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Uninsured not what's clogging ERs

Authors of new study cite other causes, warn of stigmatizing poor

The Star-Ledger Archive
COPYRIGHT © The Star-Ledger 2008


Despite common perceptions, uninsured patients with minor illnesses are not the primary cause of overcrowded hospital emergency rooms, according to a study released yesterday.

In fact, the opposite may be true. Those without insurance are less likely to visit the ER for non-urgent care because of concerns about cost, and are usually sicker when they do show up, according to the analysis, which appeared in the Journal of the American Medical Association.

"There's this cultural perception that the uninsured are coming in every day for sniffles," said Manya Newton of the University of Michigan, who led the study.

Overcrowding in emergency rooms has reached crisis levels nationwide, resulting in longer waits for all patients, according to the report. Multiple factors are driving the trend, including an aging population, increased public awareness of conditions like heart attack and stroke and decreased availability of primary care doctors on nights and weekends.

"If you have two working parents, they'd rather come in after hours when it's most convenient for them," said Dennis McGill, chairman of emergency medicine at Somerset Medical Center, who heads the New Jersey chapter of the American College of Emergency Physicians.

Newton and her colleagues based their analysis on a review of 127 medical articles where unattributed assumptions were made about the effect of uninsured adults in emergency settings. They then compared those assumptions against hospital data and peer-reviewed studies to test the validity.

Their conclusion was that existing data do not support widely held beliefs that the uninsured are the primary cause of overcrowding or turn to emergency rooms primarily for convenience.

"Policies based on inaccurate or simplistic assumptions have the potential to worsen an emergency care situation already in crisis and run the risk of further stigmatizing vulnerable populations, thereby worsening health disparities," they wrote.

At his hospital, McGill said, uninsured patients show up sicker than patients with insurance, usually because "they try their hardest to take care" of the problem themselves, even using home remedies if necessary. But he said Somerset is seeing an "across the board" increase in use of the emergency room by both the insured and uninsured.

"There is more of an aging in the population and primary care doctors not having time to do a lot of these same-day urgent evaluations, so people end up in the emergency room," he said.

About 17 percent of the 115 million annual emergency department visits in the U.S. are made by patients without insurance, the study points out. Last year, 45.7 million U.S. residents were uninsured, including 1.3 million in New Jersey.

Newton said even patients who have a primary care doctor find it harder to get an appointment on short notice in the event of an emergency, since many physicians' schedules are booked solid with little flexibility.

"And if you're uninsured, many doctors won't even see you at all," said Newton, a Robert Wood Johnson Foundation clinical scholar and lecturer in the university's Department of Emergency Medicine and Internal Medicine. "It's a huge problem."


Study finds increasing emergency room visits by elderly

Trend sparks worries that rising ER demand will prove `catastrophic'

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COPYRIGHT © The Star-Ledger 2007


Emergency room visits by the elderly are growing rapidly, fueling fears that increased demand will overwhelm the already overcrowded system, according to a study released today.

Between 1993 and 2003, the rate of ER visits by the elderly increased 34 percent — faster than any other age group, according to a study in the Annals of Emergency Medicine.

If this trend continues — and experts say it will as the Baby Boomers age — emergency room visits by the elderly could nearly double over the next five years to 11.7 million, the researchers predicted.

With hospitals around the country already so crowded that patients sometimes must wait eight or more hours to see a doctor, such a spike in ER visits could be "catastrophic," study researchers say.

"The problem for elderly folks is they are much more likely to be admitted to the hospital than younger patients and they also use up a lot more resources," said Mary Pat McKay, an associate professor at George Washington University Medical Center in Washington, D.C., and the study's lead author.

The study looked at patients between the ages of 65 to 74. Once these elderly patients are admitted, their length of stay tends to be longer, McKay said, which means bed turnover may be slower on patient floors.

McKay said hospitals need to have the resources available to increase their surge capacity so that additional areas for patient care can be created.

"Very few hospitals have that ability at this point, especially with the nursing shortage," she said.

