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Clinic of last resort for poor people

Legacy Emanuel's trauma unit faces a growing caseload of primary care for the uninsured and underinsured.
The Oregonian
August 15, 2004
 link to www.oregonlive.com

July 19, 2004: a typical Monday in the sprawling Emergency Department of Legacy Emanuel Hospital & Health Center in Northeast Portland.

It isn't exactly television's "ER." Only seven of the 142 people who pass through the automatic sliding doors are trauma patients, meaning they arrive -- unconscious or bleeding or burned or with broken bones -- in an ambulance or Life Flight helicopter.

The other 135 walk in.

While today's hospitals find themselves treating patients who, on average, are sicker than ever, their emergency departments face a paradoxically different challenge. They must remain ready 24/7 to treat the acutely ill and grievously injured, but they also see patients who would be handled more efficiently outside the hospital.

Sore throats, bunions, rashes, depression. Earaches and toothaches. Prescriptions that have run out. Routine ailments that have turned nasty.

For a growing number of uninsured and underinsured patients, hospital emergency departments are becoming the clinic of last resort. These patients often need primary care -- a checkup, medical advice, a prescription -- more than they need a trauma unit.

"We have a higher percentage of lower-acuity patients coming in," said Sue Dietderich, who directs emergency services for Legacy Health System. "That's a reflection of people not having another place to go, either because they can't find a doctor willing to see them or they have no insurance."

"Level 1 trauma, Room 1, 10 minutes," blares the intercom shortly after 8 p.m.

Four Life Flight attendants wheel the patient, an injured bicyclist, into Room 1. Safety straps come off, and a trauma team -- green scrubs, blue booties and purple gloves -- goes to work.

"Bummer," mutters a nurse as she leaves the room. Blood is leaking from the patient's ear.

Room 1 fits the "ER" stereotype.

But much more common cases are showing up in the other rooms. Gastric bleeding of unknown cause, a split finger from a softball game, lingering back pain from a fender bender, a wrenched shoulder, a cut hand.

And Tracy Brown.

If the health care system is to bring cost and benefit into closer balance, it must come to terms with patients such as Brown. What makes Brown a challenge is not his illness, which is easy to treat, but his insurance status.

Brown has no job, no health insurance, no doctor and a history of heart disease. He's all but certain not to pay his bill.

He's 41 and, with his short, spiky hair, looks a bit like baseball star Pete Rose late in his career. He lives in a group home in North Portland.

He takes five little white pills a day -- two in the morning, three at night -- to keep his blood pressure under control. The drug, clonidine, costs less than 20 cents a pill, or $28 for a month's supply.

When Brown's supply ran out last month and he started feeling woozy from high blood pressure, he went to Legacy Emanuel's Emergency Department.

For lack of a $28-a-month drug, Brown ran up a nearly $2,000 bill. He has gone to the Emergency Department three times in eight weeks, with bills totaling more than $3,800.

Two Oregon hospitals, both in Portland, have trauma units with the highest designation -- Level 1 -- meaning they are equipped to handle the most dire cases. One is at Oregon Health & Science University, the other at Legacy Emanuel.

About 48,000 patients a year arrive at the Legacy Emanuel Emergency Department. The total didn't change markedly during the past year, but the insurance pattern did.

The portion on the Oregon Health Plan, the state's Medicaid insurance for low-income people, dropped to about one in five. A state budget shortfall forced officials to trim benefits and increase premiums for a key part of the health plan, and enrollment plunged by 50,000.

At the same time, the portion of uninsured -- known officially as "self-pay" and unofficially as "no pay" -- jumped by more than half, from 12 percent to 18.4 percent.

Hospital leaders say those two trends are linked: When people drop off the Oregon Health Plan, they usually are left with no insurance.

Urgent care "doc-in-a-box" centers can turn away uninsured patients and require payment before treatment. Doctors can refuse to accept new patients. But hospital emergency departments must treat all comers, regardless of their ability to pay.

Under federal law, hospitals cannot turn away patients before ruling out a medical emergency. In the simplest case, a check of vital signs can accomplish that. Usually, it takes much more.

If an emergency patient has no insurance and cannot pay out of pocket, the hospital eats the cost. That leads to higher charges for insured patients and higher insurance premiums, which, in turn, makes insurance affordable to fewer people.

"It's a vicious cycle," said Josie Boyle, an Emergency Department nurse.

The 28-bed Legacy Emanuel Emergency Department -- it's no longer a "room" -- is three overlapping units. The main section has 17 beds, including three for psychiatric patients under round-the-clock observation. The children's unit has six.

