ER nights

Sacramento emergency-room visits soared in recent years. Obamacare promises change, but will patients have patience?

A 50-something man with a gray mane and goatee, a dead ringer for a rough-hewn Kris Kristofferson, keeps one eye on the Vikings-Packers game while chatting with strangers inside Sutter General Hospital’s emergency room. This is his fifth hour seated in a turquoise-green chair. Turns out, he’s here this Saturday night for the same reason most Sacramentans end up in the ER: He fell.

In his case, the culprits were ice skates, the occasion an outing with his 6-year-old daughter at the downtown rink. Oops. Feet in the air, head to the ground. “A compression fracture of my vertebra!” The diagnosis rolls of Kristofferson’s tongue.

During this evening at the ER, new patients arrive as frequently as shoppers to a Safeway. The health-care world calls these individuals “encounters.” Tonight, there are dozens, including: two youthful black women toting infants; an Asian girl with a black eye and a coterie of family and friends in tow; a white senior woman in a wheelchair sitting alone; a white guy in his 30s who forgot his coat in the restroom; and a 20-something blond woman with a boozy spice who tells fellow patients she wants to kill herself.

It’s a veritable smorgasbord of encounters. But not all necessarily of the emergency kind. In fact, according to a new report by the Sacramento-based Sierra Health Foundation, nearly half of these patients likely shouldn’t be in the ER.

And that’s the rub: The emergency room is often fingered as the quintessence of this country’s health-care woes. It’s expensive, yes—costs run anywhere from four- to 10-times a normal doctor’s visit, according to reports—and while the country’s health-care ills boast many other symptoms—from a lack of affordable insurance to sticker-shock medical costs to poor management of chronic illness—the numbers don’t lie: ER encounters are up by nearly 50 percent in Sacramento County since 2006. For-profit urgent-care centers keep popping up. And at some hospitals, such as Kaiser Permanente Sacramento Medical Center and Medical Offices in Arden Arcade, costly ER visits have more than doubled in five years.

It’s an emergency—but not one in want of solutions.

This year, because of President Barack Obama’s Affordable Care Act, California has a once-in-a-lifetime shot to revolutionize its health-care industry. A chance to, among other remedies, divert a majority of the nearly half-million Sacramentans who visit the ER each year to preventative care. Industry leaders are planning ways to spur doctors to build meaningful relationships with patients. This move toward primary care and clinics will save billions of dollars annually.

The catch is, though, that we have to spend billions to save billions. And, as Assemblyman Richard Pan told SN&R recently, “things will probably get worse before they get better.”

Obamacare mandates, for instance, that the 7.7 million uninsured Californians attain coverage. A large chunk of these individuals will join Medi-Cal, a health-care program for low-income individuals, families and seniors. But the state already spends $15 billion, or 17 percent of the general fund, on the program, and experts worry new costs will suck state coffers dry—and, invariably, force these newly insured, who will have difficulty landing a primary-care doctor, into ERs, too.

As Scott Seamons with the Hospital Council of Northern and Central California put it, “We’re all working hard to take on the tsunami wave that’s coming.”

The Sacramento region’s busiest ER can be found inside an imposing, dated maroon-brick building just off Alta Arden Expressway a few miles from the mall. Inside at 11 p.m. on a recent Sunday night, CNN hums on the corner flat screen, and 41 patients and visitors, including nine children, rest in chairs or pace anxiously on faux-wood floors. A woman who doesn’t speak English seems like she’s going to cry. A 20-something girl sleeps while sitting on a guy’s lap. The Kaiser Sacramento nurses, who pop their heads out of a door every so often, routinely smile and behave compassionately.

An elementary-school-age black girl seated nearby is antsy. “You’ve got ADD, huh?” a man to her right asks.

“What’s that mean?” she replies.

“It means you can’t sit still.”

It’s not unethical, per se, for a journalist to lurk in an ER—most hospitals actually call them “emergency departments,” perhaps because of unpleasant Hollywood associations with the abbreviation. But Kaiser and others also insist that reporters not violate the Health Insurance Portability and Accountability Act of 1996 and conduct interviews in the ER. Plus, it turns out few people are interested in recounting ER blues.

