Down For The Count


knockoutMedical care in this country is rapidly heading for a K.O.

Baltimore’s Bon Secours Hospital considers closing as it is getting crushed under the costs of providing uncompensated care. The hospital lost $22 million last year.

Northeastern Hospital in Philadelphia is also preparing to close. Its emergency department usually sees 50,000 patients per year. The hospital lost $6 million last year and expects to lose $15 million this year. Charity care has increased by 33% in the past 12 months and more than three quarters of the patients at the hospital are Medicare or Medicaid – “insurance” plans which “do not pay the full cost of care.” State lawmakers and community activists are trying to force the hospital to stay open.  State Sen. Michael J. Stack stated that “closing this ER is going to have a devastating effect.” The article made no mention of how the good senator planned to fund his grand initiative .

A Chicago Tribune “Watchdog” article criticizes “for profit” hospitals that pass the buck on uninsured patients, showing how for profit hospitals provide patients with an “EMTALA screen” in the emergency department, stabilize any emergencies, and then send indigent patients to public hospitals for further care – sometimes with directions on how to get to the public hospitals. The article quotes one University of Pennsylvania emergency physician as stating that the practice amounts to “legalized patient dumping.” No word on how much of a pay cut the emergency physician has taken to curtail such problems in his own state. Also no word on when the Chicago Tribune is going to stop “advertiser dumping” – a process that requires all advertisers to pay in advance for advertisements in its newspaper.

A Naples Daily News (Virginia) article shows how communities are creating more and more “freestanding” emergency departments that cater to patients with the ability to pay. The article notes that out of 12,000 patient visits per year, the freestanding emergency department “is seeing very few people with no insurance”. Incidentally, wait times are 10 minutes in the freestanding emergency department and 5 hours in the traditional emergency departments.

The manner in which healthcare providers fight for financial survival is causing rapid market adjustments. Hospitals that cannot afford to comply with the federal EMTALA laws are either curtailing emergency services or closing. Patients with public insurance or no insurance that depend on EMTALA laws to survive are being herded into larger public institutions where waits become untenable. Private physicians increasingly refuse to care for patients with public insurance due to low reimbursement and administrative hassles.

Government-created market forces are pushing us toward a two-tiered socialized system at a dizzying pace. Those fortunate enough to have insurance will receive faster and likely more competent care, but care that will come at an increasing financial cost. Those patients without insurance will receive “free” care that is time-rationed and haphazard. Emergency medical care for all Americans will be less accessible because of continuing hospital and emergency department closures.

We asked for it.


  1. I’d like to see a discussion on the impact of the ever accelerating technologies and advancements in care on the financial crunch These are all wonderful things and countless lives have been saved due to them. But the fact remains they are very very expensive.For example,a raging sepsis with no source? a ceretic scan…$8000 dollars. I think unknowingly we opened a pandora’s box. Every hospital has to have the latest technology to stay competitive. Lab tests that are increasingly more sophsticated and sensitive…cts. mris… pet scans… Medicine cannot be practiced without these things now. Ferrari medicine on a kia budget. This is not a criticism of these things but even under the ideal model, these costs are crushing. any thoughts?

  2. I still don’t understand your EMTALA obsession; the Chicago example makes quite clear an ER can cheaply and quickly comply, and still engage in profitable patient dumping. EMTALA isn’t a big deal from the policy perspective, you just find it personally annoying.

    Frankly, the ease with which you (and other physicians) conflate issues makes it very hard to take any of you seriously. Do you want to be treated like a private industry or like a public utility? In the same breath you complain that the state is not providing funding and that the state imposes too many limitations on you. Who you think you are, Wall Street?

    Normally, we do not give an industry state funding without substantial controls on it, including controls to ensure widespread availability of the industry’s services. But you apparently want the former but not the latter. Well, so do I. I want taxpayer money to go about my private business. Ain’t gonna happen.

    I, personally, favor the public utility route, and would be happy to pay the extra taxes to fund it. Where do you fall?

  3. Great post, as usual.

    Recently my daughter went to the gyn to have a routine pap smear. In the good old days, a routine preventive screening like this would be 100% covered by insurance– but no more. Months after the pap smear, she received a bill for $100+ for the procedure– the balance that Aetna wouldn’t cover. (This is not a lot of money, but she’s a full time college student who doesn’t have a lot of money.) Her comment was, “What’s the point of having this health insurance? I should have gone to the public health clinic or Planned Parenthood and gotten the screening for $20 or less!”

