Financial Crisis in the U.S. and Overcrowded ER's

In September, 2001 I wrote a letter to OSF-SFMC administrator Keith Steffen.

I thought that OSF-SFMC had too many elective inpatients which dangerously slowed moving sick Emergency Room (ER) patients to inpatient beds. I also thought that OSF was stacking insured patients in inpatient beds to the detriment of the ER patients. Sick patients at OSF were waiting a long time to be admitted.

I was put on probation the day after I sent the letter, and during my first meeting with Mr. Steffen he likened me to a cancer that needs to be cut out "before it metastasizes".

I was fired from OSF-SFMC three months later.

Below are bullet points from an article in the Annals of Emergency Medicine, February 2009:

1. There were 119 million visits to U.S. Emergency Rooms in 2006.

2. Emergency Departments are part of the nation's early warning system of the severity of our socioeconomic problems. The nation's Emergency Departments are uniquely responsive to the symptoms of a diseased economy.

3. Employer-insured people are one layoff away from having no health insurance.

4. Mortgage foreclosures could produce social dislocation in both forms and degrees that threaten the quality of medical care for large parts of the population.

5. Crowding in the entire hospital produces crowding and boarding in the Emergency Room.

6. It is possible that hospitals allow themselves to be over capacity with elective insured patients because that maximizes profits. In my opinion this is one of the main reasons OSF-SFMC in Peoria's Emergency Room was/is so dysfunctional.

7. Rising numbers of uninsured people heighten the pressure in Emergency Departments. There is also increased use by middle-class patients whose usual source of care is the private physician's office.
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Annals of Emergency Medicine
February, 2009

If emergency departments (EDs) are part of the nation's early warning system for underlying socioeconomic problems, the crowding that emergency physicians have seen in recent years may have presaged the deep-seated, population-wide strains that are now recognized as a severe recession. The failure of major financial institutions, the decline of the stock market last October, and the proposals for the federal government to bail out the Big Three automakers and other sectors of the economy have made it impossible for economists and officials to ignore something that American emergency physicians have seen for years: that large numbers of their fellow citizens live on the financial precipice.

The employer-insured are one layoff away from a drop through a porous safety net; many of the uninsured are already falling through. And over the coming months, say physicians and economists, the health care system is likely to see a drastic shift from the former group to the latter.

“A serious downturn in the next few months, unless there's emergency help, is going to lead to a real influx of people who formerly had insurance and have no other place to go,” says Robert J. Blendon, ScD, professor of health policy and political analysis at the department of Health Policy and Management, Harvard School of Public Health. The newly unemployed and the firms that once paid their medical premiums are not the only ones whose wellbeing is at risk during the economic contraction. States will be hard-pressed to cover the rising costs of Medicaid and the State Children's Health Insurance Program (SCHIP), Blendon believes, and some hospitals may even face threats to their viability. The crash of 2008, he says, “appears to be the largest-scale recession we've had since the Great Depression.”

Moreover, say some policy analysts, the nature of this recession is poorly understood, and the difficulty of recovering from it is hard to predict. The dramatic headlines to date have involved collapsing investment firms leading to a plunging Dow Jones industrial index, but the effects are not limited to the shareholding classes. The triggering events, says Glenn Melnick, PhD, senior economist at the RAND Corporation and Blue Cross of California Chair of Health Care Finance at the University of Southern California, affected the most important assets most Americans hold: their homes.

Mortgage foreclosures in some areas could produce social dislocation in both forms and degrees that threaten the quality of medical care for surprisingly large parts of the population. “This is a much more complicated economic crisis than we've faced in many years, and I'm not sure that it's been figured out yet,” Dr. Melnick comments. “I think the whole mortgage/foreclosure crisis could depress economic growth for many, many years if they don't figure it out…. There could be waves of foreclosures, a couple million every year, for the next 3 or 4 years.”

