Think of it this way: Instead of an ER doctor, I'm a cook.
Most of my patients don't realize it, but except for university and government-run hospitals, ER docs are "cooks," working in a hospital-owned restaurant -- that's why there are two parts to every emergency room bill, one for my work and one to keep the bandages stocked and the lights on.
Let's say my specialty is steak. You come in, I cook one, you eat it. Appetite satisfied.
Now imagine we California cooks make the best steaks anywhere. Chefs from other countries come to learn here, and our restaurants are the envy of the world. For emergencies and trauma care, our ERs are exactly that -- the best anywhere, 24 hours a day every day. It might not feel that way when you are waiting four hours on a Saturday night, but it's true.
One day, a salesman from Steak-Net knocks on your door. He'll sell you a $10-a-month card that you can use when you're hungry. With it, go to a restaurant, and Steak-Net will pay for your dinner. Steak when you want it, for pennies.
How can Steak-Net afford such an offer, when steaks are $14.99 each? Well, a lot of people belong to Steak-Net, and they don't all eat steak every day. And Steak-Net restaurants are more efficient, the salesman says. From pasture to plate, Steak-Net applies "cutting-edge industrial food technology" that makes Steak-Net steaks cheaper but just as tasty and filling as other restaurants' steaks. The salesman would tell you how, but it's a trade secret.
So you join, happy to be covered by Steak-Net.
The next time you get hungry, you find a Steak-Net restaurant. It's a decent steak, and the price is right.
Then one day you find yourself on my street, ravenous -- you plop your card down: "One steak -- I'm a member!"
But my restaurant doesn't participate in the Steak-Net program, I tell you. It used to, but Steak-Net would send only $5 to cover the cost of each steak. That's what the company says a steak costs in its restaurants, so that's all it will pay. But it costs my restaurant $8 to buy the steak, $5 to cook it and $2 to serve it -- $15 total. After losing money on Steak-Net customers for a while, my restaurant dropped out.
So now when you come in, I feed you and hand you a bill. After SteakNet kicks in $5, you have to cover the balance. You owe $10 for your $15 steak.
Fair, right? You wouldn't blame my restaurant for charging you for the filet or accuse it of gouging because the steaks cost more than $5. Nor would you expect the cops to make my restaurant charge the same as Steak-Net. After all, if my restaurant did charge only $5 per steak, it would close. There would be fewer places to eat, fewer choices.
You wouldn't do that to any restaurant or chef, but you would to an ER and its doctors.
The California Supreme Court made such things possible when it outlawed "balance billing" -- the bane of patients who have HMO insurance that, like Steak-Net, pays below-cost fees that even the HMOs' own ERs can't survive on. Of course, most HMOs (except Kaiser Permanente) don't actually run ERs anyway -- too costly.
These on-the-cheap insurance groups contract with some ERs to accept lower payments, but many ERs -- like the restaurant in my example above -- stay independent because they can't charge pennies for things that cost quarters. That's why you got a bill for the balance after your insurance paid only $250 toward care that cost $1,000 to save your child's life or treat your stroke or fix your broken ankle or treat you after a car crash.
Because of that ruling, hospitals that run ERs and the doctors who work in those ERs now have to eat the difference -- the cost of keeping a specialist in an expensive room supported by highly trained nurses, technicians and sub-specialist doctors. That's the true cost of keeping the restaurant open 24 hours.
In the ER, we work for you -- regardless of insurance, color or citizenship. No one is turned away because he or she can't pay. And unlike a restaurant -- or any other doctor -- a federal law requires that we see every patient who comes in, any time, even if it's not an emergency.
But our California Supreme Court decided to "protect" patients by caving into the HMOs and insurance companies, making it illegal to send a bill to the person who ate the steak, and allowing HMOs to decide what they will pay, regardless of what it costs. Now there will be a race to lower fees for doctors and hospitals -- and our emergency medical safety net will begin to fall apart.
More ERs will close. As for the few that stay open, I wonder who will be cooking?
Good schools, uncrowded roads, cheap gas -- soon ERs will join the "remember whens." Generally, we get what we pay for, and neither Californians nor their insurers want to pay for emergency care. ER docs are everybody's hero -- until we send a bill.
I love my job and I think it's an important part of a good world, holding a rope of the safety net. I'll keep doing it as long as I can, but it is harder now that California has decided that the insurance man is more important to the patient than the doctor. When hospitals can't make ends meet, ERs are the first place to go. I don't know how to fix this, but the answer isn't taking money from doctors who take care of patients every day.
The California Supreme Court has left crumbs for doctors and patients in the state while the insurers get fatter. There is plenty of money in healthcare, but where it ends up may be the most unpalatable meal of all.
Morocco is an assistant professor and associate residency director of emergency medicine at UCLA Medical Center, and was the medical supervisor for "ER."