Good gravy, what the hell did you think we've been saying??

[sirs]

Health overhaul may mean longer ER waits, crowding

By CARLA K. JOHNSON, AP Medical Writer Carla K. Johnson, Ap Medical Writer - Fri Jul 2, 2010

CHICAGO - Emergency rooms, the only choice for patients who can't find care elsewhere, may grow even more crowded with longer wait times under the nation's new health law.

That might come as a surprise to those who thought getting 32 million more people covered by health insurance would ease ER crowding. It would seem these patients would be able to get routine health care by visiting a doctor's office, as most of the insured do.

But it's not that simple. Consider:

_There's already a shortage of front-line family physicians in some places and experts think that will get worse.

_People without insurance aren't the ones filling up the nation's emergency rooms. Far from it. The uninsured are no more likely to use ERs than people with private insurance, perhaps because they're wary of huge bills.

_The biggest users of emergency rooms by far are Medicaid recipients. And the new health insurance law will increase their ranks by about 16 million. Medicaid is the state and federal program for low-income families and the disabled. And many family doctors limit the number of Medicaid patients they take because of low government reimbursements.

_ERs are already crowded and hospitals are just now finding solutions.

Rand Corp. researcher Dr. Arthur L. Kellermann predicts this from the new law: "More people will have coverage and will be less afraid to go to the emergency department if they're sick or hurt and have nowhere else to go.... We just don't have other places in the system for these folks to go."

Kellermann and other experts point to Massachusetts, the model for federal health overhaul where a 2006 law requires insurance for almost everyone. Reports from the state find ER visits continuing to rise since the law passed ? contrary to hopes of its backers who reasoned that expanding coverage would give many people access to doctors offices.

Massachusetts reported a 7 percent increase in ER visits between 2005 and 2007. A more recent estimate drawn from Boston area hospitals showed an ER visit increase of 4 percent from 2006 to 2008 ? not dramatic, but still a bit ahead of national trends.

"Just because we've insured people doesn't mean they now have access," said Dr. Elijah Berg, a Boston area ER doctor. "They're coming to the emergency department because they don't have access to alternatives."

Crowding and long waits have plagued U.S. emergency departments for years. A 2009 report by the Government Accountability Office, Congress' investigative arm, found ER patients who should have been seen immediately waited nearly a half-hour.

"We're starting out with crowded conditions and anticipating things will only get worse," said American College of Emergency Physicians president Dr. Angela Gardner.

Federal stimulus money and the new health law address the primary care shortage with training for 16,000 more providers, said Health and Human Services Department spokeswoman Jessica Santillo.

But many experts say solving ER crowding is more complicated.

What's causing crowding? Imagine an emergency department with a front door and a back door.

There's crowding at both ends.

At the front door, ERs are strained by an aging population and more people with chronic illnesses like diabetes. Many ERs closed during the 1990s, leaving fewer to handle the load. The American Hospital Association's annual survey shows a 10 percent decline in emergency departments from 1991 to 2008. Meanwhile, emergency visits rose dramatically.

At the back door, ER patients ready to be admitted ? in hospital lingo, ready to "go upstairs" ? must compete for beds with patients scheduled for elective surgeries, which bring in more money. "If you've got 10 ER patients and 10 elective surgeries," Kellermann asked rhetorically, "which are you going to give the beds to?"

That's why easing crowding will take more than just access to primary care. It also will take hospitals that run more efficiently, moving patients through the system and getting ER patients upstairs more quickly, Kellermann said.

Ideas that work include bedside admitting, where a staffer takes a patient's insurance information as treatment starts.

That and other strategies are being tried at St. Francis Hospital and Health Centers in Indianapolis. There, the performance of nurse managers is measured by how long admitted patients wait in the emergency department for a bed upstairs.

And to stave off inappropriate ER visits, the hospitals have opened after-hours clinics staffed by primary care doctors to handle patients who can't leave work to see a doctor, said Indianapolis hospital executive Keith Jewell. ER wait times have fallen.

A Chicago hospital, too, is readying for the onslaught of ER patients. On the city's South Side, Advocate Trinity Hospital handles 40,000 emergency visits a year and is expecting more because of the new law.

Greeter Stephanie Bailey makes sure patients don't get frustrated while they're waiting. She can take their vital signs and inform staff if the patient is about to leave without treatment.

Inside the emergency department, a giant sheet of paper hangs on a wall. It's hand-lettered in orange and purple, and tracks daily progress on hospital goals: How many patients left before they were treated? How many minutes did patients stay in the ER?

