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Saving the ER for real emergencies

Costly `frequent fliers' are being encouraged to visit clinics in L.A. test.

January 22, 2007|Sam Quinones | Times Staff Writer

Mauricio Hernandez's belly was swollen like a pregnant woman's.

Every month for four years, he'd been going to the emergency room at Los Angeles County-USC Medical Center to have his abdomen drained of fluid, the result of cirrhosis caused by years of heavy drinking.

It wasn't exactly an emergency, but the ER was his only medical care. An illegal Mexican immigrant, Hernandez had learned that emergency rooms legally cannot turn away patients without examining and stabilizing them. He had stopped drinking, he said. But his job unloading big rigs paid little and offered no health insurance.

At each ER visit, he waited from five to 10 hours, received immediate treatment and left with no long-term plan for follow-up care. So his condition worsened, making more ER visits necessary.

Hospital officials estimate that in the first four months of 2006 alone, Hernandez's ER visits and hospitalizations cost taxpayers $37,500.

Hernandez, 45, is among a relatively small -- but extremely costly -- group of patients known in the field as "frequent fliers." They are chronic users of the emergency room whose care would be far less expensive, and who would probably be less sick, if they were seen regularly in a primary-care clinic.

He is an extreme example of a wider problem: About 40,000 people each year -- about 22% of ER patients -- go to the emergency room at County-USC with health problems that do not qualify as true emergencies, according to county officials. Millions of people across the country do the same thing, but the problem is especially acute in Los Angeles County, where a quarter of non-elderly adults are uninsured.

Many of these patients are homeless or working poor people. And in Los Angeles County, many are immigrants, legal and illegal. Collectively, they have strained the more than 70 emergency rooms in the county to the breaking point, helping to boost uncompensated care costs to $1.6 billion annually.

Nine ERs have closed in the last five years in L.A. County alone.

Partly to ease this strain, Gov. Arnold Schwarzenegger proposed earlier this month to ensure coverage of all legal residents of the state and illegal immigrant children. But even if his proposal passes, undocumented adults such as Hernandez would still have to depend on the county system.

Moreover, the governor proposes shifting $2 billion away from indigent healthcare -- money that counties count on -- to pay for universal health insurance, said Robert Ross, president of the California Endowment, a nonprofit foundation devoted to healthcare solutions for the poor.

Thus, what to do with people such as Hernandez "represents a part of the soft underbelly of the governor's proposal," Ross said. "To pencil out," the proposal may have to require counties to train frequent fliers to refrain from overusing emergency rooms, he said.

Even before the governor's proposal, County-USC and a private nonprofit called COPE Health Solutions were working on a potential solution. (COPE stands for Community Outreach for Prevention and Education.) They began a three-year, $250,000 pilot program to steer patients such as Hernandez into private clinics. There, they can be treated more regularly and inexpensively, and the visits cost eligible patients nothing but time.

"Our goal is to identify the 5 to 10% of our population that is driving 50 to 60% of our [ER] costs," said Pete Delgado, County-USC's chief executive.

The county is starting small, with 100 patients at its flagship hospital. Judging from the Hernandez case, it will not be an easy job.

Mother from heaven

Looming over Los Angeles' Eastside, the massive Los Angeles County-USC Medical Center is sometimes known in the community as "Madre del cielo": Mother from heaven.

Many Eastside residents are used to going to the hospital for what ails them.

"It's like when you go into the cathedral and ask for sanctuary," said Dr. Ed Newton, the hospital's director of emergency services. "No matter who you are, how messed up or poor you are, you can come here and receive care."

On L.A.'s Eastside, hospital officials say, the majority of non-elderly adults may be uninsured.

They go to the hospital for hypertension, migraine headaches, the flu, colds, insulin refills and prescriptions. Others go with conditions caused by poor diets or drug abuse. Some figure it's the only way to get an appointment with a specialist.

Emergency room overuse is rooted, in part, in good intentions. In 1986, the U.S. Congress passed the Emergency Medical Treatment and Active Labor Act, which required emergency rooms to screen and stabilize anyone who shows up at their doors, regardless of their ability to pay. The law was intended to prevent hospitals from dumping nonpaying patients.

But as the number of uninsured people has grown, the law has turned emergency rooms into de facto clinics. Making matters worse, ERs attract nonemergency patients with insurance as well, particularly at night.

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