G U Y L . C L I F T O N , M . D .
RUTGERS UNIVERSITY PRESS NEW BRUNSWICK, NEW JERSEY, AND LONDON
Flatlined
LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA Clifton, Guy L., 1949–
Flatlined : resuscitating American medicine / Guy L. Clifton. p. ; cm.
Includes bibliographical references and index. ISBN 978–0–8135–4428–1 (hardcover : alk. paper)
1. Health care reform—United States. 2. Medical policy—United States. I. Title. [DNLM: 1. Health Care Reform—United States. 2. Economics, Medical—trends—United States. 3. Emergency Medical Services—organization & administration—United States. 4. Hospitals—trends—United States. 5. Insurance, Health—trends—United States. WA 540 AA1 C639f 2009]
RA395.A3C618 2009 362.10973—dc22
2008011239 A British Cataloging-in-Publication record for this book is available
from the British Library.
Figures 4.1 and 12.2 were reproduced with permission from the Henry J. Kaiser Family Foundation. The Kaiser Family Foundation, based in Menlo Park, California, is a non-profit, privately operating foundation focusing on the major health care issues facing
the nation and is not associated with Kaiser Permanente or Kaiser Industries. The author is donating his proceeds from this book to San Jose Clinic, Houston, Texas.
Copyright © 2009 by Guy L. Clifton, M.D. All rights reserved
No part of this book may be reproduced or utilized in any form or by any means, elec-tronic or mechanical, or by any information storage and retrieval system, without
writ-ten permission from the publisher. Please contact Rutgers University Press, 100 Joyce Kilmer Avenue, Piscataway, NJ 08854–8099. The only exception to this prohibition is
“fair use” as defined by U.S. copyright law. Visit our Web site: http://rutgerspress.rutgers.edu
To my wife, Karen, my mother, Marjorie,
and the memory of my father, O. B. Clifton
Do not remember the former things, or consider the things
of old. I am about to do a new thing; now it springs forth,
do you not perceive it? I will make a way in the wilderness
and rivers in the desert.
—Isaiah 43: 18–19C O N T E N T S
List of Figures and Tables ix
Preface xi
Acknowledgments xvii
PART ONE
Why the Uninsured Should Be Covered
1
Not Business As Usual
3
2
Unreliable Emergency Services
10
3
An Eroding Infrastructure
16
4
Fifteen Years Lost
25
5
Handed Health Care’s Leftovers
35
PART TWO
Why Health Care Is So Expensive
6
Where We Are Headed
49
7
30 Percent Waste—or 50?
57
8
Poor-Quality Primary Care
67
9
Dangerous Hospitals
77
10
Violation of Dignity: The End of Life
94
11
Unnecessary Surgery
103
12
Perverse Payment Incentives
120
13
Three Pathways to Hospital Profitability
139
14
Pharmaceuticals: Remarkable Innovation,
Shameless Puffery
157
15
Private Health Insurance: No Added Value
170
PART THREE
Reforming American Health Care
16
Three Options for Covering the Uninsured
179
17
No Coverage Expansion without Cost Control
201
18
A Workable Plan for Reform
212
19
Establishing Standards
224
20
Prioritizing Primary Care
232
21
Reducing Spending on Hospitals and Specialists
243
22
Positioning of an American Medical Quality System
261
Notes 275
Figure 3.1 Number of U.S. emergency room visits 22 4.1 Percentage increase in cost of
health insurance premiums, 1988–2006 32
7.1 Components of U.S. gross domestic product, 2006 65
8.1 Relationship between quality and Medicare spending as expressed by overall quality ranking, 2000–2001 75
9.1 Typical handwritten patient progress note 91
9.2 Typical physician’s order sheet 93
11.1 Cross-sections of spine 112
11.2 Surgical spine procedures on the low back 113
11.3 Spinal surgery as a percentage of U.S.
hospital charges 116
11.4 Number of U.S. hospital admissions
with coronary catheter procedures 118
12.1 Annual changes in Medicare spending
per beneficiary with federal actions 122
12.2 Annual changes in private per-capita national
health spending with federal actions 123
16.1 Hospital payment-to-cost ratios for private
payers, Medicare, and Medicaid 190
Table 12.1 Generalists’ Income and Annual Workload 128
12.2 Specialists’ Income and Annual Workload 128
F I G U R E S A N D T A B L E S
P R E F A C E
I
am a neurosurgeon, perhaps the last person you might expect to write a book calling for reform of the medical industry. Yet despite all the good in medicine, I have witnessed bedside tragedies that no one would expect in the United States. After studying the U.S. health care system, I became so disturbed by my discoveries and experiences that I left my practice and my home to undertake a yearlong stint as a Senate staffer, focusing my efforts on health care reform. I also decided to write this book.In Flatlined I have worked to make my ideas understandable to a person whose only experience of health care is as a patient. You will find no unexplained medical jargon or highly technical terminology, just the stories and the necessary facts that describe the current—and unacceptable—state of affairs in American medicine. The stories are all real events or composites of real events that I have seen unfold. During my thirty years of medical practice, I have found doctors, nurses, and the staff and administrators of hospitals to be unusually principled people, and I have always been proud to be among their ranks. My stories are not about bad people but about good people working in bad systems.
The term flatlined refers to loss of the heart and brain’s normal, rhythmic electrical signal when a patient hooked up to a machine dies. Between 1999 and 2005 I watched patients die of injuries that should not have killed them. They were flatlined by the failures of the medical system. At present, being insured does not guarantee timely care or protection. An ambulance is waved away from an American emergency room every minute without regard for who is inside the vehicle. This situation will only grow worse without immediate reform.
Flatlining also faces the U.S. health care system as a whole if it con-tinues on its present trajectory. In 2007 Medicare and Medicaid
accounted for 23 percent of the federal budget and are on track to con-sume one-third of it by 2018. At any given time, 47 million Americans are without coverage or access to standard medical care, but that figure understates the problem. More than one-third of the non-elderly population—82 million people—has either insufficient, unstable, or no health insurance coverage. As a percent of wages, business spending on health care is at an all-time high; and small businesses are dropping cov-erage because they have been priced out. Health care costs are growing at twice the rate of the economy; meanwhile, American businesses face relentless global competition from companies that do not bear such costs. The overall budget for health care is already exorbitant. But at least 30 percent (about 700 billion dollars) of all delivered health care services are unnecessary for treating illness or ensuring wellness. Many proce-dures are also harmful. There is no just reason for a country as wealthy as ours to be delivering and consuming large quantities of wasted medical services when so many of its citizens have insufficient or unstable access to standard medical care. There is no excuse for disenfranchising so many people from medical services when they could be covered by the simple creation of a more efficient system. Full-access coverage and the reform of medical practice to reduce waste would also improve the quality of med-ical care. Too many people are victims, both the insured who get excessive or poor-quality medicine and the uninsured who get too little care, too late. Medical waste is a moral issue: it is the wrong use of money, and it hurts innocent people.