The researchers also found racial differences in the data when it comes to the use of emergency rooms by the elderly. Among elderly black patients, visits increased by 93 percent — or 77 per 100 population — during the 10-year study period, compared to a 26 percent increase, or 36 visits per 100 population for whites.

Complications from diseases such as diabetes and hypertension may be contributing to greater use of the emergency room by black elderly patients, the researchers said.

Eunice Guiles, 79, of Orange woke up in pain early Monday morning and quickly made the decision to go to the emergency room at East Orange General Hospital, rather than waiting to see her own doctor.

"When I get that pain, I come here," said Guiles, who is black, explaining that her shoulder kept her awake all night.

McKay and her colleagues note that older people are surviving longer with chronic conditions that often result in complications requiring medical care. They also point to access problems, that is people being unable to see their doctors at a time convenient for them.

Doctors at JFK Medical Center in Edison, where elderly visits to ER increased 27 percent this year, say they are seeing many more such patients being referred by doctors.

"In off-hours when people have symptoms that might suggest something serious, they are being directed to the emergency room, in part because of liability fears," said Michael Cali, chairman of emergency medicine.

Visits by the elderly to Community Medical Center in Toms River, meanwhile, have increased about 30 percent this year over 2006, with the admission rate up 45 percent to 50 percent, hospital officials said.

"The elderly who are coming to the emergency department have real emergencies. They are sick and the great majority end up being admitted to the hospital," said Laurence DesRochers, Community's chairman of emergency medicine and president of the New
Jersey chapter of the American College of Emergency Physicians.

Unlike many younger patients, seniors tend to seek help at the first signs of a problem, said Esmat Sharobeem, chairman of emergency medicine at East Orange General Hospital.

"They are much more sensitive to their symptoms, acting on them much quicker," he said.

But tough economic times have led to the closings of several community hospitals in New Jersey in recent years, meaning fewer emergency departments to handle the growing number of elderly patients.

"If hospitals are declaring bankruptcy and closing their doors, the situation is just going to get worse," said Douglas Johnston, governmental affairs manager for AARP New Jersey. 


Barnert Hospital closes its doors this weekend

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COPYRIGHT © The Star-Ledger 2008


Barnert Hospital in Paterson — whose closing had been rumored even before it declared bankruptcy last summer — will shut its doors this weekend, hospital officials announced yesterday.

The hospital's remaining 41 patients are scheduled to be transferred to other hospitals and all outpatient services, with the exception of mental health services, will shut down today, said Peter Betts, Barnert's interim president and CEO.

Barnert's emergency room will remain open, at least temporarily, he said, but ambulances are already being diverted to other facilities.
"Barnert surprised everybody. Everybody thought we would close long before now," said Betts, adding the hospital had lined up a potential buyer, but could not complete a deal in time.

According to Betts, he and other officials of the money-losing hospital walked into a hearing in U.S. Bankruptcy Court in Newark on Thursday hopeful it would be able to remain open. But in the end, he said the federal Department of Housing and Urban Development refused to back a deal that involved Barnert borrowing $3.2 million to stay afloat until an agreement could be finalized, sometime in April.

"There was no signal that would happen," he said of the deal rejection.

The proposed buyer had plans to turn part of the hospital into a long-term care facility, he said.

While the hospital was able to meet payroll yesterday, it will be out of money next week, he said.

Betts held a series of meetings yesterday with the hospital's 400 or so employees and members of its medical staff to inform them of the news.

The mood was gloomy inside the century-old, 256-bed community hospital, with a steady rain outside seeming to serve as an appropriate backdrop. Betts said he was trying to arrange for severance pay and said job fairs will also be held next week to assist employees in landing jobs elsewhere.

"I'm extremely upset," said Karen Walker, a community activist who has lived in Paterson for nearly 30 years.

Walker, who is vice chairwoman of a coalition called People United to Save Barnert Hospital (PUSH), said Barnert offered some unique healthcare services, including a mental health program for the deaf and a juvenile sexual offenders program. Walker also expressed concern about access to birth control and other reproductive services, since St. Joseph's Regional Medical Center — the other hospital in town — is a Catholic institution.

