Hospitals turn away ill, injured
Some question ER screenings that limit care for uninsured
 

June 29, 2003
Marsha Austin

Denver Post Business Writer

Dr. Donald Lefkowits, emergency services director at Rose Medical Center, has treated patients who were turned away by the two public hospitals. Their 'solution seems so barbaric,' he says. GRAPHICS: The Denver Post Charity care by hospitals

Patients leaving ERs without care

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 still 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 know 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 millions 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 emergency are told they must pay for their care or leave. The result is that uninsured people like Martinez go without medical attention or seek help elsewhere.

In the year since the screenings began, a steady stream of patients, most of them indigent or working poor, has filed into the emergency rooms of nearby private hospitals. And physicians who have treated such patients say the screenings are dangerous, possibly illegal and ethically impossible for them 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 month 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 problems 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 emergency 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 require emergency-room staff to only briefly examine a patient and ensure the person is stable before sending him away, said Thomas Barker, senior policy adviser at the national Centers for Medicare and Medicaid Services.

In addition, University and Denver Health have followed rules set up in the 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 visiting 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 full-service Denver hospital that receives tax money to treat the uninsured. But a nurse 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 without proper care, those patients can unexpectedly go downhill fast, doctors say.

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," Glaser said.

Glaser remembers treating a young woman who came into his ER complaining of nausea, vomiting, diarrhea and cramping. She was pregnant, and University had turned her away because a nurse said she just had irritated intestines. 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 from the not sick. At some point, they are going to miss and miss big," he said.

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 centers 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 drugs 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 patients 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 to 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 of 20 years and director of emergency medical services at Rose. "He was really 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 the 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 kept other hospitals from following Colorado's example.

"I know a bunch are talking about it, but so far no one has had the guts to do it," Bitterman said.

Lefkowits said he remembers a man who hobbled the two blocks from University to Rose with gout in his ankle and another who came to the ER at 2 a.m. with 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 are 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 specific 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 cluttered 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, said 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 researchers conducted a pioneering study on emergency-room screening exams, nurses made 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."