When I began considering the best manner of paying for and provid-ing health care in the United States, I did not begin with any biases. I have visited Canadian hospitals, and I know many Canadian doctors. I have a good opinion of that country’s health care system, which is managed through the government as the single payer. But the United States, with more than 300 million people, is not Canada, whose population is only about 34 million; moreover, their cultures are different. After spending a year in a Senate office watching the inner workings of Medicare payment policy, I cannot support a single-payer system. In the short run such a plan would reduce the considerable health care administrative waste, but in the long run there is no doubt that it would bankrupt the United States
unless it is managed very differently from Medicare. Medicare must be reformed because it already poses a serious fiscal threat to the country.
Another option is to patch the existing system. Large businesses con-sider the provision of health benefits to their employees a key strategy, although they have been unable to manage health care cost. Small busi-nesses, however, are dropping coverage because they can’t afford it and want out of employer-based health care. Thus there is an impasse. The other alternative is to disconnect insurance from employment and to sub-sidize individuals in their direct purchase of insurance in a competitive national insurance market, opposed by large businesses and insurers.
The underlying principle of this plan is that individuals will have enough personal financial investment in the purchase of health care so that consumer pressure will reduce health care costs. But market forces will not be enough to make health care affordable. Reducing the cost of health care will require the efforts of private industry, government, and the American people. Hospitals function as regional monopolies or oli-gopolies, and doctors are mired in historic modes of practice that are inefficient and mediocre in quality. Doctors and hospitals will not, and cannot, reinvent themselves without the cooperation of the buyers of health care: the public. People will have to submit to the care of a single doctor who coordinates and ensures the quality of their care. There must also be patient accountability. If individuals want procedures and treat-ments that are proven to have little value, they will have to pay for some of the cost. The problem of waste in medicine is collectively owned by doctors and patients.
The problems of insurance coverage and of the cost of health care are two separate but related topics requiring separate federal policy initia-tives. The magnitude of waste is so large and the prospects for savings and improved quality are so great that the only way to significantly reduce health care cost is to follow a targeted, federally led initiative to reduce waste. Such an initiative would provide the information and leadership necessary to establish benchmarks for quality medical care, discover and teach efficient processes of care, and change the method of paying doc-tors and hospitals to one that shares with them the savings from efficient practice.
THE SEVEN POINTS OF HEALTH CARE REFORM
1.
Every American should have access to adequate and
afford-able health insurance regardless of their health or job
status.
2. Individuals should directly pay for enough of their health
insurance premium or health care cost to have a sense of
stewardship.
3. Insurance premiums should be the same for the healthy
and the ill.
4. The health insurance industry should be reformed so that
competition among insurers reduces the cost and
improves the quality of health care.
5. A primary care doctor of the patient’s choosing should be
the first point of contact with the medical system and
should coordinate care and manage chronic illnesses.
6. The adherence of doctors and hospitals to benchmarks of
quality should be reported to them and to the public.
7. Doctors and hospitals should be paid based on the
qual-ity not the quantqual-ity of care they deliver and the savings
from efficient practice shared with them.
The United States pays at least two times more per unit of health care services than any other country in the world. Why shouldn’t the nation develop the first high-performance health care system in the world since it is already paying for one? Before assuming that these proposals are too rad-ical, too drastic a shift, consider the financial industry itself as a model for balanced regulation. Reforming U.S. medicine is like turning a giant air-craft carrier; compare it to the process of banking reform begun after the Depression. It will take time; and if we do not start now, we may be too late. When the Federal Reserve System was established in 1913, it was designed as a quasi-public institution with both private and government arms of oversight and management. Its functions have changed over the years but always with a single purpose: maintaining a stable financial sys-tem. I propose a similar model for health care, the creation of an American Medical Quality System responsible for providing the informa-tion necessary to reduce waste and improve the quality of U.S. medicine in each area of the country. The objective is to reduce the cost of health care so that it is affordable for individuals, families, and the national economy. Cutting the waste in health care will also free up money that can be used for coverage of the uninsured.
The only obstruction to reforming American medicine is lack of polit-ical will, but both raw statistics and unnecessary individual tragedies justify change. My hope is that Flatlined will contribute to public understanding and ownership of our nation’s health care problems. My only goals are accountability and justice. Americans want change, but we must rise to the challenge because our problems do not belong to someone else. We all must be willing to accept responsibility. With clear direction and sufficient political will, more than enough wasted money can be extracted from U.S. health care to cover all the uninsured, improve everyone’s quality of care, and permanently reduce the cost of American medicine.
A C K N O W L E D G M E N T S
I
t was my great good fortune to work with Marilyn Alice McDonald almost daily for thirteen years, and for three of those years she toiled shoulder to shoulder with me on this book, as dedicated to its completion as I was. Together we undertook the primary research, and we constantly debated our findings and conclusions. Her conservative midwestern judg-ment and keen intellect kept the book’s content grounded. I alone am responsible for its errors, as Marilyn rarely makes any.Sister Margaret Byrne of New Orleans and now Houston is a dear friend who in 2001 directed me through the Ignation Spiritual Exercises that led me down the unexpected and dangerous path of attempting to reform U.S. health care. I thank her for the wake-up call.
My father, O. B. Clifton, whom we lost while I was writing this book, and my mother, Marjorie Jean Clifton, taught me and my brothers the principles and the faith that have guided our lives. God smiled upon our families through our parents.
I was indeed fortunate in marriage. My wife of thirty-one years, Karen Florance Clifton, insisted that I had to try to do something about health care, not knowing that in the process she would be uprooted from her home, her friends, and her family. She never wavered, simply stating that we had an obligation to do whatever needed to be done. Karen has been my constant companion and support and, from my first sight of her, the love of my life. She gave up three years of weekends as I researched and wrote this book, and she read each version, encouraging me to keep going until I got it right.
