Small community hospitals can do many things – set broken bones, treat wounds, prescribe medication – but there are some things we just can’t do. We are not – nor should we be – a cancer care center. We do not do open-heart surgery. We are not a children’s hospital. Instead, our job is to assess each patient and – if the patient’s condition exceeds what we can provide in treatment – move them on to a specialty hospital that can provide that treatment.
Only we can’t. As a recent front-page story in the L.A. Times shows, our patients often linger for days – sometimes a month or more – waiting for a transfer, even as their health deteriorates.
There are many reasons why transfers can be difficult (a healthcare workforce shortage, lack of beds) but one common denominator trumps all else: Medi-Cal. In a nation where doctors are paid more to treat some patients (those with Medicare or commercial insurance) and less to treat others (Medi-Cal), who gets a bed becomes yet another fault line in our separate and unequal healthcare system.
Case in point: We recently treated a man who needed heart valve surgery at a specialty-care hospital. He had limited scope Medi-Cal insurance, which doesn’t cover many services. The patient lingered in our hospital’s intensive care unit, in terrible pain and towards the end delirious, while we pleaded with other hospitals to perform the surgery he needed.
During a case review, one of our doctors got on the phone and called the physician who had originally rejected this patient for transfer at a bigger, specialty-care hospital. It was a tense, compelling conversation and ultimately resulted in the other doctor taking a second look at the case.
Simultaneously, our heroic care managers were able to get this patient promoted to full-scope Medi-Cal– a better, but still inadequate, insurance. The patient was transferred.
Begging and pleading is obviously not an ideal way to handle patient transfers. Nor can we petition the media to pay attention to every injustice. There are just too many. We need structural and legislative change now to keep these tragedies from playing out – again and again – in our emergency department. Here’s what needs to happen:
Raise Medi-Cal reimbursement rates. California pays too little to providers to take care of those enrolled in Medi-Cal, the public insurance that covers one-third of our state’s population. We are in the low end of states in terms of our provider reimbursement rates.
Hospitals get paid eight times more to treat a commercially insured patient than they do a Medi-Cal patient. Unsurprisingly, doctors won’t work in areas like South LA with large Medi-Cal populations.
The lack of doctors (at last count, we lack 1,500 doctors relative to average-sized areas) means people here cannot get the care they need. As a result, they get sick (or even sicker) and end up in our crowded emergency department.
Often, they come with simple, manageable conditions that have advanced to a severe state due to basic lack of access to preventive care. Think about a small sore that doesn’t get treated and worsens to the point where the patient has to have his or her leg cut off. It’s awful. It’s common. The payment creates the scarcity that results in the tragedy. It’s as simple as that.
Prioritize urgent, rather than elective, procedures. One of the reasons patients can’t get transferred is that hospitals everywhere – and especially specialty hospitals – are full to the brim. They often tell us they have no beds when we call asking for a transfer. What is less acknowledged is that many of those beds are filled with patients seeking non-urgent (but highly compensatory) elective surgery. There is no real system in place to prioritize patients by medical need. We could use a more organized system.
Of course, the way big hospitals stay in business is through lucrative elective surgeries and not by serving low-paying Medi-Cal patients. That’s the problem. It’s easy to blame bigger, more affluent hospitals for refusing to accept transfers, but they are driven by the negative incentives of Medi-Cal.
The problem is not the big rich hospitals versus the small, less-affluent hospitals. It’s the system. And it’s long past time for that system to change.
Dr. Elaine Batchlor is the chief executive officer of Martin Luther King Jr. Community Hospital in South Los Angeles.
