Hospitals expand to meet demand

Rhode Island Hospital doubles its ER space, as the large numbers of sick, injured and worried patients reflect flaws in the health-care system.

01:15 AM EST on Sunday, April 3, 2005

BY FELICE J. FREYER
Journal Medical Writer

On Tuesday, Rhode Island Hospital will open a palatial new emergency department. Atop five 45-ton steel trusses, the Bridge Building that houses the new ER fills the sky over Dudley Street, offering twice the space of the previous ER, more diagnostic equipment, and 100 additional staffers -- ready to examine, diagnose and treat anyone at any time.

Three years under construction, the $70-million structure is a major source of pride for the state's largest hospital and one of the country's busiest emergency rooms.

But the Dudley Street behemoth also stands as an emblem of a troublesome trend: Around the country, more and more people are seeking costly care in hospital emergency rooms; visits increased 23 percent from 1992 to 2002. Often they go for problems that aren't emergencies or for emergencies that could have been prevented.

In Rhode Island, the problem is especially puzzling. Here the percentage of people without health insurance is one of the lowest in the country. Rhode Islanders visit their doctors more often than the rest of the nation, according to a recent study. But they also go to the ER about 10 percent more often than the national average.

The result is crowding that can get dire in the winter months, and expenditures that should worry anyone who pays taxes or health-insurance premiums.

Nearly every hospital in the state has expanded its emergency department in recent years, spending tens of millions of dollars on construction, as well as the continuing cost of staffing and equipping the ER around the clock. Like Rhode Island Hospital, at least two others have doubled in size.

"We're investing in the highest-cost part of the health-care system," says Merrill R. Thomas, the chief executive officer of the Providence Community Health Centers, which serve the poor and uninsured. "It's just crazy."

"We need that emergency room," says Rhode Island Hospital President Joseph F. Amaral, noting that the current ER was built 22 years ago for half the people it now serves. "The institution needs to do what is best for the people who come here."

WHO ARE THOSE PEOPLE? Those you'd expect: The car-crash victim with multiple injuries. The middle-aged man with chest pains. The elderly nursing home resident with pneumonia.

But also: The factory worker with a sinus infection who couldn't get time off from work during her doctor's office hours. The young man who wants his headache diagnosed and treated, quickly, at a time that's convenient for him. The immigrant mother terrified by her child's fever. The man with a painful tooth abscess who couldn't find a dentist willing to accept his Medicaid coverage. The homeless man whom the police found drunk on a street corner.

In some ways, hospital emergency departments have become costly catchbasins for the health-care system's failures. Among them: the limited options for the mentally ill, who often go without care until someone brings them, suicidal or psychotic, to the emergency department; the lack of dental care for the poor, whose untreated toothaches fester into major infections; a shortage of other after-hours options for urgent care; the estimated 100,000 Rhode Islanders without health insurance.

In others ways, bustling ERs illustrate the consequences of success. "Patients are older and sicker because we've been keeping them alive longer," says Dr. Andrew Sucov, medical director of Rhode Island Hospital's emergency department. When their health takes a turn for the worse, "we are the only place open 24 hours a day."

A study published this year found that, nationwide, most people who frequent emergency departments have insurance and have a usual place of care. What they don't have is good health. ER users are sicker, and by all accounts there are more sick people out there.

The ERs' popularity also reflects what Dr. Daniel H. Halpren-Ruder, a former emergency room doctor, called "our Burger King society."

"We want what we want now," Halpren-Ruder says.

"Our society is about convenience, rapid answers," Amaral agrees. "Patients definitely come in because they get rapid diagnosis and treatment."

NO MATTER WHO shows up, no matter why, no matter whether they can pay, hospitals are obliged by federal and state laws to take care of them all. So emergency departments are busier than ever.

In Rhode Island this winter, Landmark Medical Center, Our Lady of Fatima Hospital, Roger Williams Medical Center and Rhode Island Hospital all reported seeing more patients than ever before. One day in February, 289 people went to Rhode Island's emergency department -- the largest ER census for any single day in the hospital's history.

The crowding -- often exacerbated by backups because there aren't enough beds elsewhere in the hospital -- leads to long waits for the sick and can affect the quality of care.

At Kent Hospital, in Warwick, a 60-year-old woman died of cardiac arrest on a hallway stretcher on Jan. 20, after her severe chest pains went untreated and virtually unmonitored for nearly an hour. In its response to a Health Department investigation, the hospital noted that at the time "the Emergency Department was overcrowded with patients needing care."

More commonly, for those whose problems could be treated elsewhere, quality suffers in subtler ways. Unlike your private doctor, the people in the emergency room don't know you or your history. They're apt to run a battery of tests to pinpoint what's wrong, including tests your doctor may have already done. They will treat your immediate problem, but not any of the underlying issues that led to it. When you return with a recurrence, a different doctor will see you.