I interviewed a number of people, all of whom were open and gener-ous with their time. They include Joe Antos, scholar at the American Enterprise Institute; Judith Cahill, executive director of the Academy of
Managed Care Pharmacy; Carolyn Clancy, director of the Agency for Healthcare Research and Quality; Terry Clemmer, director of Critical Care Medicine at LDS Hospital, part of the Intermountain Health Care System of Salt Lake City; Janet Corrigan, president and CEO of the National Quality Forum; Helen Darling, president of the National Business Group on Health; Karen Davis, president of the Commonwealth Fund; Suzanne Delbanco, CEO of the Leapfrog Group; Carol Diamond, managing director of the health program at the Markle Foundation; Judy Feder, dean of the Georgetown Public Policy Institute; Herb Fritch, chairman, president, and CEO of HealthSpring; James K. Geraughty, chief medical officer of HealthSpring; Paul Ginsburg, president of the Center for Studying Health System Change; K. Lance Gould, professor and Martin Bucksbaum Distinguished Chair in Cardiology at the University of Texas Medical School at Houston; Stuart Guterman, senior program director for Medicare’s future at the Commonwealth Fund; Bill Hermelin, director of government affairs and general counsel at the Academy of Managed Care Pharmacy; Ada Sue Hinshaw, professor and former dean at the University of Michigan School of Nursing; George Isham, medical director at HealthPartners; Brent James, executive director at the Intermountain Institute for Health Care Delivery Research; Arthur Kellerman, professor in the Department of Emergency Medicine and associate dean for health policy at Emory University School of Medicine; Sid King, managing part-ner at the Sumpart-ner Medical Group; Richard Kronick, professor and chief of the Division of Health Care Sciences in the Department of Preventive and Family Medicine at the University of California San Diego School of Medicine,; Lucian Leape, adjunct professor of health policy in the Department of Health Policy and Management at Harvard University; Jack Meyer, principal of Health Management Associates; Robert E. Moffit, director of the Center for Health Policy Studies at the Heritage Foundation; Marilyn Moon, vice president and director of health pro-grams at the American Institutes for Research; Len Nichols, director of the health policy program at the New America Foundation; Nina Owcharenko, senior policy analyst in the Center for Health Policy Studies at the Heritage Foundation; Jeffrey S. Passel, senior research associate at the Pew Hispanic Center; Steve E. Phurrough, director of the Coverage and Analysis Group at the Centers for Medicare and Medicaid Services
AC K N OW LE D G M E N TS x i x
(his comments were personal, not official); Eugene Rich, Tenet Healthcare Endowed Chair and professor of medicine at the Creighton University Medical Center; Sean Tunis, director of the Center for Medical Technology Policy; Andrew Webber, president and CEO of the National Business Coalition on Health; John G. West, surgical director of the Breast Care and Imaging Center of Orange County; and Dan Wolterman, presi-dent and CEO of the Memorial Hermann Healthcare System.
Michie I. Hunt incisively synthesized the literature on managed care, international health care, and pharmaceutical costs. Tom Reynolds of the University of Texas School of Public Health assisted with primary research in the Healthcare Cost and Utilization Project database. Roy Prichard of the Graphic Communications Department of the University of Texas Medical School at Houston created the illustrations.
In the fall of 2006 I received a Robert Wood Johnson health policy fel-lowship, which each year allows a few health professionals to study health policymaking from the inside. Marie Michnich is responsible for the man-agement and content of this excellent program. Between August and December 2006, six other medical professionals and I listened to private presentations and then peppered more than seventy leaders in health policy with questions. We were then given the opportunity to work in con-gressional offices. I spent one year working as a fellow in the office of Senator Orrin G. Hatch under the direction of his health policy director, Pattie DeLoatche. It was an extraordinary opportunity. The public is for-tunate to have such people looking out for our interests.
Despite all my assistance from these various people and organiza-tions, I want to clarify that none of the opinions expressed in this book reflect the opinions of the University of Texas Health Science Center at Houston, the Robert Wood Johnson Foundation, the Robert Wood Johnson Health Policy Fellowship Program, Senator Hatch or his staff members, or any of the people I interviewed. All opinions and conclu-sions are mine alone.
Finally, creating a book that is not quite an academic book and not quite a trade publication requires a lot of editing. The book’s first editor was my longtime friend and teacher of English, Dr. Charles Novo. Rose Vines, whose specialty is technical writing, performed major surgery on an early version of Flatlined, expunging hundreds of pages of gratuitous
information. Jerry Gross, who usually edits novels, helped organize the cadence and transitions for the lay reader. My colleague, Dr. Len Nichols, a leading health economist and policy analyst at the New America Foundation, critiqued the policy sections, offering invaluable advice. I owe the title Flatlined to Lawrence Wright, who won the 2007 Pulitzer Prize for A Looming Tower. My son Dr. Guy Travis Clifton refined medical aspects of the work. My editor at Rutgers University Press, Doreen Valentine, was the first enthusiastic supporter of this project in the pub-lishing world and provided insightful advice on organization and skillfully edited the final drafts of the book. This book had many midwives, and I am grateful to all of them.
PART ONE
Why the Uninsured
Should Be Covered
O
ne hot Saturday afternoon in the summer of 1999 I was on neuro-surgery call at Memorial Hermann Hospital in Houston, Texas, one of the largest trauma centers in the United States. Houston is the fourth-largest city in the country, and its metropolitan area is home to 5 million people. The page operator connected me with an emergency room doctor in the little town of Lake Jackson, fifty miles south of Houston, and we began a routine conversation for a busy on-call weekend.“Dr. Clifton, I have a forty-year-old woman who has a brain hemor-rhage. The car she was driving struck a tree. She is unconscious but mov-ing everythmov-ing. Can I send her to you?”
“We’ll send the helicopter to get her,” I responded. “Is she intu-bated?” Intubation is a procedure in which a tube is put into the airway to control breathing and is standard practice in an unconscious patient.
“Yes, I intubated her and gave her mannitol as well.” Mannitol is a sugar solution that extracts water from the brain and decreases brain pressure for a little while until surgery can be performed to evacuate the blood clot. The doctor in Lake Jackson was competent.
Hospital conversations between two doctors about a transfer are always recorded and silently monitored by a nurse in the transfer center. The recorded conversation provides proof of compliance with federal law that governs the transfer of patients between hospitals. “Dr. Clifton,” the transfer center broke in, “We do not have any ICU [intensive care unit] beds. We are on diversion.”
3
1
Not Business As Usual
I witnessed a series of personal tragedies that began to morph
into an alarming overall picture.
These were not words I had heard before, and my instant response was a question: “What do you mean we don’t have any ICU beds?”
“Dr. Clifton, we are full.”
After a moment’s thought I said, “Let me go through the unit; I am sure I can move someone out. . . . Doc, I will call you back.”
The term diversion is used when a hospital’s emergency room turns away ambulances because either the ER or the hospital is full and cannot accept any more patients. But at that time, it was a new word to me.
Memorial Hermann Hospital’s neuroscience ICU has twenty-eight beds and is one of the largest of its sort in the country. The hospital has always cared for the region’s worst neurosurgical emergencies—any time, every day—flying them over the city’s clogged streets by helicopter. The hospital’s ICU is the city’s core resource for emergencies of the brain and spine.
The charge nurse and I walked past one patient after another— ventilators pumping, heads wrapped, oxygen hissing, tubes projecting from natural body openings and from openings we had made.
“Can this one be moved to the regular ward?” “No, Dr. Clifton—too unstable.”
“What about this one?” “No, she just had surgery.”
In every bed lay patients too sick to move. I had been chief of the neu-rosurgery service at Memorial Hermann Hospital for ten years, and this was the first time I had ever turned down a patient for lack of a bed. I thought the situation was strange.
I redialed the doctor in Lake Jackson. “Doctor, I went through our ICU, and I can’t move anyone. I don’t have anyplace to put the patient.”
Through the phone I could feel his anger. “Dr. Clifton, I have been turned down by three other hospitals. I cannot find a bed. What am I going to do? This lady needs surgery and she needs it soon!”
