Re: Hospitals turn away ill, injured

> Hospitals turn away ill, injured
>
> Some question ER screenings that limit care for uninsured
> By Marsha Austin, Denver Post Business Writer
>
> He'd already been turned out of two hospital emergency rooms that day, but
> Michael Angelo Martinez wasn't giving up as he pushed open the door to the
> third.
>
> "This time they'll help me," the 38-year-old told himself as he walked
> toward the ER reception nurse at Rose Medical Center.
>
> He was drooling because each swallow meant excruciating pain. His face
> muscles twitched. He slurred his words through the clenched teeth that

> clung to his shattered jaw.
>
> But he wasn't dying. And, according to federal law, he was stable, meaning
> he could walk out the door. And that's all doctors and nurses at Denver
> Health Medical Center and the University of Colorado Hospital needed to

> before they suggested Martinez seek treatment elsewhere.
>
> When Colorado's two largest public hospitals resorted to screening out
> anyone without an immediately life-threatening medical problem,
> administrators said it was because they could no longer afford the

> it cost to treat the uninsured who crowded emergency rooms with minor
> complaints.
>
> So now, a nurse examines every would-be patient. Those without an

> are told they must pay for their care or leave. The result is that

> people like Martinez go without medical attention or seek help elsewhere.
>
> In the year since the screenings began, a steady stream of patients, most

> them indigent or working poor, has filed into the emergency rooms of

> private hospitals. And physicians who have treated such patients say the
> screenings are dangerous, possibly illegal and ethically impossible for

> to stomach.
>
> Those doctors also worry that as public hospitals nationwide struggle
> financially, more will find ways to turn away uninsured patients, and that
> new federal guidelines due out this summer could open the door for more
> aggressive screening by the nation's hospitals.
>
> "This is a disturbing precedent," said Dr. Dennis Beck, president of
> CarePoint, the medical group serving HealthOne's five Denver emergency
> rooms, including Rose.
>
> Since Denver Health started screening emergency-room patients in May 2002,
> an average of 110 patients of the 4,200 who sought care in the ER each

> were referred elsewhere. At University, where screenings began in October,
> an average 176 patients of 3,655 seeking care each month were not treated.
>
> That Martinez was turned away is no surprise. Patients with medical

> that require more than emergency care - broken bones, Hodgkin's disease,
> cancerous lumps, detached retinas - are routinely told to seek care
> elsewhere, said Dr. Norman Paradis, director of the department of

> medicine at University Hospital.
>
> "It really is, in my mind, unconscionable," Beck said. "What we do in the
> emergency room is put our head down and take care of people."
>
> So far, federal officials have not challenged Denver hospitals' screening
> policies, in part because the hospitals are obeying regulations that

> emergency-room staff to only briefly examine a patient and ensure the

> is stable before sending him away, said Thomas Barker, senior policy

> at the national Centers for Medicare and Medicaid Services.
>
> In addition, University and Denver Health have followed rules set up in

> Emergency Medical Transfer and Active Labor Act, or EMTALA, which says the
> hospital cannot inquire about a patient's ability to pay until it has
> determined whether the person has an emergency.
>
> Because virtually no hospitals outside Colorado have pushed the limits of
> EMTALA, federal regulators have not aggressively scrutinized the practice,
> said Barker, a health care attorney involved in crafting the new federal
> guidelines. The guidelines, he said, would outline limited, clearly
> nonemergency cases where hospitals can block admission - such as someone
> wanting stitches removed or a prescription refilled.
>
> Barker had strong words for Denver's hospitals and others considering
> adopting screening programs:
>
> "I would be very, very careful. You are walking a very fine line, and you
> had better make sure you stay on the right side of the fence," he said.
>
> When Martinez walked into the Rose ER on April 27, he told the nurse he'd
> already been to Denver Health, where a doctor confirmed he'd broken three
> ribs and fractured his jaw.
>
> But the same doctor refused to treat him unless he had insurance or cash
> because he did not live in Denver County, he said.
>
> "They told me to go back to New Mexico," said Martinez who had been

> his girlfriend and her mother in a small town outside Santa Fe when he was
> attacked and beaten.
>
> The Aurora resident rode a bus five hours north from Santa Fe to Denver to
> seek medical care.
>
> He next looked for help at University Hospital, the only other

> Denver hospital that receives tax money to treat the uninsured. But a

> there told him the same thing: He'd have to pay before a doctor could fix
> his jaw.
>
> And so he walked down the street to Rose.
>
> The risk in turning away patients with broken bones, infections and other
> non-life-threatening but possibly serious medical conditions is that

> proper care, those patients can unexpectedly go downhill fast, doctors

>
> Even minor symptoms such as a headache can quickly turn deadly, said Dr.
> David Glaser, head of Exempla St. Joseph Hospital's emergency department.
>
> "There are snakes in the grass hiding behind every minor complaint,"

> said.
>
> Glaser remembers treating a young woman who came into his ER complaining

> nausea, vomiting, diarrhea and cramping. She was pregnant, and University
> had turned her away because a nurse said she just had irritated

> The woman turned out to be suffering from gastroenteritis, inflammation of
> the digestive tract that can cause severe cramping and dehydration. But
> Glaser was infuriated. It could have been much worse.
>
> "To me it's a scary prospect that they have nurses weeding out the sick

