale County, such as those in Greenhill and Lexington, have helped ease the burden on the emergency room at ECM, Bailey said.

But it also presents a loss in revenue, too, as ER patients often translate into patients who are then admitted into the hospital for care.

"I know I sound all doom and gloom, but we're on the verge of a health-care crisis," he said. "Alabama is a little more vulnerable than other states because of our high population of uninsureds. We have the lowest Medicare payments in the country and Blue Cross/Blue Shield doesn't pay hospitals as well as other third-party insurers. All you have to do is look at Decatur to see how this is playing out."

Earlier this year, Decatur lost its last group of obstetricians and gynecologists, citing low reimbursements and rising numbers of Medicaid patients among reasons for pulling out.

Miller said improvements must be made in how the state allows doctors and hospitals to practice emergency medicine.

"One solution that I've witnessed is to allow hospitals to sponsor urgent-care clinics that are staffed with physicians who are ER physicians and that's funded by the hospital," she said. "Some of the physicians would need to be trained in ER medicine as well as primary care medicine"

This solution is short term at best, Miller said, but it would ensure that the patient who leaves the ER without a primary care physician will have one for follow-up care.

"Unless we come up with an alternative (to our situation), it's possible that the system will stop functioning altogether," she said.