I gave him the name of two large nearby hospitals with neurosur-geons and said, “I am sure they will help.”
He curtly responded, “Okay, I hope she lasts.”
Several weeks later I was talking to Dr. Greg Bonnen, a neurosurgeon who practiced at the University of Texas Medical Branch in Galveston (UTMB) near Lake Jackson. “Greg,” I asked, “Is UTMB turning away transfers?”
“Yeah, all the time now,” he answered. “I operated on a lady a few weeks ago, ten hours after she was injured. You would not believe what they did to get her in.” Greg told me that the patient’s doctor in Lake Jackson could not find a neurosurgeon-staffed hospital with an available bed. He reasoned that if a call were made to one of the big hospitals from the scene of an accident rather than from his emergency room, then the hospital would fly a helicopter for a pickup even though it was full. No hospital would leave a patient dying at the roadside.
According to Greg Bonnen, the emergency room doctor had put the patient into an ambulance and sent it to the tiny local airport. At the air-port, the ambulance crew called UTMB saying they were at the scene of an accident with a patient and asking if a helicopter be sent right away. At that time UTMB’s policy was always to accept a patient from the scene of an accident, regardless of the availability of beds. The helicopter flew, and the patient was retrieved.
I asked Greg, “So what happened?”
“She herniated before she got there.* She ended up in a vegetative state in a nursing home—left three children at home. It was pretty sad.”
From Barbarism to Sophistication
As a neurosurgeon who has also been a medical school faculty member for twenty-five years, I have operated on more than 6,000 patients in my career, undertaking everything from complex brain surgery to procedures on the spinal cord and the back. But when I was a medical student in the early seventies, I remember watching the neurosurgeons at work and thinking, “This specialty has no place to go but up; it’s fascinating but it’s barbaric.”
The claim sounds like a cliché, but doctors do go into medicine because they want to help people. In the early days of neurosurgery, how-ever, doctors could not get too close to the patients or their families. N OT B U S I N E SS A S U SU A L 5
* Herniation takes place when a blood clot in the brain causes so much pressure within the skull that it steadily squeezes a small but critical part of the brain, called the brain-stem, down through a hole in the base of the skull. Both Greg and I understood that if the patient had been operated on to remove the blood clot within two hours after the accident, she would likely have returned home to care for her children.
We knew that the majority of our patients would die or be severely dis-abled and that our treatments were not very effective and often painful. At the time we could not change those outcomes. Patients arrived in dizzying numbers, some of whom had invited disaster by drinking and speeding, others of them innocents selected by fate. Our best encourage-ment was that sometimes a patient we all thought would do badly woke up in a few days and went home. Thirty years later, I still remember the faces of such patients.
Until 1976 there was no computerized axial tomographic (CT) scan to determine who needed surgery. In the hospital where I trained, a neuro-surgeon determined if a patient had a mass in her head by rushing her into a dark little X-ray room with a heavy metal table in its center, its chipped paint a sign of heavy use. The patient was hastily laid on the table and covered with a sheet. Then the neurosurgeon would loudly instruct the confused patient not to move while he (at that time neurosurgeons were almost always male) plunged a large needle through her neck into an artery. An accurate penetration produced a two-foot stream of squirt-ing blood. I practiced this and became expert at impalsquirt-ing the artery with only one or two quick thrusts. Dye was then injected into the needle by hand, and it streamed into the brain’s blood vessels. X-rays showed the shifting of the vessels by the mass, so the surgeon could tell if its location was right or left, front or back. But he could tell little else. No one could actually see what was inside or how far it extended; so scalp incisions were a foot long, and we made an opening as big as one-fourth of the skull so as not to miss the mass.
Sometimes patients would be strapped into an ugly green metal chair, also with chipped enamel but equipped with worn leather restraints, for a procedure called a pneumoencephalogram. I had never seen an electric chair, but I imagined that the devices were similar. We performed a spinal tap through a hole in the back of the chair—patients squirming, with their arms, legs, and head strapped to the chair; the sur-geon yelling at them to keep still so they would not be injured by the procedure. Air was then injected into the spinal column through the nee-dle. The patients always groaned as the air bubbled over the brain, an action that produced a blinding headache followed by waves of nausea. The chair was then turned upside down so the air would stream into the
right compartment in the brain. In our hospital an average of one patient a year died during this procedure because the air allowed unexpectedly large brain tumors to shift within the skull. It was good fortune for me and for the patients that technology transformed neurosurgery in the next thirty years.
These days, with CT and magnetic resonance imaging (MRI) scans, neurosurgeons can determine if a mass is a blood clot or a tumor, what kind of tumor it is, how close it is to speech and movement centers, and how it is affecting the surrounding brain. The patient is simply required to remain still for a few minutes without additional discomfort from the imaging procedure. The mass can then be removed through a tiny open-ing in the skull while the surgeon watches on an MRI exactly where he is in the brain, sometimes with the patient awake.†There is a night-and-day
difference between what was and what is for neurosurgical patients. I have seen medicine advance from groundbreaking diagnostic imag-ing scans such as CTs and MRIs in the 1970s and 1980s, to revolutionary instrumentation such as implantable deep-brain stimulators for Parkinson’s disease in the 1990s, to recent fundamental discoveries such as stem cell biology. This pace of discovery and development is so rapid and unprecedented that its implications and applications overwhelm us. For almost every disease we treat in medicine, the history of technologi-cal change is similar.
Health economists debate about how much medical technology has added to the length and quality of life and what it is worth in dollars.1I’m
not going to discuss what medical science has given us. Most Americans understand medical advances and value them. What I will discuss is how the public values them indiscriminately.
Health Care in Decline
During my years of practice I was allowed into the lives of both the poor and the very wealthy at the worst times of their lives as well as when they N OT B U S I N E SS A S U SU A L 7
†It bothers me that there is no gender-neutral pronoun for a human being. Women
now make up half of all medical school classes and perform any job in medicine that a man ever did. I use “he” or “his” to refer to both genders unless I am obviously refer-ring to a specific person.
were liberated from disease. I also saw a darker side of medicine, and I have watched trends develop that I now believe to be inexorable unless change takes place at the federal level.
■ I saw the educated and affluent undergo risky procedures that they did not need, although they believed they were receiving the best care available.
■ I saw the uninsured, 1 million of them, systematically denied all but emergency care in the fourth-largest city in the nation.
■ I saw both the uninsured and the insured suffer death and disability from easily preventable diseases because they were ignorant about basic preventive care, did not have access to it, did not know how to get access to it, or their doctors did not provide it.
■ I saw both the insured and uninsured suffer preventable medical errors that they did not know about—errors that hospital administra-tors, nurses, and doctors viewed as a condition of medical practice. ■ I saw the insured and uninsured die from delays in emergency care in
overloaded hospitals.
■ I saw patients whom I knew had no chance of recovery treated inten-sively for days because the technology was available.
■ I saw culture and mass communication legitimize an obesity epi-demic that is estimated to account for more than one-quarter of the yearly increase in the cost of health care.