But there isn’t a lack of stories: In 2011, the Kaiser Sacramento ER experienced 84,700 encounters, a more than 100 percent increase from 2006, when 40,353 patients passed through (according to data provided by hospitals to the California Office of Statewide Health Planning and Development). Kaiser Permanente Roseville saw a 62 percent surge, and Kaiser Permanente South Sacramento saw a 38 percent jump during the same five-year period.

While Kaiser hospitals boast the highest ER-visit upticks in the region, other hospitals are not immune to soaring emergency-room numbers.

Encounters at the UC Davis Medical Center in south Sacramento, for instance, are up by more than 88 percent since 2006. Mercy Hospital of Folsom has seen a 33 percent jump since 2005. Sutter Roseville Medical Center is up 36 percent; Sutter General Hospital in Midtown is up 15 percent.

These are unprecedented spikes—and the kicker is that the industry says a shockingly high number of patients don’t actually need to go to the ER.

According to a 2012 Sierra Health Foundation report—which is titled “Preparing for Transformation: Rethinking, Revitalizing and Reforming the Sacramento Region’s Health Care System” and was researched by dozens of local health-care leaders—more than 40 percent of ER patients in 2010 probably didn’t need to go to an emergency room.

“Those patients could have been treated in a more appropriate and less costly setting, freeing up the emergency department for cases that were actual emergencies,” it reads.

The average cost of an ER visit in California varies from source to source, but estimates are upward of $500 for a simple doctor consultation, no tests. Anything more than that—CT scans, X-rays, etc.—can cost upward of $3,000 for every hour with a doctor.

It’s a stunning dilemma: This writer spent more than a dozen hours in three area ERs—Kaiser, Sutter General and Mercy San Juan Medical Center in Carmichael—and patients filled each waiting room. Most people didn’t ostensibly have a medical emergency; not a lot of shortness of breath, chest pain or blood. Many times, security officers had to tell visitors to stand so that patients could rest. And wait, wait, wait.

Back at Sutter General in Midtown, the Kris Kristofferson look-alike is becoming an expert in patient patience. He says he missed his bus ride home because of his five-hour wait and, giving up, places a Regional Transit pass on an empty chair across from him. He then mumbles something to the fact that maybe another person can use it. This is his karmic moment: Within a few minutes, a nurse calls him and he—bad back and all—jumps out of his chair.

Health-care reformers such as Pan, who’s chairman of the Assembly Health Committee this year, says he hopes that the Affordable Care Act will change things for Sacramentans like Kristofferson.

“Coverage is a very important step, but it’s not the whole picture,” Pan said.

The assemblyman explained that Obamacare is a window to incentivize doctors and providers to build real kinship with patients. “If you don’t have an existing relationship, you may be more likely to go to the emergency room,” Pan argued.

The challenge, however, is that doctor-patient kumbaya is in part a cultural shift: Most emergency-room patients already have coverage; only 18 percent of Sacramento County ER encounters are “self-pay.”

Pan says people use the ER instead of a primary-care doctor for many reasons: They work during the day, they don’t have an adequate network of doctors via their provider, they don’t understand what constitutes an emergency. A rapport with a doctor and staff will keep more people out of the ER; a guy like Kristofferson might, say, call his doctor, who would recommended a pain reliever overnight and see him in the morning. But this sort of communication could take years, even a decade, to foster. Meanwhile, ER visits likely will spike in the coming years—Pan calls this a “wave of demand”—as millions of Californians are added to the insurance rolls.

But it could work. In fact, this shift is not unlike the Sacramento region’s “frequent users project,” which targeted chronic ER regulars and diverted them to primary care or clinics such as The Effort, which offers treatment and substance-abuse support. Obamacare is a similar chance to help.

And help is needed: On a Saturday night in January at the Sutter General ER, a woman in a wheelchair with long brown-blond hair and ragged, high-water jeans moans in discomfort. Her situation isn’t an emergency, but she’s not doing so hot. And probably hasn’t been for some time.

A young man seated next to her asks: “What’s wrong? You got the flu?”

“Something like that,” the woman in the wheelchair responds. “I’ve got the homeless disease.”