Critical Condition

By Daniel Eisenberg

The rush of cranky customers began around Christmas. Just as hordes of frazzled parents were descending on shopping malls, crowds of feverish, aching bodies were flooding the emergency department at Thunderbird Samaritan Medical Center outside Phoenix, Ariz., desperate for relief from this winter's nasty, widespread strain of flu. On many days, a couple of hundred patients, from wheezing senior citizens to crying babies in their weary mothers' arms, clogged the waiting room, sitting for up to six hours to see a doctor. It didn't take long for the 35 beds in Thunderbird's ED, and many on its other floors, to fill up. The hospital occasionally had to go on "bypass," shutting its doors and diverting patients to other EDs.

Most of the visitors cramming the hallways were the usual hard-luck suspects, some of the estimated 44 million Americans who have no health insurance and nowhere else to go. But many others were a relatively new breed: refugees from managed care--which managed not to be available to them. "More people seem to be told, 'We can't see you until next week,'" says Dr. Kathryn Perkins, who has watched annual patient volume at Thunderbird's ED nearly double in the past five years. "When nobody will see them, they come here."

Who can blame them? After all, emergency departments must treat any patient, regardless of his or her ability to pay. And most of us would like to think that in the event of an accident or sudden illness, an ambulance would be on the scene in minutes to whisk us off to the emergency department, where doctors would be at the ready.

Well, don't bet your life on it.

This winter's flu onslaught has added another talking point to the health-care debate: the declining state of emergency services. Certainly the doctors are good, and the equipment gets better every year; in fact, the number of trauma centers that can deal with serious injuries is on the rise. But the ability to deliver service is being compromised. Medicare funds have been slashed as the number of uninsured patients has skyrocketed. A lack of beds and skilled nurses hasn't helped matters. In the past decade the total number of EDs in the U.S. has dropped from about 5,000 to 4,600, while the volume of visits has steadily risen, reaching 100 million in 1998, according to the National Center for Health Statistics.

Simply getting to the ED has become potentially life-threatening. Financially strapped EMSs are having trouble keeping pace with a growing slate of 911 calls. In many communities, emergency transportation has been taken over by for-profit ambulance companies that were supposed to increase efficiency and save taxpayer money. But in some cases they've been lethally inefficient--and none too profitable to boot.

The bottom line: "Unless something is done in the near future," warns a report in the current Annals of Emergency Medicine, "the general public may no longer be able to rely on EDs for quality and timely emergency care."

Managed care was meant to lighten the load on emergency services by emphasizing affordable preventive care that would keep people out of the ED. Instead, says Dr. Vincent Markovchick, emergency-services chief at Denver Health Medical Center, "the exact opposite has happened." Like many ED docs, he contends that primary-care physicians--feeling overworked and discouraged from doing expensive "extra" tests like an MRIs or EKGs--often hand off patients to the ED. Now patients who turn up there are sicker than ever before. Today 20% of visitors are admitted to the hospital, compared with around 12% a decade ago (although some of that increase can be traced to an aging population).

Many disgruntled HMO members, tired of wading through red tape and waiting for referrals, don't necessarily mind making that trip. On a snowy morning in Denver, Yvonne Leyba, an airlines reservation clerk, sat in the crowded waiting room in the emergency department at St. Anthony Central Hospital complaining about abdominal pain. She had tried to see a specialist but had been told it would take hours to get a referral. "I needed help," says Leyba. Even so, she expects "a fight" for coverage.

There's a good chance she'll get one. These days, many HMOs as well as Medicare dispute claims on the basis of what constitutes an emergency--rejecting one if, say, a patient who thought he had a heart attack turned out to be suffering from mere heartburn. "We are caught in the middle," says Dr. Stephan Lynn, residency director in the ED at St. Luke's--Roosevelt Hospital in Manhattan, where the medical staff has been cut 15% to 20% over the past five years even as the number of visits has risen 25%. "I get letters from patients every day saying, 'You made a mistake and put the wrong diagnosis on the chart.'"

Managed-care companies, not surprisingly, deny that their cost controls have put the system in jeopardy. They claim that retrospective rejections are becoming less common and that they've stopped requiring preauthorization for visits to the ED; a good portion of those visits, they add, are unnecessary. "Even though people complain about waits at the doctor's, the wait in many EDs is longer," says Dr. Charles Butler, chief medical officer at the American Association of Health Plans.

Traditionally, emergency departments have been overused and underfunded, routinely collecting only about half of what they bill and being subsidized on the backs of other, moneymaking parts of the hospital. But with the funding cuts in 1997's balanced-budget agreement added to managed care's fiscal pressures, that cushion has all but disappeared. And later this year, new Medicare payment schemes could cause even greater pain for both EDs and ambulance services. "The HMOs and the government have taken the fat out of the system, which used to cover the cost of emergency care," says Dr. Leo Berkenbile, who runs the ED at Verdugo Hills Hospital in Glendale, Calif., the state where EMS is most under siege.