■ I saw the development of a medical industry that so favors the unfet-tered use of expensive technology that it is pricing working families out of health care and sealing the fate of the country’s 47 million uninsured.
These are all symptoms of a health care industry that is so sated with wealth that many of the people who populate its protected interests have forgotten their purpose for coming to work. Health care has become a consumer good with a price tag so high that it is only affordable if some-one else pays—an employer, a state government, or a federal government. For many of us, no one else pays. The “haves” consume the health care of the “have-nots,” to the disadvantage of both. The term structural violence describes social structures that harm some members of society. A society that indulges in excessive consumption of health care services at the
expense of its low-wage workers and their families, who cannot afford even basic services, is committing structural violence. This is what I see happening in the United States.
I reluctantly concluded that health care’s problems transcend state and local government after spending several futile years working to help the uninsured gain access to health care services in Houston and stimu-late the development of a safe emergency services system for the region. To address these two problems we created councils, performed studies, released white papers, and acquired some funding. Although the commu-nity felt better, in the end our efforts to stabilize the region’s emergency services did little more to protect its citizens than the levees did to protect New Orleans. None of these conclusions were evident when the crisis began; their implications dawned on me slowly as I witnessed a series of personal tragedies that began to morph into an alarming overall picture. N OT B U S I N E SS A S U SU A L 9
1 0
I
n the late 1970s, I was a resident physician training in a public hospital. My colleagues and I had become furious at groups of neurosurgeons in two Texas towns who often referred to us patients with problems that they said were too complicated to manage in their hospitals. Hours later, we would go down to the emergency room to receive some poor soul who was often medically unstable and had been transferred at his peril only because he lacked health insurance and could not pay.These abuses became so outrageous and widespread that the media took notice and alerted the public, which was shocked. A woman in active labor whose fetus did not have enough oxygen was dismissed from the emergency room of a private hospital and told to go to a county hospital across town, where her baby died because of the delay in care. An injured patient bled to death after the emergency room of a private hospital transferred him in shock with low blood pressure to a county hospital only because he was uninsured. But these were not isolated stories.1
This so-called “dumping” of uninsured patients was a widespread prac-tice before the Emergency Medical Treatment and Active Labor Act (EMTALA) was signed into law in 1986. EMTALA ended these practices by forbidding hospital personnel from even inquiring about insurance in an emergency situation and prohibiting hospitals and doctors from refusing emergency care to anyone at all. In a properly handled emergency, no one has time to ask about insurance, and the information is often not available anyway. We all look alike when we are injured, undressed, and covered in blood.
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Unreliable Emergency Services
The public should not look to the medical industry or to
organ-ized medicine for leadership in solving medicine’s problems.
U N R E LI A B LE E M E RG E N CY S E RV I C E S 1 1
EMTALA has two qualifiers that relieve the doctor and the hospital of responsibility for emergency care. A hospital is only required to accept patients who have an emergency if it has the capability and the capacity to deal with that emergency. Capability means that if the hospital pro-vides the service on a regular basis, it must provide the service on an emergency basis. For example, if the hospital provides brain surgery dur-ing the day, then it must provide it around the clock. Capacity means that emergency patients must be admitted if the hospital has room but not if it is full. When hospitals are over capacity, they typically send out a diver-sion signal to notify ambulances that they cannot take any more patients. Simultaneous diversion signals from every major hospital in the region doomed the woman from Lake Jackson to end her days in a nursing home, vegetative and tube-fed.
Federal law makes an important distinction between emergency and non-emergency care. No hospital or doctor is compelled by law to provide care to a patient with a medical problem that is judged by medical per-sonnel not to be an emergency, defined as a condition that, if not treated promptly, is likely to place the patient in serious jeopardy. Routine med-ical care of the uninsured is rationed and isolated from routine care of the insured. For emergencies, however, there can be no distinction, a situa-tion that has led to a growing problem for all members of society.
More Preventable Deaths
By 2001 Houston and San Antonio trauma centers were on diversion 30 percent of the time, with the problem becoming steadily worse. The day after Halloween in 2001, I got a call from a neurosurgeon of long acquain-tance. Had I heard about Bill Huntsman (not his real name)? He was a twenty-one-year-old man from Katy, a bedroom community near Houston. On Halloween night in the early evening, Bill had left work and was walking home along the edge of a busy road. A car swerved and hit him from behind. Unconscious and badly broken up, he was taken by ambulance to nearby Katy Memorial Hospital, a small community hospi-tal with eighty-eight beds and an emergency room more accustomed to treating stomach pain, asthma attacks, and broken noses than life-threatening trauma.
The mnemonic for the priorities of trauma care is ABC: airway, breathing, circulation. That is, make sure that the airway is open, that breathing is adequate, and that the blood pressure is sufficient. The emer-gency room doctors quickly intubated, ventilated, and administered intra-venous fluids to Bill Huntsman. He had a severe brain injury with coma, injuries to his chest, and broken legs. The doctors in Katy did not possess the technology to determine if there were injuries to his major arteries or his abdomen, and they did not have the capability to repair them. Their only purpose was to stabilize him for transport to a trauma center where surgery and intensive care could be performed, a practice that should hap-pen within about one hour of injury—the sooner the better.
Bill’s father quickly came to the Katy emergency room to behold an unimaginable horror. Michael Huntsman is an engineer, and I later lis-tened to him describe with precision the experience of watching his son’s body systems fail one by one as laboring doctors attempted to reverse the course of the injuries. He listened helplessly as one hospital after another, when contacted by the Katy doctors, refused his son admittance. Finally, hours after his injury, Bill Huntsman was shipped by helicopter to Austin’s major trauma center, 150 miles from Katy, where he died the next day. No one really knows if the delay in his care caused his death: whether it did or not, he never had a chance. Michael Huntsman confided to a friend of mine that he believed his son would have found a bed in Houston if he had still been covered by his father’s insurance. I never got the message to him that insurance would have made no difference; I did not think he wanted to talk to any more trauma doctors.
The genesis of the problem was that Texas’s trauma centers were los-ing more than 200 million dollars per year from care of uninsured trauma patients. Because of EMTALA, if a hospital has an active emergency room, the mix of patients it admits reflects the uninsured rate in the commu-nity, with attendant losses from large numbers of uninsured. In 2001 Texas had the second-highest uninsured rate in the nation: more than 23 percent.2Half of the state’s trauma centers were either turning down
or delaying acceptance of transfers.
There were several causes: too few intensive care beds, too few nurses, insufficient emergency room capacity, and too few specialists willing to take call. The problem was not limited to the trauma centers; all
Houston area hospitals were on diversion an average of 14 percent of the time, usually due to a shortage of beds.
Patients in need of transfer from small to large hospitals were in par-ticular danger. An emergency patient needing more specialized care should be transferred within two hours, at the outside limit. Only one-third of area hospitals could meet that standard, and delays in transfer of more than six hours were common. Every small hospital in the area reported that its patients were frequently endangered by transfer delays.3
It was clear that the handful of preventable deaths that we knew about were just that—only the ones we knew about.