MICHELLE LUPOLI'S mission is to find out why her people are choosing such care -- and to see whether there's a better alternative for them. Her people are members of Neighborhood Health Plan of Rhode Island, a Providence-based HMO that serves the poor, young families enrolled in the state's RIte Care health plan.

Under a new initiative, Neighborhood tracks when a member makes multiple visits to the ER over a three-month period. Then Lupoli, the plan's head of care management, picks up the phone to find out what's going on.

Recently Lupoli spoke with a 24-year-old mother of three. The woman had taken her 6-year-old to a nearby emergency department four times in five days, because he had a fever, diarrhea and vomiting. She was worried about him -- and the easiest thing to do was walk two blocks to the hospital.

Lupoli told the mother that RIte Care provides transportation to doctor's offices, and urged her to call the doctor first the next time a child is sick. The mother agreed to do that. Lupoli made sure she had a follow-up visit with the doctor.

Emergency room use by Neighborhood members, and RIte Care enrollees in general, has been creeping up in recent years, despite efforts to connect everyone with a "medical home." Although they have good health coverage, RIte Care members use the ER as often as Rhode Islanders without any health insurance, and almost twice as often as those with commercial insurance. Neighborhood estimates that about 20 percent of its members' ER visits are for problems that would have been better cared for in a doctor's office.

But Eulogio Acevedo, 52, of Providence, clearly falls in the other 80 percent, and he and his wife, Maryelyn, 34, followed the rules when he fell ill in January. They went to his doctor first -- and landed in the emergency department anyway.

Eulogio Acevedo has been hospitalized seven times since October, his wife says, always going first through the emergency room. He has an artificial heart valve that's not working properly, causing anemia and problems with many organs. This time he was jaundiced because of a liver blockage. Alarmed, the doctor sent them to the ER, where Acevedo was admitted to the hospital.

No one would question that the ER was the appropriate place for him that day, but his wife questions whether he had to get so sick in the first place. His troubles started a year ago, but the family had no insurance at the time and didn't dare risk the cost of a doctor's visit.

Blue Cross & Blue Shield of Rhode Island, which also saw a steep increase in ER use, has case managers contact frequent ER users with chronic illnesses to help them better control their illness, spokesman Scott Fraser says. Sure, Fraser says, an acute asthma attack is a life-threatening event needing ER care, but can the next one be avoided? Can medication and lifestyle changes keep the person healthier?

Many people go to the emergency room because they are afraid something horrible is happening to them. News reports about bizarre and frightening illnesses, such as SARS and avian flu, can lead to hypervigilance about health. If you've just seen a program on brain tumors, your headache takes on a new urgency. And immigrants often don't have the education to know how to respond to, say, a child's fever; they only have memories of the child who, back in their village, died of a fever.

IN BETWEEN the acutely ill and the acutely worried, there are many who simply happen to get sick after their doctors' offices have closed. Very few medical practices in Rhode Island offer evening or weekend hours.

The reason, doctors say, is that it costs money to stay open late, and the insurers who wail about cost of emergency care still won't pay a little extra for a doctor's office to stay open late.

"Blue Cross hasn't provided the incentive for practices to stay open after 5 o'clock," says Dr. Michael D. Fine, a family practitioner. "It costs more money. You have to pay people to stay late." Blue Cross will, however, pay an enhanced fee to doctors who open their offices after hours to treat a patient's urgent problem.

Neighborhood Health Plan does provide extra payments to practices that hold evening and weekend hours.

UnitedHealthcare of New England declined The Journal's requests for information and interviews.

Fine's Pawtucket practice, Hillside Avenue Family and Community Medicine, has enough physicians to stagger hours so that the office can be open until 7 p.m. But most Rhode Island doctors work in smaller groups, making night hours difficult.

"Evening hours -- that's a lot to ask a physician who starts early in the morning . . . ," says Dr. Mark D. Jacobs, a Smithfield internist. "You probably couldn't pay me enough to work more hours."

Regardless, Jacobs says, "there is a spectrum of services offered in the emergency room that cannot be duplicated in the doctor's office. . . ."

"One potential solution," Jacobs says, "is a partnership between urgent care and primary care. A balance between primary care during specified hours and urgent care, for the types of problems that are acute but not life-threatening."

Harvard Pilgrim Health Care of New England, an HMO that shut down in 1999, had its own walk-in urgent care center that patients trusted and used. Nothing like it has been established since.

Years ago, Dr. Robert H. Woolard, physician-in-chief of emergency medicine at Rhode Island and Miriam hospitals, established an urgent care center with colleagues as an alternative to emergency rooms. Because these were the same doctors who worked in the ER, they thought people would trust them. But the insurers would never pay more than the rate for a doctor's office visit, despite the center's higher costs, he says. After a year and a half, the emergency doctors abandoned the program.