On a recent day, the note said "0.0 percent" of the patients left without treatment. Someone had added a smiley face. But there was no smiley face next to the average ER length of stay for the same day ? nearly four hours. The hospital's goal is three.


And you ain't seen nothing yet

[sirs]

Health law risks turning away sick
By Julian Pecquet - 07/01/10
 
The Obama administration has not ruled out turning sick people away from an insurance program created by the new healthcare law to provide coverage for the uninsured.

Critics of the $5 billion high-risk pool program insist it will run out of money before Jan. 1, 2014. That?s when the program sunsets and health plans can no longer discriminate against people with pre-existing conditions.

Administration officials insist they can make changes to the program to ensure it lasts until 2014, and that it may not have to turn away sick people. Officials said the administration could also consider reducing benefits under the program, or redistributing funds between state pools. But they acknowledged turning some people away was also a possibility.

?There?s a certain amount of money authorized in the statute, and we will do our best to make sure that that amount of money insures as many people as possible and does as much good as possible,? said Jay Angoff, director of the Office of Consumer Information and Insurance Oversight at the Department of Health and Human Services (HHS). ?I think it?s premature to say [what happens] when it?s gone.?

The administration has not discussed asking Congress for more money down the line if the $5 billion runs out before Jan. 1, 2014. Uninsured sick people could start applying for participation in the high-risk insurance pools on Thursday.

Healthcare experts of all stripes warned during the healthcare debate that $5 billion would likely not last until 2014. Millions of Americans cannot find affordable healthcare because of their pre-existing conditions, and that amount would only cover a couple hundred thousand people, according to a recent study by the chief Medicare actuary.

Republicans continued to hammer that point on Thursday, asking HHS officials to brief them about the program.

We are ?deeply concerned that these pools may not provide quality coverage or will limit enrollment,? Reps. Joe Barton (R-Texas), John Shimkus (R-Ill.) and Michael Burgess (R-Texas), the ranking members on the Energy and Commerce panel and its health and oversight subcommittees, wrote in a letter to HHS Secretary Kathleen Sebelius.

The letter requests a briefing on high-risk pools by July 15, particularly on three topics: protections and services in place ?to make sure that access is efficient and unimpeded; whether HHS believes the program is financially sustainable through 2013; and details about how each state?s pool will be administered and what options they?ll have available.?

Leading health reform advocate Ron Pollack, founding executive director of Families USA, said the pools were a ?very imperfect tool that could be implemented quickly? but were the best option available for the interim period before 2014.

?The pools are going to be helpful for a significant number of people,? he told The Hill, ?but nobody thought they?re the ultimate answer for helping people with pre-existing conditions.?

Still, he didn?t rule out that Families USA could press lawmakers to allocate more money in a few years if it looks like the program needs it.

Each state has a certain budget allocation for its pool, and the first step to stay under budget would be to shift money around between states that don?t see a lot of applicants and those that do, said Richard Popper, deputy director of the Office of Consumer Information and Insurance Oversight at HHS.

?If we have that situation where we have strong demand in one state and not as strong demand in another state, the secretary of HHS after a year or two has the authority to reallocate the funding,? said Popper, who used to run Maryland?s high-risk pool.

?Along with that, we can work with the states to adjust their benefit structure, the deductibles, the co-pays, the overall plan structure to address some of those cost drivers, again to help the plan make it to 2014, when it will no longer be needed.?

In addition, Popper said, many people won?t be able to afford to participate in the program since premiums will range between about $140 and $900 a month, depending on applicants? age and where they live. HHS estimates that at least 200,000 people will be in the program at any one time. To be eligible, applicants have to be citizens or nationals of the United States or be lawfully present; have a pre-existing medical condition; and have been uninsured for at least six months before applying for the high-risk pool plan.

?There are going to be meaningful premiums that are going to be required to stay in this plan ? premiums in the hundreds of dollars every month,? Popper said. ?There are a significant number of people out there with pre-existing conditions who are uninsured, but a significant number of those people ... also have limited income. And some of them, while they may need this plan, the premiums may not be something they can afford.

?We have that to think about as well,? he added. ?But for those who can afford it, this is going to be a great, great plan.?

If it looks like too many people are signing up ? states will get monthly updates on how many people they can cover with the money they have left ? there?s always the option of turning people down.

The bill ?does give the secretary authority to limit enrollment in the plan ... nationally or on a state-by-state basis,? Popper said. ?So that is present, but at this point, we?re starting with no one in the plan as of today ... so we don?t see that happening anytime soon.?


Saw this one coming as well