> the not sick. At some point, they are going to miss and miss big," he

>
> Advocates of the screenings argue that treating every patient who walks
> through the door will bankrupt the public safety-net system, which is
> already overtaxed.
>
> For the first time in recent history, the nation's academic medical

> will post a collective loss this year, Paradis said.
>
> "Even the well-run hospitals are operating on razor-thin margins," Paradis
> said. "There's just not enough money to take care of everyone."
>
> Denver Health Medical Center, the city's safety-net public hospital, lost
> $6.4 million in the first five months of this year and expects losses to
> grow because its uninsured caseload is far beyond what accountants
> predicted.
>
> On Thursday, Denver Health approved more than $15 million in budget cuts
> that included layoffs, the closing of clinics and restrictions on what

> will be bought and offered to patients.
>
> "More and more people who never thought they'd be without health insurance
> are finding themselves on our doorstep as the economy continues to
> flounder," chief executive Patricia Gabow said.
>
> Both Denver Health and University get federal money to offset the costs of
> caring for the uninsured, but it's not nearly enough, Paradis said.
>
> During the year ended April 30, University's spending on uninsured

> increased 35 percent to $68.2 million. For the fiscal year ending in June,
> the federal government paid the hospital $29 million.
>
> "We are just going to have to say some of these people are just too sick

> be saved," Paradis said. "They've handed us a certain amount of money. We
> are trying to do the best we can with it. I think that this is a more
> reasonable solution than closing the ER."
>
> When Dr. Donald Lefkowits saw Martinez, he was dehydrated and in obvious
> pain.
>
> "This guy had been through the wringer," said Lefkowits, an ER physician

> 20 years and director of emergency medical services at Rose. "He was

> hurting."
>
> Lefkowits got Martinez hooked up to an IV, gave him painkillers and paged
> the on-call oral surgeon.
>
> "I kept thinking to myself, 'There was this thing they called the
> Hippocratic oath,"' Lefkowits said.
>
> What University and Denver Health are doing may be legal, but it's highly
> unethical, said Dr. Robert Bitterman, a physician, attorney and head of

> Department of Emergency Medicine at Carolinas Medical Center in Charlotte,
> N.C.
>
> A national expert on EMTALA law, Bitterman has closely watched Denver
> hospitals' screening programs.
>
> He said ethics and a fear of looking uncaring - not legal issues - have

> other hospitals from following Colorado's example.
>
> "I know a bunch are talking about it, but so far no one has had the guts

> do it," Bitterman said.
>
> Lefkowits said he remembers a man who hobbled the two blocks from

> to Rose with gout in his ankle and another who came to the ER at 2 a.m.

> an excruciating earache.
>
> "Was he going to die? No," Lefkowits said. "But could he sleep? No. Severe
> pain can be an emergency. This solution seems so barbaric. And how much

> they saving?"
>
> While it's not yet clear exactly how much University and Denver Health are
> saving, it is clear Rose and other private downtown hospitals are spending
> more to treat some of them.
>
> Between April 2002 and April 2003, uncompensated care increased 22 percent
> at Exempla St. Joseph's Hospital and 24 percent at Centura St. Anthony
> Central Hospital. Rose corporate parent HealthOne would not release

> numbers, but doctors there say charity-care spending has substantially
> increased.
>
> And the steady stream of patients makes it difficult for doctors at St.
> Anthony Central to keep staff and beds available for trauma patients, said
> Dr. Peter Vellman, emergency department director.
>
> "It makes it tough when you run a Level 1 trauma center and you're

> with fallout from other hospitals," he said.
>
> But so far the hospital isn't turning anyone away. Instead it's expanding
> capacity.
>
> Vellman and some other doctors say they'd support the screenings if they
> knew patients were actually getting in to clinics.
>
> "The people at University, when they hand them this list of clinics, they
> know very well there's little chance they're going to be able to get in
> there," Lefkowits said. "I don't know how they live with themselves."
>
> Dr. Stephen Cantrill, director of Denver Health's emergency department,

> he knows the solution is not perfect.
>
> "My frustration is that the system is broken, and no one will fix it," he
> said. "What we have now is not the answer."
>
> At UC-Davis Medical Center in California, where in the mid-1980s

> conducted a pioneering study on emergency-room screening exams, nurses

> follow-up calls to every patient they sent away.
>
> The medical center worked out agreements with community clinics and
> neighboring hospitals to ensure patients got care, said Victoria Ritter, a
> nurse and director of the emergency department.
>
> "We really had to stop the way of thinking that the purpose was to keep
> everybody out - that wasn't our purpose," she said. "If you've got that
> mentality, you've got problems."
>
> The same practice is in place at UCLA Harbor Medical Center, which refers
> colds, back pain and other minor medical problems to its own clinics.
> Patients are guaranteed an appointment within 24 hours, said Dr. Bob
> Hockberger, head of the ER.
>
> Denver Health is experimenting with a program that will guarantee patients
> at its 14 community health centers an appointment within 48 hours, rather
> than the previous six to eight weeks, said Terence Shea, director of
> community health nursing.
>
> For Martinez, the whole experience was an eye-opener.
>
> "I didn't see how these days, in the United States, anyone could be denied
> care," said Martinez, who is making payments to the doctor who fixed his
> jaw. "I'm just happy I got referred to somebody. I felt like Neanderthal
> man."
>
>