Halpren-Ruder, owner of three urgent care centers in Smithfield and Cumberland, faces similar frustrations. He estimates that 70 percent of his clinics' patients would have gone to the emergency room if his walk-in centers weren't there, and the potential is even greater.

He believes people prefer emergency rooms because they feel safe there, while the walk-in centers vary in quality. A certification process that would guarantee the competence and safety of all walk-in centers could win the public's trust, Halpren-Ruder says.

But you have to pay for quality. Halpren-Ruder says that he currently receives the same rates a primary care doctor receives, even though his facilities require more equipment and longer hours. His true costs are more than a doctor's but less than an emergency room's, he says.

THE INSURERS seem to prefer the financial stick. Blue Cross has recently imposed $100 copays for emergency room visits, for plans enrolling 86,000 of its members. The objective is to encourage people to call their doctors rather than go to the ER.

Some say the higher copay won't work because when people are scared by a medical problem, they don't think about money. Others say just the opposite -- the high cost could perilously deter people who need immediate care.

Governor Carcieri's budget proposal would also wield a financial stick, this one whacking hospitals rather than patients. For RIte Care patients who show up in the emergency room with what turns out to be a primary-care diagnosis, the governor proposes to pay the hospitals only what the state would pay a primary-care doctor, despite the fact that emergency room care is about five times more expensive. Hospitals, required to see all patients, say the governor's plan would only cause them to lose money, punishing them for a problem beyond their control.

MEANWHILE, Rhode Island Hospital officials crow that emergency patients will be happier and more comfortable in their new digs, and more and more will come -- with more than 90,000 visits predicted for next year. Hospitals may not have caused the legions to arrive at their ER doorsteps, but clearly they welcome these customers.

"Everything is going to be better," says Sucov, the emergency department's medical director. "The reputation of Rhode Island Hospital emergency room is 'go there when you're sick. If you're not really sick, go somewhere else, because you're going to wait.' . . . The new facility plus all the staff will enable more people to come."

It's not clear whether emergency rooms actually make money for hospitals. Rhode Island Hospital president Amaral says that, given the amount of free care the hospital provides, he's just hoping to break even.

But an emergency department is the portal to a hospital, and thus vital to its economic health. Among those admitted to Rhode Island Hospital, two-thirds of the adults and three-quarters of the children come through the emergency department.

Of those who go to the emergency room, 25 percent end up being admitted. The extra volume in the new ER is expected to result in 1,800 additional admissions next year.

Woolard thinks that, given the demographic and societal trends, emergency room use will only continue to rise, and he's proud of the quality of care Rhode Island Hospital can now offer those who seek it. No amount of social engineering will stop people from getting sick in the middle of the night.

"When you're sick, you want to be taken care of," Woolard says. "This is 24-7 with better and better quality."

Felice J. Freyer can be reached at (401) 277-7397 or at FFREYER [at] PROJO.COM

Why people use the ER

The most common complaints of members of Blue Cross & Blue Shield of Rhode Island who went to the emergency room last year:

1. Chest pain
2. Abdominal pain
3. General symptoms of unknown origin

The most common of the minor or low-severity complaints:

1. Sprains and strains
2. Sore throat
3. Earache

According to the U.S. Centers for Disease Control and Prevention, in 2002:

• 110 million visits were made to U.S. emergency rooms, up 3 million from the previous year.
• The average wait time was 3.2 hours, with two-thirds of patients waiting 1 to 6 hours.
• Abdominal pain, chest pain, fever and cough were the most common reasons for visits, accounting for one in five visits.
• 22 percent of emergency room patients needed care within 15 minutes; 34 percent needed care in 15 to 60 minutes; 19 percent had to be seen in one to two hours; and 10 percent could wait 2 to 24 hours for care. (15 percent were unknown.)

Reasons for the increased demand on emergency rooms:

• Fear. People aren't good at assessing the severity of their illnesses.
• Trust. People believe the greatest expertise, best tools are in the ER.
• Convenience. At any time of day, you can get all the tests done in one place, often with immediate results.
• Sickness. More older and sicker people are living in the community, needing episodic care.
• Lack of alternatives. Older men without insurance and new immigrants often have no other source of care. Others fall ill when their doctor's office is closed, or may lose their jobs if they take time off from work. Spanish-speaking people may not be able to communicate with their doctor's answering service.
• Lack of preventive care. Particularly for mental illness and dental issues, problems go untreated until the crisis point.
• Lack of shelter. People with small incomes cannot afford apartments. For the mentally ill or substance abusers, homelessness makes it harder to get a grip on their problems. Once they are brought in with a health or behavior problem, the hospital has no place to send them afterward and often holds them for hours.

-- Felice J. Freyer