In an effort to raise awareness of California's failing emergency system, and to force the state to begin fixing the problem, frustrated emergency physicians filed a class action lawsuit against the state in January 2009. The lawsuit asks the Los Angeles County Superior Court to rule that California must reimburse emergency physicians “at a rate that assures physicians can, at a minimum, meet their costs of care.”
According to some of the most recent data available, collected by the Kaiser Family Foundation, California's Medicaid payments per enrollee through its Medi-Cal program were $2,701 in fiscal year 2005, well below the national average of $4,662.
“A large portion of the problem is due to a lack of funding to provide an essential and vital service,” said Irv Edwards, MD, one of the physicians who brought the lawsuit, and president of Emergent Medical Associates, which staffs 14 emergency departments (EDs) in California. “As a result of the lack of funding we feel patients are suffering a great deal.”
Access to emergency care is so poor in California that the state ranked dead last in that category of the American College of Emergency Physician's (ACEP) 2009 Report Card on the State of Emergency Medicine, earning a grade of “F.” Calling access to care a crisis in California, the report noted:
“California has only 7.1 emergency departments per 1 million people, compared to an average of 19.9 among the states. The state also has a critical lack of staffed inpatient and psychiatric care beds (237.7 and 16.9 per 100,000, respectively). Contributing to the problems are high rates of uninsured adults and children and relatively low Medicaid reimbursement rates for office visits (66.7 percent of the national average).”1
In addition to those problems, the state has a critical shortage of specialists who are unwilling to take call because of low reimbursement for their services.
Dire Straights, Desperate Measures
A lack of funding has pushed California's emergency services system into truly desperate straits, said Jon Mark Hirshon, MD, an Associate Professor of Emergency Medicine at the University of Maryland School of Medicine, and member of ACEP's report card task force.
“They don't have enough nurses, they don't have enough specialists, there's not enough room in the hospitals, and they're not getting paid for the services they provide,” Dr. Hirshon said. “If it's not a perfect storm yet, they're working toward it. It's a system that's breaking apart and getting ready to implode from a lack of support.”
Emergency physicians in California say the state's safety need has long been deteriorating, but said the process has accelerated during recent years as it has reached a tipping point at which payments no longer meet the cost of services.
Even so, the cuts have just kept on coming.
In 2008, as California faced a $20 billion deficit, state lawmakers agreed with Governor Arnold Schwarzenegger to trim reimbursement rates in the state's safety net programs, Medi-Cal and Denti-Cal, by 10%, a savings of $1.3 billion. At the time several organizations, led by the California Medical Association, filed a lawsuit against the state. The legal action resulted in an injunction and prompted the state legislature to reduce reimbursement rates by just 1% to 5%. Even with the reduced cuts, the number of physicians in California accepting Medi-Cal patients has continued to fall.
Yet unlike their counterparts in other areas of medicine, because of the federal Emergency Medical Treatment and Labor Act, emergency physicians don't have the option to close their doors to certain classes of patients. As a result, a group of emergency physicians felt as though they had no alternative but to sue the state.
“We felt we had a duty as physicians to bring to the public's attention that this is now a crisis for emergency medicine,” Dr. Edwards said. “We view the emergency departments throughout the region as a safety net, and that safety net needs to be there to take care of patients regardless of their ability to pay. The system to us is as important as fire and police services, but it doesn't do anybody any good if they drop off patients to an ER that isn't functioning.”
Declines in reimbursement for emergency medicine have led, at least in part, to the closure of 70 EDs in California during the last 13 years, according to the California chapter of ACEP, with the problem becoming acute in the city of Los Angeles where large swaths of the city no longer have EDs. The results are about what you would expect, Dr. Edwards said: patients requiring transport across greater and greater distances, and ever-longer waits in the remaining EDs.
In recent years Los Angeles has seen the closure of trauma centers and EDs at Martin Luther King Jr./Drew Medical Center, Robert F. Kennedy Medical Center in Hawthorne and Daniel Freeman Hospital. In South-Central Los Angeles area, this leaves the Centinela Campus of the Centinela Freeman Regional Medical Center in Inglewood as one of the few remaining hospitals with an ED.
“Lean and Mean”
Since the recent round of nearby closures, the Centinela ED has seen its patient volume increase from 80 patients a day to between 180 and 210 patients, said Lee Weiss, MD, the department's director.
It's the hospital's policy not to close for saturation, Dr. Weiss said, although other hospitals in the region regularly do. As a result, he said, on any given day the hospital may handle between 85 and 100 ambulances.
“Obviously, we weren't built for that,” he said.