Just as the nation's EDs are uniquely responsive to the symptoms of a diseased economy, the nation's economy is headed for the policy equivalent of intensive care. The incoming administration of President-elect Barack Obama has its work cut out, as commentators have pointed out in numerous contexts. Obama's team may also encounter opportunities for much-discussed, long-delayed systemic reforms in the health care sector; as in the 1930s, a state of crisis can shake loose obstacles and foster constructive change. The chances of rebuilding the foundations of the medical economy in the long run, experts speculate, depend to a large degree on how policymakers and institutions manage the current uncertainties in the short run.

Already Peaking Before the Wave Hits

That America's EDs are already operating at or near capacity will come as no surprise to physicians working in them. Expanding capacity has not kept up with demand, which rose from 67 million visits in 1996 to 119 million in 2006, as reported by the Centers for Disease Control and Prevention (CDC).[1] As ACEP president-elect Angela F. Gardner, MD, told the New York Times, “We have no capacity now.”[2] The new National Report Card on the State of Emergency Medicine[3] establishes formal recognition of a situation that has multiple causes, including but not limited to the cause repeatedly identified in the lay press: the sharply rising numbers of uninsured patients. Conditions in EDs were approaching a critical point well before the current recession began.

Jesse M. Pines, MD, MBA, MSCE, assistant professor of emergency medicine at the Hospital of the University of Pennsylvania and senior fellow at the Leonard Davis Institute of Health Economics, points to problems well beyond the ED itself, including institutional economic incentives and internal politics as well as demographic changes. Crowding in the entire hospital produces boarding in the ED, as do procedural bottlenecks in admitting patients from the ED to inpatient beds. “It's a patient throughput issue,” Dr. Pines notes, but “it's also that hospitals allow themselves to be over capacity because that's the profit-maximizing strategy.”

Although EDs, contrary to some myths, are a profit center for many hospitals rather than a loss leader, direct admissions for non-emergent conditions make marginally greater contributions to the institutional bottom line than admissions through the ED. “A guy coming in for his elective heart procedure, a guy from the suburbs with good insurance” will offer more predictability in terms of both ability to pay and advance recognition of the time of admission, Dr. Pines says, than a random ED patient who may be uninsured or covered by Medicaid, with its lower payments. Filling beds with patients in the former category increases the likelihood of 12- to 18-hour waits for those in the latter.

Logistics, too, creates logjams that exacerbate ED crowding. Decreased effective ED capacity, Dr. Pines has observed, “tends to happen most on Mondays, Tuesdays, and Wednesdays, because those are the same days when there are a lot of elective surgeries going on… and hospitals tend to prioritize the beds for elective procedures over the patients in the ED. The hospital will be full to capacity, and you'll have patients waiting in the ED for beds on the busiest day for the ED.

“In our place, and in a lot of hospitals, Monday is the perfect storm… half the beds in the ED are dedicated to admitted patients, the other half are active beds, and essentially the effective capacity on your busiest day is one half of what it should be.” (Dr. Pines recommends “surgical schedule smoothing,” a simple policy of distributing procedures more evenly among the days of the week, as an effective strategy for breaking these bottlenecks. In practice, however, implementing such a schedule often evokes opposition from surgeons who cherish their time off; some threaten to take their profitable procedures to a different hospital if administrators raise the possibility of working larger numbers of days, even if total working hours remain constant.[5])

Rising numbers of uninsured people intuitively heighten the already-intense volume pressure on EDs, but they have not been its chief cause to date, say scholars who have studied the phenomenon. The rise in adult ED use from 1996 to 2004, according to one recent study of national Community Tracking Study Household Survey data, reflected increasing use by insured middle-class patients whose usual source of care is a physician's office.[4] Percentages of uninsured visitors remained stable, even declining by a nonsignificant amount.

Bluntly stated, it hasn't been the mythical uninsured person who follows the advice of outgoing president G.W. Bush and others[6] simply to “go to the emergency room” and thus burdens the whole system -- the popular scapegoat of a “healthy, cavalier, uninsured ER abuser,” as Dr. Pines and Zachary Meisel, MD, recently described and debunked in Slate.[7] It's been the insured patient who is unable to see his or her primary care doctor promptly.