Fast-food medicine

Under the Affordable Care Act, Sacramento ERs may have to get worse before they get better

Nothing bad ever happens in the suburbs.

This myth is being debunked inside the neutral-yellow bowels of a Folsom emergency room on a frigid Sunday. A sea of roughly three-dozen glum-faced occupants stew in their own pain, waiting for someone in a white coat or lime-green scrubs. They’ll have to wait a long time.

These days, even middle-class suburbanites aren’t exempt from the ripples of a flailing health-care system. Because modern medicine is such a vaunted mess—unaffordable to a new generation of poor folks who, somehow, aren’t poor enough to qualify for Medi-Cal but are too broke to afford private insurance—overburdened emergency rooms have become a one-stop shop to a growing number of people with nowhere else to turn.

As a result, many ER departments abdicate themselves to providing “fast-food” services: quick and nonnutritional.

This ever-increasing demand is a direct result of a perfect-storm-level collision of a national recession, dwindling reimbursement for health practitioners and reform measures, said Stacey A. Donegan, senior vice president of Marsh, a health-care consulting practice.

“The number of under- and uninsured has continued to rise, meaning people can no longer afford preventative [care] or physician office visits and utilize the emergency department as such,” she said.

Along with a bad economy that’s robbed millions of employer-provided health insurance, low-cost and free primary-care alternatives have evaporated.

As recently as 2007, Sacramento County operated six primary-health-care centers—each one offering an array of clinics—for the poor and uninsured. Today, it runs one—and it’s experiencing its own patient overload.

Over a span of just 12 months, visits to this center on Broadway jumped 12 percent to nearly 67,000 last year, says county spokeswoman Laura McCasland. The center’s dental clinic, meanwhile, has been reduced to offering only emergency tooth extractions.

“When you close six or seven clinics in the county, you don’t provide very many opportunities for [some] patients to get primary care,” said Scott Seamons, regional vice president for the Hospital Council of Northern and Central California. His council is one of three belonging to the California Hospital Association, which lobbies on behalf of all 450 hospitals in the state.

Nonprofits have been unable to pick up the slack. Sister Mary Ellen Howard runs outreach for a small primary-health clinic in the city of Sacramento. (She asked that it not be identified, since the clinic only accepts patients by referral and is struggling to keep up with demand.)

Howard says she knows why more and more patients are turning to ERs for their primary medical needs. “We believe that’s because they don’t have any place else to go for care,” she told SN&R. “And our clinic is very small. It’s just the tip of an iceberg. But anyway, it’s better to light a candle than curse the darkness.”

One flickering candle may be the county’s new Low Income Health Program. Launched in November 2012, it is an expansion of medical coverage for the poor.

“That basically is our response,” McCasland said. “We’re moving to preventative care with the expectation that we’ll reduce [people’s] reliance on ERs.”

The program has already racked up 5,145 enrollees. By next December, it’s expected to provide coverage to 10,000 to 14,000 county residents.

But the effect on local ERs has yet to be felt.

One of the goals of President Barack Obama’s game-changing Affordable Care Act is to reverse this trajectory by insuring those who aren’t currently covered and giving them access to preventative care they can’t otherwise afford. In California, that figure now hovers at 7.3 million people under the age of 65, according to the California HealthCare Foundation.

But its major provisions don’t kick in until 2014. In the meantime, ER populations swell with the poor. Between 2006 and 2011, the number of Medi-Cal recipients visiting Sacramento County ERs rose 6 percent to 132,364. The number of “self-paid” ER visits crept up more than 4 percent to 73,138.

Seamons argues that the nine hospitals in Sacramento County and others on the periphery have so far been able to manage the increased demand. The reality on the ground tells a different tale.

Like other ERs throughout the county, the one inside Mercy Hospital of Folsom has experienced a sharp spike in demand over a very short period of time. Since 2005, this 25-bed emergency department has seen patient visits jump a staggering 33 percent to nearly 30,000 in 2012.

Today, my aunt is one of those visitors.