Dr. Charles Begley, my colleague at the nearby University of Texas School of Public Health, soon attached a number to the risk from diversion. He examined the mortality rate from severe trauma for patients who were brought straight from the accident scene to one of the city’s trauma centers. For these patients, ambulances ignored the diversion status of the trauma centers. He compared this rate to the mortality rate of patients transferred from small hospitals into one of the trauma centers, patients such as Bill Huntsman and the woman from Lake Jackson, who were likely to wait too long for treatment. Begley found that on days when both of the major trauma centers were on diversion for at least eight hours, the mortality rate of severely injured patients who needed transfer was nearly doubled.4
Fragmentation
No organization was empowered to address the problem of emergency services failure. So as the crisis worsened, two Houston businessmen and I formed SAVE OUR ERS and organized a community-based board. SAVE OUR ERS sponsored the studies of emergency services in Houston and other parts of Texas that gave us the necessary critical insights to approach the Texas legislature. The data from Houston could not be ignored in Austin, the state capital, but the emergency room crisis in Texas was coin-cident with the most severe state budget crisis since World War II.
Like most states, Texas is constitutionally bound to a balanced budget. An estimated 5 billion dollar shortfall on a state biennial budget of 117 bil-lion dollars turned into a 10 bilbil-lion dollar deficit. Most of the Republican-controlled house and senate as well as the governor had run on a “no new U N R E LI A B LE E M E RG E N CY S E RV I C E S 1 3
taxes” platform. SAVE OUR ERS retained two of the most effective lobbyists in the state and then began to build statewide support for a bill providing for uninsured trauma care. Our reasoning was that if we could find 200 million dollars, existing trauma centers would voluntarily expand capacity, and more hospitals would elect to become trauma centers.
I mistakenly believed that all of the state’s trauma doctors, nurses, and hospital CEOs would support a bill to pay for uninsured trauma care; after all, they had acknowledged to me that their trauma centers were not able to meet their community’s needs and that diversion was a statewide problem. But when it came time to talk about these matters publicly, many became silent, embarrassed to air dirty linen. Others had their own ideas of how to raise the money and were unwilling to compromise on the method. I learned a critical lesson: one reason explaining why we had such poor health care policy in Texas was the fragmentation of the health care industry. The industry’s components—big hospitals, little hospitals, statewide medical societies, and specialty medical societies—would reli-ably protect their own interests first, seldom taking a unified position. I later found that this is also the case in Washington, D.C.
I remembered a management adage my father had taught me in col-lege when I questioned him about the actions of a university department. “The first energies of any organization are used for its self-preservation.” In other words, the public should not look to the medical industry or to organized medicine for leadership in solving medicine’s problems.
The Implosion Begins
The legislative session was scheduled to conclude in two months, and the torpor of both hospitals and doctors cross-checked each plan that our committee suggested. Then, unexpectedly, the numbers I had been study-ing for two years compiled into their inevitable conclusion. Texarkana, the only major trauma center in northeast Texas, downgraded its level of trauma care because it could not afford to pay on-call physicians. One of the three major trauma centers in Dallas, home to 1.2 million people, threatened to quit seeing trauma patients; and a second said, “If they go, so do we.” One of the key hospitals in rural east Texas near Louisiana closed to trauma. Emergency patients were being flown from El Paso,
on the Mexican border, to San Antonio, more than three hundred miles away. In Austin, at the center of the state, headlines announced that the city’s only major trauma center had signaled diversion for the first time.
The attention of the state’s legislators was now secured; they and their loved ones were at risk. Meanwhile, there were more stories. We knew of ten deaths in the Houston area, and no one doubted that there were many more.
The implosion of the trauma system hit the state’s newspapers within the week. Doctors and hospital administrators were scared and uttered the word “crisis.” The state’s legislators were suddenly barraged with their calls. State representative Dianne Delisi and her staff found model legis-lation from New Jersey and applied it to Texas’s problem. House Bill 3588 would raise 180 million dollars per year to pay for uninsured trauma care by fining habitual bad drivers, and the bill ultimately passed.
I never imagined that a bill to fund uninsured trauma care by taxing bad drivers would be opposed by Democrats and supported by Republicans, but that is what happened. The Democrats’ opinion was that the bill was punitive to the poor. They rejected my responses that poor people do not have to drive drunk and that paying for trauma care for the uninsured benefited everyone. In the foyer of the Texas House I was profanely accused by a prominent Democrat of being a toady for wealthy hospitals. After these experiences I resolved to remain a political independent for as long as I could.
Two years after passage of House Bill 3588, the Texas legislature nearly gutted the bill by appropriating its funding to the state’s general revenue instead of to hospitals. I watched as area hospitals took the money and put it into their general coffers without using it to increase the number of trauma patients they could care for. Houston’s ambulance diversion rate stabilized permanently at a dangerous 25 percent of all hours per hospital. At this point I began to look around the country and talk to my col-leagues. If the problem were structural, Houston could not be alone. I soon found that the city’s story was no anomaly. Emergency rooms were failing spectacularly all over the southern and western United States, including Florida and California and up the east coast. Once a community experienced emergency room failure, the problem rarely disappeared.
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he value of treating emergency patients within the Golden Hour has been drilled into me since the day I began my surgical residency in 1975. The term refers to surgeons’ brief window of opportunity for saving trauma patients, and the concept has been the linchpin of what is the best emergency services system in the world, matched only by Germany’s. Yet the Golden Hour is not only metaphor but also an outside limit: the sooner bleeding is surgically stopped and blood replaced, the greater the likelihood the patient will be saved.This insight came slowly, and its implications have only lately shifted thinking about what is logistically possible. Military medicine led the way. In World War II, 30 percent of injured soldiers died; 24 percent died in the Vietnam War. By the time of the Afghanistan War and the second U.S. invasion of Iraq, the mortality rate for combat injuries had fallen to an astonishingly low 10 percent. The key seems to be very early surgery and blood replacement as well as better body armor. Now the field hospital has moved to the soldier. In the current Iraq War, forward surgical teams in Humvees quickly assemble tent hospitals behind the troops and oper-ate to stop blood loss within moments of combat injuries, leaving the wounds packed open for closure later. They then transfer the soldiers to hospitals out of the country to be put back together physically and mentally. As a consequence, the mortality rate of injured soldiers has fallen to the lowest percentage in history.1
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An Eroding Infrastructure
Treatment within the Golden Hour after a medical emergency
is becoming an impossible standard as we witness the
progres-sive structural failure of American medicine.
A N E RO D I N G I N F R A ST RU CT U R E 1 7
America’s emergency services and trauma care system developed after the Vietnam War. When military surgeons returned to practice in their communities, they found that injured civilians in the United States were at greater risk than injured soldiers in the jungles of Vietnam. In the central Texas town where I grew up in the 1960s, hearses, sometimes driven by high school students, doubled as ambulances. All over the country injured patients were taken to the nearest hospital, and these hospitals were often not equipped or staffed to provide care for them.