The hospital succeeds in managing large numbers of patients by employing large numbers of hospitalists, rigidly managing the length of stay for patients and using a model for every disease practice, Weiss said, characterizing the operation as “lean and mean.”
But it may not be sustainable. Los Angeles County reimburses Centinela for patients seen who live within the area formerly served by the Martin Luther King, Jr. ED, but a lot of that hospital's patients lived outside the specified area. Another funding issue that has recently arisen, he said, is that revenue streams are drying up because insurance companies and Medi-Cal have slowed their payments in recent months. Neither, he said, now always repays the hospital in a timely fashion.
“There's just not a lot of fat here to cut, and if you're not getting paid in a timely fashion you've turned a small margin into a loss,” Dr. Weiss said.
Across the state, physicians say, the story is the same. Even as patient loads increase, the system's capacity to serve them declines. The US Census Bureau recently estimated that California's population will grow from 33.8 million in the year 2000, to 46.4 million by the year 2030, an increase of 37.1%. In addition to growing, the population will be graying. Yet even new facilities in the state, such as the Ronald Reagan University of California, Los Angeles Medical Center which replaced an older facility last year, are smaller. UCLA's new hospital has 525 beds, down from 750 in the older medical center.
Dr. Edwards said he and other emergency physicians have begged California legislators to address the funding issues for years, but said that every year they receive a similar response.
“Year after year the politicians tell us they would like to help us, but they have these budgetary problems,” Dr. Edwards said. “It seems like every year is never the right time, so health care seems to be perpetually put on the back burner. We have a swelling population and a need for more and more services. Meanwhile there are fewer emergency departments and no long-term planning.”
To say the state of California faces a budget crisis would be something of an understatement. The state has titanic financial issues. For the fiscal year 2009-2010, the state faces a projected $42 billion deficit, a figure unprecedented in state history. Already state lawmakers have taken dozens of measures, such as furloughing state employees and selling bonds based on future lottery revenue, to meet budget shortfalls.
Anthony Cava, a spokesman for the California Department of Health Care Services which administers the Medi-Cal program, said the state would not comment on the lawsuit beyond issuing a statement, which read:
“While the California Department of Health Care Services cannot comment on specific arguments in the lawsuit, this Administration has long maintained the need for comprehensive health care reform in California to improve the health care delivery system in ways that would benefit patients and those who are on the front lines in delivering health care, including emergency room physicians.”
Yet emergency physicians in California who sued say the state could make emergency medicine whole for a relatively small investment, $200 million. The physicians estimate the annual shortfall in ED reimbursement is about $400 million, and note that the federal government matches every $1 Medi-Cal spends. In a $137 billion budget, the physicians say, $200 million accounts for less than half of 1%.
Accordingly, the lawsuit calls for the state to meet this shortfall. It also asks for yearly adjustments to match increases in the medical consumer price index.
“The action of the Defendants in underfunding the Medi-Cal program has forced a substantial portion of the cost of public healthcare on the shoulders of emergency department physician groups, including Plaintiffs and Class members,” the lawsuit, filed by attorney Raymond Boucher, states. “It is a violation of Plaintiffs' constitutional rights and has caused them to suffer damages. If the State is not forced to adequately fund its Medi-Cal system, California's health delivery structure will soon collapse.”
Dr. Edwards said California has always found money to fight wildfires and support firefighters, and to fund police necessities such as Tasers and police cruisers.
“This is an important and vital service, and it needs to be funded in equal levels as fire departments and police departments,” he said “My argument is simple: We need to take care of the ERs because sooner or later we will always end up in one. You can't ignore funding something that you want to be there.”
Staring Into the Abyss
By sacrificing funding for emergency medicine now and driving the state's emergency system toward a cliff, Dr. Edwards said the state is also mortgaging California's future in another way. With medical schools at the University of Southern California, the University of California, Los Angeles and elsewhere, the southern half of the state is a hotbed for emergency medicine and turns out large numbers of quality residents.
“What I hear from residents is that they would love to stay here, but they cannot afford to do so,” Dr. Edwards said. “What we can afford to pay them is partially dependent upon what we get from Medi-Cal, and it just doesn't add up.”
California emergency medicine residents graduate with large debts, he said, and California's cost of living is higher than most other states. Places like Texas, Arkansas and South Carolina, Edwards said, offer a package that's “six figures larger,” and areas where homes are half the price and potentially offer a safer family life. The tragedy, Edwards said, is that California spends hundreds of thousands of dollars to train a medical resident, only to ship him or her off to another welcoming state.
“Now we're seeing the graying of emergency medicine in Californa,” he said. “I'm 57. Many of my contemporaries have gray hair. The next generation is leaving. Who will be here in the future to take care of our state's growing population?”
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