A petite German woman in her early 60s, she’s suffered chronic and undiagnosed internal pains for the past four years. A rotating cast of ’scrip-writing doctors has been prevented from ordering expensive diagnostic tests by insurance companies looking to keep costs down. But on December 16, 2012, her mystery condition metastasized considerably: Shrapnel-sharp pains invaded her chest and throat and sliced up into her ear canal, resulting in a rushed car-ride here and an unlikely family gathering.

As a retired civilian-housing official with the U.S. military, she supposedly has pretty decent medical coverage. But insurance means little sometimes, and local ERs have become the first last resort for this community as well.

My aunt is one of nearly 430,000 people in the county who pleaded for emergency care last year. On this day, she will wait five-and-a-half hours for a rushed once-over and a pain-pill prescription, the equivalent of an (un)Happy Meal.

Because of a need, interfering insurance companies and dwindling resources, health care has fully embraced America’s fast-food philosophy. One ER nurse told SN&R that insurance companies routinely block medical staff from ordering needed tests because they’re too expensive.

“That happens all the time,” said the nurse, who didn’t speak for attribution.

And because of limited space, the rush to turn over beds has become of greater necessity. A whopping 98 percent of admissions to Folsom’s Mercy ER resulted in routine discharges last year. The county average is 95 percent.

That quick turnover may be a logistical necessity for overwhelmed ERs, but it isn’t always good for the patient.

“Longer inpatient stays do not equal better outcomes. However, sending a patient home before they are ready is equally detrimental,” said Donegan, with the health-care consulting firm.

This paradigm actually could get worse in the first several months under the Affordable Care Act. Anticipating a “substantial” initial spike in ER visits under Obamacare, Seamons says hospitals are prepping to “fast-track” ER patient assessments and get them out to primary-care physicians.

The current reality has forced well-meaning ER staff to often adopt a dumbed-down version of Western medicine.

They used to ask patients to describe their pain level using a numeric scale (No. 1 being mild discomfort, 10 being “the air feels like hot acid”). Now, some intake nurses trot out a laminated sheet with crude, simple cartoon faces of people in various stages of pain and ask patients to point to the one that best describes their distress.

We’re one step away from nurses asking patients to show them on a plush doll where their ouchie is.

Back in the Folsom ER, my aunt starts to cry from the pain. A male nurse walks out to say it’ll be another hour.

“Can you last another hour?” her daughter asks.

A whimpering blond woman in a wheelchair is rolled to a nearby check-in booth. She lays her head on the desk as the attendant asks her questions about insurance coverage.

A husband, with an overnight bag, walks past into the buzzing double doors to the right. A nurse passes him going the other way and sounds out a name. It sounds like “Peccadillo.”

My aunt wants to leave. Her husband died in a place like this in 2008. Stomach cancer chewed through his body within a span of three months. He was a decimated, 90-pound shell puking bile into a plastic bedpan near the end. Uncle Don’s one wish was to get out of his starched hospital bed and die at home. That wouldn’t happen.

Mom says she’ll just call 911 next time. An ambulance ride pretty much guarantees an immediate bed. No one bats an eye at the mention of a “next time.”

A young guy wearing a hoodie saunters out of the ER with a plastic jug of Lipton Iced Tea in his hand and a jostling colostomy bag swaying by his sagging jeans. It’s one-third full with brown liquid. His thin girlfriend speed walks after him.

The waiting room in an ER is an example of “wedge” health care: Not unlike politics, where two common groups are often cynically set against each other, those waiting in the ER are put into the position of resenting everyone else who gains entry before them.

When my aunt is finally admitted, it is nearly six hours after her arrival. Her blood will be drawn, and she’ll be told to make an appointment with her primary-care physician. No further tests will be ordered. She’s then discharged with a prescription for pain pills and a reaffirmed certainty that modern medicine can’t help her.

Ninety-five percent of ER cases end like this, according to the Office of Statewide Health Planning and Development.

Before leaving, I kiss my aunt on the cheek.

“This was fun,” I say, trying to lighten the bummer mood. “Next time, let’s do it at a different ER.”

She half-smiles. Humor isn’t always the best medicine. But sometimes, neither is medicine.