And the newest section, with five beds, is called "fast track" -- for patients who have "routine emergencies" such as cut fingers or the need for drug refills. They are treated by physician assistants, who are trained to practice medicine under the supervision of medical doctors. The goal, not always achieved, is to get patients in and out within 60 minutes.

Tracy Brown seemed like a fast-track patient when he arrived -- until things got complicated

The Saturday before, he had run out of clonidine pills. By Monday, he had dizzy spells, tightness in his chest and a "wish-washy" sound in his ears.

"I don't really want to use the ER, but I don't have a choice," Brown said.

After losing his job as a fence builder, Brown enrolled in the Oregon Health Plan, but last spring he missed two monthly premiums in a row and was dropped from the rolls. Once out, patients cannot re-enroll for six months. As of July 1, the part of the health plan that covered Brown was not accepting new applicants.

Brown stopped taking his prescribed antidepressant and borrowed money from his sister to pay for his blood pressure drug. When he ran out of pills again, he was loath to ask his sister for more money.

As an unemployed single adult, Brown gets $141 a month in food stamps. Records show he has served federal prison time for robbery.

Two crucial facts took Brown off Emanuel's fast-track on July 19 and sent him back to the main Emergency Department. He had been taking blood pressure medication for seven years, since a mild heart attack at age 34. His father died of a heart attack at 53, his grandfather at 58.

"We're gonna have to check that out and make sure you didn't have another heart attack," Scott Fleck, a physician assistant, told Brown. The hospital would give Brown a seven-day supply of pills for free, but he would have to pay out-of-pocket for a prescription beyond that.

Fleck described Brown as "a classic case of what we're seeing more and more" since the economy slumped and the Oregon Health Plan started shrinking last year. He said the case also illustrates the warped incentives in a health care system with large numbers of uninsured patients.

"He has a condition -- high blood pressure -- that's very easy to treat with a drug that's relatively cheap," Fleck said. Yet Brown's hospital bill moved into the four-figure range the moment Fleck walked across the hall to order cardiac tests to rule out a heart attack.

Worse, Brown's life was in danger without the drug to keep his blood pressure under control.

"The guy's a time bomb," Fleck said.

Brown's electrocardiogram showed loss of blood supply to the heart. But without further tests, Fleck couldn't tell whether the damage was new or old. Brown would have to spend the night and be retested.

After midnight, Brown made a choice he later would regret. He decided not to stay overnight for the seven-hour follow-up test on his heart.

"Can you imagine how much that would cost?" he said. "The deeper I go into debt, the harder it will be to get my credit back."

Brown talked the decision over with Fleck, who said he understood the financial worry. But Fleck also warned Brown of the medical danger if he skipped the test. If his heart was newly damaged, that could lead to another heart attack.

Before Brown left, he signed a statement that he was doing so against medical advice.

On his way out, Brown paused in the men's room off the hospital lobby. He took two clonidine pills, his first dose in nearly three days, washing them down with a handful of tap water. Then, because it was after 1 a.m. and the buses had stopped running, he walked the 30 blocks home.

By the next afternoon, Brown's symptoms had subsided, and he felt fine. But a week later, he ran out of pills again.

When patients are discharged from the Emergency Department, hospital policy calls for referring them to primary care for follow-up. "That's a problem these days," said Dietderich, of emergency services, because so many patients have no regular source of care.

"The ER is not the place to come back for your checkup," she said. "You can't make an appointment for the ER."

But patients can show up, as Brown did July 26 -- his third visit in eight weeks.

This time, he met with Fleck and a social worker, Jill Sydnor, who gave him a list of local medical assistance programs and clinics for uninsured patients.

"He's doing what he has to do," Sydnor said. "He can't afford a drug that costs almost nothing, so he comes to the Emergency Department and runs up a bill in the hundreds of dollars, maybe more. It doesn't make sense."

Normally, she would refer a patient such as Brown to the hospital's primary-care clinic. But that clinic is jammed, with a waiting list of six to eight weeks.

By going the past week without further symptoms of heart trouble, Fleck told Brown, "you've essentially ruled yourself out for a heart attack."

But he still needed his medication.

Brown came away with 35 pills, enough for another week.

Two days later, the bill for the previous visit came in the mail: $1,470.90, not counting doctor fees. Of that total, the blood pressure pills accounted for $9.60.

News researcher Margie Gultry contributed to this report. Don Colburn: 503-294-5124;  doncolburn@news.oregonian.com

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