    By paying so little of this standard, research-based test, is the insurance company dumping these procedures on the county health departments? It seems like it.

    Is cost discouraging women from having life-saving screening procedures– like mammograms and pap smears? Probably.

    • Check to see if there are programs in your area to provide Pap tests and mammograms to uninsured/underinsured women – some are free, others are on a sliding fee scale based on the pt’s income.

  4. I had a patient today who called 911 at 4:00 AM because her “nose was dry”.

    Another patient who called because she had a cough for 4 days. When informed that 911 ambulances only transport her to the nearest ER, and not the one she wanted to go to, she said “but this isn’t an emergency!”

    80-90% of the 911 calls I go to every day are not emergencies. Our “elected representatives” do not have the political will to fix the system, they will just continue to blame the other party and raise taxes. I can’t even vote any more because I don’t believe that any of the candidates is even going to try to do the right thing.

    I don’t know what the solution is. I’m scared of all the possibilities I can think of.

  5. Max,

    I suppose it’s a waste, but I’d remind you that EMTALA is an unfunded mandate. JCAHO and the governments like to regulate us but they don’t then supply money for us–therin lies the rub. If we were mandated to take indigent patients–completely unfunded, not even medicare reimbursed patients–but we were compensated for them, there wouldn’t be half the problem there is. And we’re not conflating. Or, did I miss where you practice medicine so you actually can talk about it from our perspective?

    • I could be snide and point out that EMTALA isn’t an “unfunded mandate” because it’s not a “mandate,” it’s a condition for the receipt of Medicare funds, and then ask about missing the part where you practiced law…

      But I won’t, and your point about it not being specifically funded is understood.

      That, however, doesn’t answer the bigger question: do you want more funding and thus more regulation, or less regulation and thus less funding?

      You also seem to want both more funding and less regulation. It doesn’t work that way.

      • Max — I just wish the government would pony up the funds to pay for the “condition for the receipt of Medicare funds” as you term it.

        Seems to me there is some law about what I would call forcing a person to to a job without compensation. I suppose legally it is poor negotiation on our part for accepting this “condition for the receipt of Medicare funds” in our negotiations with Medicare. But wait, I don’t recall our group negotiating anything… it was a case of the hospital telling us we have to take medicare because they have to take medicare. Maybe one day my hospital will no longer take medicare…

      • Igloodoc, you’re making my point. I can’t tell if you want more funding/regulation (“I just wish the government would pony up the funds…”) or less funding/regulation (“Maybe one day my hospital will no longer take medicare…”). You’re not going to be more funding and less regulation. It just doesn’t work that way.

        Some extra dough to cover screening & stabilizing is not going to cure out health system, nor even the problems facing EDs. EMTALA is just not that big an issue from a policy perspective, and it’s also a policy the public happens to like and expect very much. Directing energy at eliminating EMTALA is like car companies railing against safety regulations — suck it up, we expect you to operate this way. Tell us how we can make it happen.

        Hemming and hawing about if you want it or not isn’t a solution, which makes it impossible for those of us outside the industry to take the complaints seriously, it just sounds like groveling for a comparatively small amount of money, like if GM and Ford said they’d be fine if we just subsidized air bags. That’s crazy, and complaining about such small matters creates the impression that your industry is fine.

        Universal health care would sure do a lot to pad ED’s bottom lines, is that what you want? We could also fold up private EDs all together and make them operate like police and fire departments, with express state funding and guarantees, how about that?

      • Max– I was referring to the government paying for what they have already mandated, although you objected to the term “mandate”.

        As for the more vs less funding/regulation/govenment intervention question, what I want, or even what the medical profession wants, is moot. We are getting, and will continue to get mandates/regulation without funding. The analogy of car safety airbags is somewhat flawed. An automobile manufacturer can (and does) pass the cost directly to the consumer, with the blessing of the government. In the case of EMTALA, the government expressly forbids this cost being passed, until government criteria is met. So imagine going to an ED with a condition and asking “do you take my insurance”. I cannot tell you until after the medical screening exam is done to a standard the government has set for your presenting condition is met (ie chest pain would get an ECG, CXR, cardiac enzymes, O2, IV, nitro etc) BEFORE I can ask you anything to do with money.

        By then, it is too late and the uninsured patient is on the hook for the bill, which often is never paid. In my ED, our payment rate of this group of people is about 10% of billed, and they comprise about 30-40% of our ED population. The insured patient will be out their co-pay, at a minimum.

