Emergency rooms facing public health crisis

"Emergency rooms are reaching capacity more frequently, beds for new patients are unavailable and full ERs are requesting ambulances to bypass them for other hospitals."

Alex is a middle-aged man with many health issues, not the least of which is mental illness. To make matters worse, he's an alcoholic and homeless. He's brought into the emergency room so often that he's joined the ranks of the so-called "frequent fliers."

Joe is a young man barely getting by. He has insurance for the first time through Medi-Cal, California's version of Medicaid, but comes to the emergency room for care because he can't find a specialist who takes Medi-Cal.

Anne is in her late 30s with a couple kids and a good job. She's brought her kids to the emergency room several times when they were slightly ill because it was too hard to see a physician elsewhere at a convenient time.

At emergency rooms in San Diego County and throughout California, these scenarios are occurring more often. Emergency rooms are reaching capacity more frequently, beds for new patients are unavailable and full ERs are requesting ambulances to bypass them for other hospitals.

The reasons are myriad, the problem complex. And it's more than hospitals can handle alone.

Hospitals here have seen a surge of Medi-Cal patients in emergency rooms since Medi-Cal's expansion. One in three Californians are now enrolled. But California ranks 49th in the country for what it pays doctors and hospitals through Medi-Cal. Many doctors won't accept it; those who do have increased patient loads and longer waits for appointments.

So, patients are turning to ERs. We've seen a 109 percent spike in Medi-Cal patient visits since 2011 at Scripps ERs alone. In December, several groups filed a complaint alleging California has violated the rights of low-income residents by paying Medi-Cal providers at "inadequate" reimbursement rates, thus limiting access to care.

Compounding the problem is the impact on emergency rooms by patients who also have behavioral health conditions — an increasing share of all ER visits. Acute care hospitals are woefully underfunded to pay for the psychiatrists or facilities these patients require. Yet every day, they come to us for help or are brought in by law enforcement because there is nowhere appropriate to take them. And they stay in the ER too long for that same reason.

Frankly, I am worried about behavioral health in this country. Only 7 percent of all health care dollars go to behavioral health, while 1 in 4 adults experiences mental illness in a given year. There is an inadequate supply of community outpatient resources, inadequate payment for psychiatric illness, and a shortage of qualified professionals, special skilled nursing facilities and long-term care facilities.

For many, access to care when they want it is the main driver of an ER visit. That's understandable. For too long, healthcare has been focused on what works best for us as providers. Care hasn't been available at times and in locations that work best for patients. But increasing use for routine care affects an ER's ability to deal with real emergencies. At Scripps, there was a 160 percent increase in the number of emergency room visits for non-emergencies from 2014 to 2015.

I don't believe this issue is unique to California. Throughout this nation, emergency rooms are being misused, they are overcrowded, they're boarding behavioral health patients while searching for someplace willing to take them, and there's a lack of funding and focus needed for behavioral health issues both inside and outside the hospital.

By law — and because it's the right thing to do — emergency rooms treat anyone coming to them for care. But, emergency rooms cannot safely accept patients coming in by ambulance if they don't have the capacity and resources to care for them.

How to solve all this?

The obvious answer for many is to expand or to build new emergency rooms. But we've done that. Scripps has expanded its emergency rooms at two of its hospitals and will be opening a new emergency room at a third. Several other local hospitals have built new or expanded existing ERs, as well. And it still isn't enough.

Patients with non-emergencies should seek treatment from their regular physician, or at an urgent care or other venue. And hospitals need to expand hours, locations, telemedicine and other access points.

Medi-Cal reimbursements need to be increased so patients can get care with primary care doctors and specialists outside of an emergency room. California's governor has just released his draft budget, so discussions will begin soon on that and on proposed legislation to increase Medi-Cal payments to something closer to the cost of care.

Solutions to the behavioral health impact on ERs include specialty care sites with staff to address psychiatric emergencies, closer collaboration among healthcare providers, insurance, government and community services, and more funding. We should draw a lesson from other industrialized nations whose higher spending on social services translates to lower spending needed on healthcare.

None of this will be easy to do. But something must be done — and soon — because what's happening in California ERs is a public health crisis, and it's happening now.

Chris Van Gorder is president and CEO of San Diego-based Scripps Health, a nonprofit integrated health system.

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