In the 1970s the American College of Surgeons’ Committee on Trauma, made up of ex-military surgeons, determined to see that civilian patients were cared for by military standards. The committee began to push for designated trauma hospitals. Although this proposal met predictable resistance from local medical communities, it eventually crumbled under the weight of the hard data collected and put forward by these heroes of medicine.
Dr. John West was at the center of this transforming initiative. I inter-viewed West in his busy breast-care clinic in Orange County, California, thirty years after the fact. He is a lean, fit man in his sixties: a brisk speaker, mover, and thinker. West finished his surgical residency in 1974 at the University of California in San Francisco, operating at the San Francisco General Hospital, the publicly funded hospital that cares for the city’s uninsured. He related that in those days, the ambulance crews in San Francisco had all agreed to transport seriously injured patients directly to the county hospital from the scene of injury. At San Francisco General Hospital the patients received military-style care under the direc-tion of the chairman of the American College of Surgeons’ Committee on Trauma, Dr. Donald Trunkey. Trunkey was also leading the committee’s effort for establishment of trauma centers nationally, but he had little hope of success.
West had become used to excellent trauma care during his training, but when he arrived in Orange County to set up his practice he found that twenty-five of the thirty-three hospitals in the county were physician-owned, each competing aggressively for all patients, including trauma patients. The young surgeon was repulsed by what he saw.
A wallet biopsy is a common medical term not found in any medical glossary. It refers to the practice of determining whether or not a patient
has insurance before deciding to treat. A positive wallet biopsy means that the patient has insurance and will be treated. A negative wallet biopsy means that the patient is uninsured and will be transferred. At that time it was not illegal to deny emergency care to an uninsured patient; it is now. West said, “They would do wallet biopsies on the patients, and if a patient had insurance the doctors did X-rays, blood work, you name it.” He then related the story of a patient he still remembers thirty years later. A nine-year-old boy with a scalp laceration was brought into a nearby hos-pital after a car accident. It was sewn up, and the boy was discharged. The child later hemorrhaged to death from a ruptured kidney, a detail missed in the emergency room. He was uninsured and had received an inade-quate examination after a negative wallet biopsy.
At the time Orange County was proud to possess one of the first organ-ized ambulance services in the country, and the Board of Supervisors was discussing how to use county ambulances to lower the rate of deaths from cardiac arrest. West appeared at the public meeting and explained that the lives saved from improving cardiac arrest care were nothing compared to those that could be saved by addressing trauma care. He commented, “I didn’t know that someone from the Register was in the back of the room, and I found myself in the paper the next day. I didn’t have any choice but to prove it after that.”
West’s unwelcome allegations created a violent reaction in the med-ical community. He recalled one meeting in which six doctors stood out-side the Orange County Medical Society and berated him for going to the press. In another, a drunken surgeon stood on a desk and called him names. He attended medical gatherings where murder-for-hire was men-tioned, presumably in jest.
The only way to prove that patients were dying because of disorgan-ized trauma care was to examine the autopsy records of those who had died in Orange County. This investigation was conducted entirely from West’s medical office with no outside funding. West and Trunkey at San Francisco General Hospital collaborated, examining the autopsy and medical records of ninety trauma patients who had died in San Francisco compared to ninety-two in Orange County. Two-thirds of the patients who had died from trauma in Orange County were judged to have died unnec-essarily from delayed care, while only one such death occurred in
San Francisco.2The story was picked up by Associated Press and became
the subject of national attention.
The Orange County doctors challenged the study’s validity, and the Rand Corporation was retained to independently examine the data. West said, “They concluded that we got it wrong—Trunkey and I had
underesti-mated the number of preventable deaths in Orange County. After this, all
the opposition was silenced.”
The concept of the Golden Hour was born from this study. To reliably provide trauma patients with care in the Golden Hour after injury, trauma and emergency service systems were rapidly organized through-out the country. Hospital-based helicopters flew the most seriously injured patients over traffic jams to specially designated trauma centers that provide emergency services to patients with stroke, heart attacks, and a variety of other time-sensitive emergencies. Today 84 percent of U.S. residents live within sixty minutes of a major trauma center. Yet in the coming years American trauma hospitals are estimated to lose 1 billion dollars per year and to pay medical staff 485 million dollars per year to take call.3
The advance of science has outstripped the nation’s ability to deliver medical care. Treatments rendered within the Golden Hour can save the lives of patients with trauma, stroke, heart attack, and cardiac arrest; but for patients with stroke, cardiac arrest, and trauma, care is suffering. A minus-cule percentage of stroke patients receive such therapies. Science is moving into the next millennium, while the way we finance health care is taking emergency medicine back to the sixties—with the biting difference that we in medicine now know for certain the right way to do things. The Golden Hour after an emergency is becoming an impossible standard as we witness the progressive structural failure of American medicine.
The Golden Hour Turns to Lead
Ambulance diversion was not a serious problem in the United States before 1999, but by 2001 it was occurring throughout the country and has never receded. An ambulance is diverted from an emergency room once every minute in the United States. Diversion is not evenly distributed geo-graphically or among hospitals. The southern and western states, where A N E RO D I N G I N F R A ST RU CT U R E 1 9
uninsured rates are more than 20 percent, are most affected. For instance, in four populous regions of California, including Los Angeles County, hos-pitals diverted ambulances about one-quarter of the time in 2005.4
Ambulance diversion is concentrated in large emergency hospitals and trauma centers, where hours on diversion are often much higher than they are in non-emergency hospitals.5The very emergency
condi-tions that tend to kill you if you receive late care are the ones treated only in large emergency hospitals. Pray that such hospitals are not on diver-sion on the day you need them.
The Institute of Medicine provides science-based advice to the fed-eral government using panels of medical experts to develop its conclu-sions and recommendations. The institute’s findings are devoid of politics because it does not depend upon any federal appropriation and is scrupulous in maintaining its objectivity. In June 2006 it released a three hundred–page analysis entitled Hospital-Based Emergency Care: At the
Breaking Point that called for nationwide coordination of emergency
services. Echoing conclusions that I had already reached, the report declared: “The emergency system itself appears to be crumbling in major cities. In Los Angeles, for example, eight hospital emergency departments have closed since 2003, bringing the total closed countywide to over sixty in the last decade.”6
Dr. Arthur Kellerman, then chief of the Department of Emergency Medicine at Emory University, co-chaired the report. He and I discussed the risk of being sued for medical malpractice from mistakes caused by the dysfunctional environment in chaotic, stressed emergency rooms. He told me that he had never been sued but that, as the world of emergency medicine became more unsafe, he had begun to pray for the welfare of his patients before he went to work each day. He also told me that no federal agency in Washington seemed particularly concerned about the report.