        Right now ED’s across the US are straining to stay open, due in large part to these unfunded mandates. I disagree that “a little dough” to cover the costs would not make a difference. It would be an admission by the government that they are indeed responsible for the financing of their mandates, and may actually keep some ED’s open.

        Overall, I would love to see much less intervention by the government. Our leadership has essentially raise the white flag, however. I think the only way to effect change is disgruntled individual docs or small groups going through the court system.

        So, Max, a legal question. Is there legal grounds to challenge EMTALA?

  6. 2:01 until the first lawyer troll jumps on your post. why is it that your blog seems to be the only one i frequent with a lawyer infestation? maybe the other guys just delete their comments?

      • Lawyers tend to behave themselves so long as you don’t mention tort reform. They’re A-OK with regulating our industry, both through public policy as well as through malpractice cases. Just don’t suggest regulating their industry… Who do we think we are? …Telling them how to run an industry we don’t entirely understand and aren’t licensed to practice in.

  7. Pingback: My View « WhiteCoat’s Call Room

  8. “They’re A-OK with regulating our industry, both through public policy as well as through malpractice cases.”

    Actually, if you read my posts, you’ll find exactly the opposite position. I’m begging you physicians to step away from the third party payment model that has us speeding headlong toward nationalized healthcare. That’s why you’re regulated more than any other profession, because you gave the government the power to do it when you take their money. If that’s an incorrect assessment, please, correct me. Don’t get me wrong, for 40 years it’s been quite profitable to take the govt.’s money, resulting in physicians having the highest average pay of any profession by nearly 50%, but those days are going to end as the deficit balloons and costs are looking to be cut.

    Tort reform is frustrating not only because you guys are on the wrong side of the issue, but because I see you waste so much lobbying time, money, and effort on something that has a miniscule effect on your lives and healthcare in general when compared to the debacle that the third party payment model has become and where it is taking us.

    As for malpractice claims in general, that has little to do with your industry as a whole. It’s one plaintiff and one case, each with individual facts and individual outcomes.

  9. Matt – we certainly agree about third party payment and government intervention. As indicated above, I fear it is too late. Our medical leadership, upon ascension to their gilded thrones, seem to develop Stockholm syndrome. Strangely, I see litigation as the salvation of the system. These mandates have to be challenged in court by the front line grunts and struck down. For example, if extortion is forcing me to do uncompensated work by threat, why is EMTALA not extortion? Seems to me an enterprising lawyer might make a name on that case, if not some money for the compensation if the suit was successful, and the class action that would result. (I am sure there is some legal reason it is not extortion, though)

    Malpractice, however, is where we disagree. It is much greater than one plaintiff – one case… it causes defensive medicine. I know you do not like that term because it cannot be defined or quantified. To us, that kind of thinking is tantamount to the lion wondering while the herd of gazelle scatters when the lion attacks. After it is only one gazelle, one day and one outcome, right?

    Matt – I would love to have you come and observe the bobcat rodeo I call my Emergency (wait for it, WC) Department. Might change your perspective a bit.

  10. ” It is much greater than one plaintiff – one case… it causes defensive medicine. ”

    Let’s assume all physicians could agree on whether this or that procedure was “defensive medicine”. And then let’s agree that we’ll take the highest estimates for its cost. Even then, it is still less than 10% of the total cost of healthcare.

    What “reform” would eliminate it? What reform would significantly reduce it? You can’t say caps on damages because several states have had those for decades and there’s no evidence it worked.

    What’s more, where is the evidence all the “defensive medicine” works to reduce claims against you? Why are we talking about something that even if we could define it, you’re not even sure it works to help the problem you’re trying to avoid?

    What we DO KNOW decreases your risk of malpractice claims is quantity of time spent with the patient explaining what’s going on. So why don’t you do that? Because you’re not incentivized to do so. You’re paid for your time.

    I’d love to observe an ER from a perspective other than patient, but me observing you won’t change whether or not 1) you and all other physicians can agree on what is and is not defensive medicine; 2) whether any of the reforms proposed would actually reduce it; and 3) whether it works at all!

    You say malpractice is bigger than one plaintiff one case, but there are, according to WC, over 1 billion patient-physician interactions every year. How many malpractice claims are there out of those 1 billion? Is it possible your fears are out of whack with the actual risk?

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