"People will no longer have a choice of where they want to go," said Walker, who also worried that the time it takes to see a doctor in the emergency room of St. Joseph's will grow longer.

Assemblywoman Nellie Pou (D-Passaic) vowed to "work closely with Barnert and St. Joseph's to help ensure that health services to our vulnerable population are not compromised." State health officials, meanwhile, which had advanced Barnert $1 million in charity care funds last fall, even as HUD kicked in $2.5 million to help the troubled institution, are keeping a close eye on things during the transition.

"We believe there are sufficient services in the area that can service the community," said Tom Slater, a spokesman for state Health Commissioner Heather Howard. "Our role is that we will be monitoring them (Barnert) as they wind down to ensure access to services, quality of care and patient safety."


Report: Jersey ERs diverting ambulances

Hospitals turn away emergency an hour

The Star-Ledger Archive
COPYRIGHT © The Star-Ledger 2007


With emergency room visits on the rise, some New Jersey hospitals are straining to find enough staffed beds to treat patients, resulting in a statewide average of one ambulance an hour being diverted, a report released yesterday found.

The stress on bed capacity is so bad — especially during flu season and other peak periods — the state's hospitals would have a difficult time responding to a major health disaster without displacing many existing patients, according to the report by the Rutgers Center for State Health Policy.

"During peak periods, the state's hospitals appear to be extremely constrained," the report concluded.

In 2005, the number of emergency room visits in New Jersey rose to 3.36 million — up 4.5 percent over the previous year and more than 25 percent since 1998, according to the report.

The problem of capacity is especially acute in hospital units such as critical care, where the nationwide nursing shortage has hit hard.

"It's not always as simple as saying hospitals have fewer staffed beds," said state Health Commissioner Fred Jacobs. "Emergency department diversions occur when units like critical care are full."

Since 1995, 17 financially strapped acute care hospitals have closed in New Jersey and a commission appointed last year by Gov. Jon Corzine to review how the state's health care resources are distributed could result in the closing of other weak performers.

Because many procedures that once required hospital stays are being done in an outpatient setting, the average daily census in hospitals has dropped, said Ron Czajkowski, a spokesman for the New Jersey Hospital Association.

As a result, hospitals have consolidated some units in an attempt to increase occupancy and reduce costs. While increasing efficiency, it has also resulted in fewer beds available for sick patients.

In 2005, for example, there were 47 days when more than 95 percent of all staffed hospital beds in the state were occupied, up from 29 days in 2004 and 11 days in 2003, according to the report.

That meant about once every hour an ambulance carrying a sick patient had to be diverted to another hospital, said Derek DeLia, the senior policy analyst and Rutgers assistant professor who authored the report, titled, "Hospital Capacity, Patient Flow and Emergency Department Use in New Jersey."

He said diversion tends to increase during times of peak demand, such as the first three months of the year, when flu season is at its height.

Hospitals also see an increase in volume on Mondays, resulting in many being nearly 90 percent full Tuesday through Friday, before rapidly emptying on the weekend.

He said doing a better job managing factors that affect capacity — such as ensuring patients who are ready to leave the hospital are cleared by doctors for discharge in a timely fashion — can help the system run smoother.

"Hospitals that are better at streamlining these kinds of issues can take on more volume," DeLia said.

But under current conditions, the state's hospitals have "almost no surge capacity available" to respond to major medical emergencies, such as a terrorist attack or a pandemic, he added.

From 2003 to 2005, there were fewer than 500 empty staffed beds available per million residents on any given day, the report found.
And with growing use of the emergency room, things are not likely to improve.

Hospital Association officials say emergency rooms are treating a growing number of uninsured, as well as patients who don't have access to a family physician.

"We're also hearing that even insured patients who don't choose to wait a few days for a physician's appointment are using the emergency department more," said Czajkowski, the association spokesman.

Even people with chronic health conditions such as asthma and congestive heart failure are increasingly making more visits to the emergency room, the report notes.