Fatal Delays
Ambulance diversion is dangerous. Chuck Begley’s research, which showed a 78-percent increase in mortality for serious injuries needing transfer when ambulances were diverted in Houston, has been echoed by Dr. Linda Green’s in New York City. In the boroughs, where more than 20 percent of
emergency department time was spent on ambulance diversion, the mor-tality rate for heart attacks in 1999–2000 was increased by 47 percent.7
Rapid access to definitive therapies is the reason that the death rate from trauma and heart attack has plummeted over the years, so the cause of the fatalities is sure to be delayed care. An ambulance driving around looking for the right hospital is a death sentence for these patients and for others with time-sensitive emergencies.
When ambulances are diverted from emergency rooms, critically ill patients are also turned down for transfer from small hospitals to large emergency hospitals. Ambulance crews routinely take serious emergen-cies such as the woman from Lake Jackson and Bill Huntsman to the near-est hospital for stabilization. If the patient needs specialized care, such as cardiac or neurosurgical attention, the smaller hospital is often unable to transfer the patient to a larger hospital for the same reason that ambu-lances are on diversion: full beds. The patient needing transfer just waits as the blood clot expands or the heart attack becomes irreversible. If a delay in care injures the patient, the family is unlikely to know. If a patient dies from a delay and the family does find out about it, there is no one to sue: all the medical personnel did the best they could under the circumstances.
Two million people a year are transferred from one hospital to another that offers specialized care. If our experience in Houston is rep-resentative, this figure hides a tragedy in regions that are diverting ambulances. In the Houston region in 2005, 15 percent of patients requir-ing transfer to a specialized hospital waited for more than eight hours. Every small hospital in the region reported that patients were routinely endangered by delays in transfer. Only 30 percent of patients could be transferred within the recommended two hours.8
Decreased Supply Meets Increased Demand
With the worst possible timing, declining hospital capacity has been met with an increase in demand for emergency services, the result of bad per-sonal behaviors such as overeating and inactivity and a shift away from preventive care by a generalist. In the decade before 2003, the United States experienced a 26 percent increase in emergency room visits with A N E RO D I N G I N F R A ST RU CT U R E 2 1
only an 11 percent increase in population accompanied by a 12 percent
decrease in the number of emergency rooms.9Figure 3.1 shows the steady
and dramatic increase in emergency room visits nationally beginning in 1999. The surge in visits is coincident with the progressive failure of the emergency services system.
Displaced Patients
The first notion of most observers was that the increase in emergency room visits was simply a flood of uninsured who had no place to go for pri-mary care. The data, however, show that the uninsured and the insured visit emergency rooms with about equal frequency. In contrast, the unin-sured visit clinics much less often than the inunin-sured do; emergency rooms are often their only source of care. A recent survey, in fact, found that the uninsured are less likely than either Medicare or Medicaid patients to visit emergency rooms, probably to avoid the expense. Communities with the highest emergency room use are not those with the highest uninsured rates but those with the longest waiting times for clinic appointments.10
The surge in emergency room visits is driven by everyone: the pri-vately insured, Medicare patients, Medicaid patients, and the uninsured.11
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Emer
g
ency room visits (in millions)
114 108 102 97 91 85 80 94.7 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 92.8 94.8 99.5 103.1 105.6 110.0 111.1 112.6 114.6 118.3 93.1
FIGURE 3.1 Number of U.S. emergency room visits
Source: Health Forum, “Hospital Statistics” (Chicago, American Hospital Association,
It is no wonder—anyone who calls a doctor’s office at 5:00 P.M. or on week-ends hears the same recording: “If you think you have an emergency, call 911 or go to your nearest emergency room.” In almost every survey, about 40 percent of emergency room visits are non-urgent or semi-urgent, and only Medicaid patients stand out in their use of the emergency room both for both urgent and non-urgent care.12Not only are Americans displaced
from regular medical care, but they also appear to have gotten sicker over the past decade.
Increased Real Emergencies
Of the people who come to an emergency room, 12 to 14 percent are so sick that they require hospital admission. This percentage has been stable at least since 1993.13 In some regions the situation is worse. In the
Houston area the percentage of emergency room patients who require hospital admission is 22 percent, almost twice the national average. In California emergency rooms, the percentage of true emergencies increased by 59 percent between 1990 and 1999.14
Further evidence that people are sicker than used to be is that the percentage of people ages thirty to forty-nine who are disabled increased by 50 percent from 1980 to 2000.15The prevalence of diabetes has increased
by 53 percent over the past twenty years, related to a doubling in the prevalence of obesity. Kenneth Thorpe, professor at the Rollins School of Public Health at Emory University, believes that 27 percent of the growth in health spending in the past twenty years is accounted for by the rise in obesity. The prevalence of lung disease has shown a similar trend.16
An increase in disease among Americans, heavily driven by personal sloth, collided with another event that proved to be a one-two health care punch. In the early 1990s a botched version of an insurance product called managed care was widely instituted to control health care costs. Managed care is a financing mechanism that rewards either an insurance company or a doctor for coordinating care and controlling the amount of technology applied to patients. If done well, managed care is a physician-driven system that results in an improvement in quality of care and reduced cost; if done badly, it is performed by an insurance clerk and lim-its access to appropriate care. What was billed as managed care in the A N E RO D I N G I N F R A ST RU CT U R E 2 3
1990s was care provided by doctors and hospitals who had taken a 30 percent cut in pay. The only pretense of coordinated patient manage-ment was the intrusion of an insurance company’s employees between the doctor and the patient.
Managed care was summarily rejected by both physicians and patients but not before it financially destabilized hospitals and doctors. When Americans rejected it, they found themselves displaced from med-ical care and often really sick. Now when they seek emergency care, they are often faced with overcrowded emergency rooms and hospitals that are turning patients away. The United States has paid a high price for the managed care fiasco.
H
ospitals are primarily financed by private and public health insurance. Their revenues come from care of patients with (1) private insurance, (2) Medicare, and (3) Medicaid and its affiliated programs. Hospitals earn income from investment of their profits and from services such as cafete-rias, parking, and medical services that they contract out, but patient care is the core business. Private hospitals finance the care of the uninsured and low-paying publicly insured patients (Medicaid) by shifting their losses to increased prices for privately insured patients. Many hospitals also receive funds from a federal program called the Disproportionate Share Hospital (DSH) program, which is aimed at hospitals that care for a disproportionate share of low-income patients and is a substantial source of hospital rev-enue. The only hospitals that receive direct tax revenue are public hospitals, which account for 16 percent of hospital beds in the United States.1Whileonly 6 percent of the services that hospitals provide nationally are to the uninsured, a few hospitals in each region provide most of that care; these are usually emergency hospitals, and they are often financially unstable.
By the late 1990s Medicare’s cost to the federal government had been growing so fast that it threatened to bankrupt the Medicare program within the foreseeable future and push the country further into debt. Funds from two public programs, Medicare and Medicaid, account for half of hospital revenue.2Beginning in 1999, the Balanced Budget Act of 1997 reduced DSH
funds by 17 percent and also sharply cut hospital payments for Medicare patients. These cuts crippled some key emergency hospitals. For example,
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