There are real health risks in this new tightfistedness. Since there's little or no scheduled follow-up, the ED is not the best place to get general medical care. In many states, ED doctors are concerned that HMOs require trauma patients, once they're stabilized, to be moved to an in-plan hospital too soon. And specialists in California, fed up with managed care's unwillingness to compensate them fully, are rebelling against providing voluntary, on-call backup, a critical component of the ED system. To keep them on duty, some hospitals have to fork out $1,000 daily bonuses to neurosurgeons and orthopedists. "We are on the brink of an implosion," cautions Dr. Loren Johnson, director of the ED at Sutter-Davis Hospital in Davis, Calif., and co-chair of an industry task force that investigated the problem. The state lacks the capacity to handle a major catastrophe, like an earthquake or forest fire, a report by the California emergency-medical-services authority recently found.

Even the process of getting to the hospital in an ambulance has become more fraught. Consider the tragedy of Londell King, a 16-year-old straight-A student from Bridgeport, Conn., who was shot in the hip while standing on the street one March afternoon in 1997. Though an ambulance operated by American Medical Response arrived promptly, the EMTs on the scene allegedly didn't take King's vital signs or recognize his internal bleeding. They kicked him out of the ambulance and drove off, according to a lawsuit filed against AMR. Relatives took King to the hospital, but he died there a few hours later. The company declined to comment, but two of its EMTs were fined and put on probation.

The King incident may be an extreme example, but it is symptomatic of service changes in the ambulance industry--all of them bad, say consumer advocates--wrought by a combination of managed care, Medicare and privatization. A handful of negligence lawsuits have been filed in Connecticut against AMR, the nation's largest private ambulance corps. Cobbled together out of more than 200 mom-and-pop firms, AMR has built a $1 billion-a-year business providing ambulance service to an increasing number of communities that outsource their EMS.

The idea is that private companies can provide services more efficiently than governments and that a large corporation is more efficient than hundreds of smaller ones. In the past year, though, AMR has been attacked in states from Connecticut and Georgia to Colorado for lagging response times, shoddy service and putting the profit motive first. After a series in the Hartford (Conn.) Courant last year exposed glaring lapses in AMR's service record, Connecticut's attorney general tried to inject a dose of healthy competition, forcing AMR to sell some ambulances and give up some contracts.

AMR's chief operating officer, Greg Guckes, argues that much of the criticism comes from public EMSs, which feel threatened by such a large challenger. The company makes no more mistakes than any of its peers, he claims, but gets more attention because of its size. "I would put our record against any company's--public, private or volunteer," says Guckes.

Yet even an unblemished record wouldn't help AMR's bottom line, battered by unpaid bills and the cost of exiting unprofitable markets. AMR became such a drag on earnings that parent company Laidlaw (1999 sales: $2.3 billion) put it on the block. Like all other ambulance services, including its chief for-profit rival, Rural Metro, AMR has been hard hit by private and government insurers that demand more documentation and reject claims on the ground that they are not genuine emergencies. "Seniors hesitate to call 911 because they're afraid they'll get a big bill," says Dave Huisenga, EMS chief for the St. Paul, Minn., fire-and-safety services. Last year a Medicare carrier in the St. Paul area rejected a claim--three times--as "medically unnecessary" even though the patient died within an hour of arriving at the hospital.

So what, if anything, can be done to stop the bleeding? In the cities, a few hospitals are trying the Domino's pizza-delivery model pioneered by the Robert Wood Johnson Hospital in New Brunswick, N.J.: service within 30 minutes or it's free. Northwestern Memorial in Chicago and Sinai Hospital in Baltimore, Md., have led the way in opening state-of-the-art ED wings, where patients are efficiently triaged and then moved to independent treatment centers, depending on the severity of their condition. Rural communities, unable to sustain both emergency and convalescent care, are converting general hospitals to critical-access centers--15-bed facilities that stress urgent care.

The next phase of managing emergency care is under way. Most HMOs have turned to companies like Access Health, a division of McKesson HBOC, which set up round-the-clock telephone triage lines staffed by nurses whose mission is to direct patients to the appropriate level of medical care. The HMOs emphasize that people who think they have a real emergency should dial 911 immediately. Many EMTs, though, are worried that grave mistakes can still be made by telephone diagnosing. "Answer a question wrong, and you can be in big trouble," says Jeff Forster, a Denver ex-paramedic who runs his own upstart ambulance company, Pridemark Paramedic Services. And unless health-care providers can come up with the right answer to their own ailing EDs, we all may be.

--With reporting by Richard Woodbury/Denver, James Willwerth/Los Angeles, Leslie Everton Brice/Atlanta and Maggie Sieger and Michele Donley/Chicago

With reporting by Richard Woodbury/Denver, James Willwerth/Los Angeles, Leslie Everton Brice/Atlanta and Maggie Sieger and Michele Donley/Chicago