Some inner-city hospitals have responded by developing chronic disease management systems within their emergency departments, according to the report.

Laurence DesRochers, president of the New Jersey Chapter of the American College of Emergency Physicians, said the report presented no surprises, noting hospitals are continually working on capacity issues.

"Many hospitals are now even using outside consultants to help from a business perspective," said DesRochers, who is an attending emergency physician at Community Medical Center in Toms River.


Muhlenberg hospital to shut its doors

130-year-old Plainfield facility cites flood of red ink

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COPYRIGHT © The Star-Ledger 2008



Faced with mounting deficits caused mainly by insufficient state aid to cover all its uninsured patients, officials at Muhlenberg Regional Medical Center in Plainfield said yesterday they plan to close the 130-year-old facility later this year.

The Union County hospital plans to file formal papers with the state Department of Health and Senior Services on March 1 seeking the closure. If approved, programs and services will be phased out during a "wind down" period before Muhlenberg finally stops admitting patients.

"Do I expect people to be upset? Yes. I am upset," said John P. McGee, president and CEO of Solaris Health System, which owns the hospital.

More than half of New Jersey's 78 community care hospitals are operating in the red, a result of a convergence of economic forces including declining reimbursement from major insurers like Medicare and increased operating costs. In the last six months, three hospitals — Barnert in Paterson, Pascack Valley in Westwood and Union Hospital in Union Twp. — have closed.

Others, including Saint James and Columbus in Newark and Greenville in Jersey City, are scheduled to close soon.

The decision to close the 396-bed Plainfield hospital was a "last resort" after an attempt to find a buyer failed, McGee said. Muhlenberg, which also has 1,100 employees and 350 affiliated physicians, was put up for sale last November. Officials say they reached out to more than 60 potential buyers.

McGee said one reason for the lack of interest is economics: Muhlenberg will likely show a loss of $18 million for 2007.

The hospital — whose emergency room treats 35,000 patients a year — doled out some $15.4 million in uncompensated care last year, but received only $6.2 million from the state in charity care funding, spokesman Steven Weiss said.

McGee said the hospital absorbs whatever the state does not provide in charity care funding.

Muhlenberg has also been treating a growing number of uninsured patients as well as undocumented patients, most of whom are not insured and do not qualify for charity care, he said.

"The cost of providing this care is more of a burden than anything else," he said. "But don't think that closing Muhlenberg solves this underlying public policy issue. It doesn't."

The hospital's financial problems have also been affected by declining numbers of patients and competition from free-standing outpatient surgery centers in Central Jersey, officials said.

Once it closes, the hospital plans to maintain, at least temporarily, a satellite emergency room with limited services. Plans also call for the nursing school to remain open, although some change in accreditation will be required.

A home care service the hospital jointly operates with its sister facility, JFK Medical Center in Edison, will continue to function. Muhlenberg merged with JFK in 1997 to form the Solaris Health System.

JFK, with 380 beds, is located about five miles away, in Middlesex County, and will be the closest acute-care hospital to Plainfield.
Local elected officials concerned about issues like transportation are hoping to create a task force to ensure Plainfield residents get the essential medical services they need after the closing.

Leading the effort is Assemblyman Jerry Green (D-Union), who wants officials from Overlook Hospital in Summit, Somerset Medical Center and Saint Peter's University Hospital in New Brunswick to either offer services in Plainfield or take in patients from Muhlenberg.

"We're hoping we can sit down in Central Jersey and come up with a plan that will be efficient for everyone," Green said.
Katrina Pagan, of North Plainfield, who's been coming to Muhlenberg for her routine pregnancy check-ups since September, spends about $7 for a taxi to the facility. She estimated it will cost her about $25 to get to JFK.

"It's going to make it difficult," said Pagan, the mother of a 21-month-old son who feels patients should have been notified sooner.
McGee said only about one-third of the hospital's employees may be retained initially and conceded that the other two-thirds are "at risk." Green is hoping the task force can play a role in finding jobs for some of them.

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