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Who pays when someone without insurance shows up in the ER? – USA TODAY

Right now, GOP senators are trying to gather enough votes to pass their Obamacare replacement plan, but even fellow Republicans are having a time a hard time accepting the health care bill. USA TODAY

An ambulance arrives at a hospital emergency room.(Photo: PhotoDisc)

WASHINGTON If an uninsured patient shows up in the emergency room, who pays? The hospital? Taxpayers? The patient? Other patients?

The question is important as Republicans debate health care legislation that could result in more than 20 million fewer Americans having health insurance in ten years.If that happens, some people will go without care. Others will show up at hospitals, but wont be able to pay their bills.

The year the Affordable Care Act passed, hospitals provided about $40 billion in “uncompensated care” that is, care they were not paid for.That was nearly 6% of their total 2010 expenses.

A 1985 federal law requires emergency departments to stabilize and treat anyone entering their doors, regardless of their ability to pay.

But that doesnt mean the uninsured can get treated for any ailment.

Theres lots of medical care we want to consume thats not an emergency, said health care economist Craig Garthwaite, an associate professor and director of the health care program at Northwestern University’s Kellogg School of Management.

It also doesnt mean that hospitals wont try to bill someone without insurance. And the bill they send will be higher than for an insured patient because theres no carrier to negotiate lower prices.

As a result, the uninsured are more likely to be contacted by collection agencies, as they face problems paying both medical and non-medical bills. One study, published in 2016 by the National Bureau of Economic Research, found that someone who goes into the hospital without insurance doubles her chances of filing for bankruptcy over the next four years.

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For the bills that go unpaid, hospitals can try to compensate by charging other patients more. But that doesnt happen as much as many people including policymakers — think.

The authors of the ACA believed thatincreasing insurance coverage through Medicaid and subsidies for private insurance would lessen the cost-shifting that leads to higher insurance premiums. Supreme Court Justice John Roberts also mentioned that benefit in the 2011 decision he authored upholding the laws constitutionality. But researchers havent been ableto document much of a cost shift.

Studying the effects of expanding Medicaid in Michigan where more than 600,000 gained coverage researchers at the University of Michigan havefound no evidence that the expansion affected insurance premiums. They did, however, document that hospitals uncompensated care costs dropped dramatically by nearly 50%.

Conversely, when Tennessee and Missouri had large-scale Medicaid cuts in 2005, the amount of care hospitals provided for free suddenly increased. In a 2015 study published by the National Bureau of Economic Research, Garthwaite and his co-authors estimated every uninsured person costs local hospitals $900 in uncompensated care costs each year.

This is not a trivial thing for a hospital to deal with, Garthwaite said. While hospitals average 7% profit margins, uncompensated care costs can be more than 5% of revenue.

Hospitals do get help with the unpaid bills from taxpayers.

The majority of hospitals are non-profits and are exempt from federal, state and local taxes if they provide a community benefit, such as charitable care. Hospitals also receive federal funding to offset some of the costs of treating the poor.

The ACA scaled back those payments in anticipation that hospitals’ uncompensated care costs would go down. The GOP proposals to overhaul the ACA would reinstate the payments, while making changes to Medicaid and private insurance subsidies that the nonpartisan Congressional Budget Office estimates would result in more than 20 million fewer people having insurance by 2026.


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The return of extra federal payments to hospitals for uncompensatedcare wouldnt be enough to offset the unpaid bills, according to an analysis by the Commonwealth Fund. The study examined the Medicaid changes included in the bill that passed the House in May, and co-author Melinda Abrams said the effects of the Senates pending proposal would be at least as great.

Hospitals operating margins in all states would decline. And hospitals in most of the 31 states which expanded Medicaid under the ACA would have negative operating margins by 2026, according to the analysis.

Ultimately, you have to cut services, fire people, or both, Abrams said. It is shifting the burden of the cost. What is currently shared between the federal government and state governments will be shifted largely to the states. And the burden will be felt by the providers, the patients, the community and the taxpayer.

Pressure from hospitals was often a factor in states decisions to expand Medicaid under the ACA. In some states, such as Indiana, hospitals even agreed to a pay new taxes in exchange for the additional federal revenue from Medicaid patients. Most of the recent decline in hospitals uncompensated care costs has been in states which expanded Medicaid.

And hospitals are among those fighting hard against GOP efforts to phase out the expansion and cap overall Medicaid payments to states.

If these proposed cuts take place, devastation would occur for local rural economies due to hospitals closing and patients incurring huge amounts of debt, Trampas Hutches, CEO of Melissa Memorial Hospital in Holyoke, Colo., said at one of the many events organized by the American Hospital Association and other health care providers in opposition to the GOP bills.

One reason Medicaid has been harder to cut than other safety-net programs such as welfare cash payments is that a large part of the spending is a transfer to health care providers, Garthwaite argues. Thats particularly true for hospitals which are essentially insurers of last resort when there are large coverage gaps.

When policymakers decide not to provide health insurance for a portion of the population that otherwise could not afford insurance,” Garthwaite and his colleagues wrote in their 2015 analysis, “hospitals ultimately bear the cost of that decision,

As President Donald Trump continues to push his agenda of repealing and replacing Obamacare, Americans are not on his side about this. Susana Victoria Perez (@susana_vp) has more. Buzz60

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Who pays when someone without insurance shows up in the ER? – USA TODAY


18 Salinas farm workers rushed to emergency room – KSBW The Central Coast


Salinas Valley farm giant Tanimura & Antle is under investigator by state and local officials after 18 of its field workers may have been exposed to pesticides in a Salinas field.

The crew had showed up at a farm field at Harden Ranch near the corner of Abbott and Harris to plant celery early Thursday morning.

About an hour later, workers started getting sick and one employee begin to vomit. The workers were immediately bused to the emergency room at Salinas Valley Memorial Hospital.

The incident triggered a mass casualty incident at the hospital.

“We immediately called a ‘Code Triage,’ said Jeremy Handland of SVMH’s Clinical Emergency Department. We activated our command center and the staff worked extremely well together to treat the patients.”

Workers suffered from dizziness, nausea, vomiting, and abdominal pain, Hadland said.

Investigators say nearby fields where the workers were planting had pesticides applied the night before.

Pesticides applied include Lannate, Coragen, Movento, Pounce, Actara, Fulfill. The fungicides Revus and Previcur were also applied to one field.

Lannate is considered to be a dangerous insecticide.

Its possible the workers may have been overcome by lingering odors.

“Because of the nature of the chemical, there certainty was a risk for serious medical complications,” Hadland said.

Employees were stripped down and showered in a decontamination unit.

Monterey County Agricultural Commissioners Office officials are leading the investigation.

“This is what is characterized as a priority investigation because of the number of people involved,” said Bob Roche, Monterey County assistant agricultural commissioner.

“Its still early in the investigation. But at this point we have no indication anyone violated any pesticide use laws or regulations,” Roche said.

“This investigation will go all the way back to the U.S EPA,” Roche said.

Clothing samples were collected and sent to the state department of pesticide regulation for testing of residues.

“We value our employees, their health, and well being. We take something like this very serious,” said Samantha Cabaluna, spokeswoman for Tanimura & Antle.

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18 Salinas farm workers rushed to emergency room – KSBW The Central Coast


‘It’s a big frustration’: Local hospital emergency rooms overwhelmed since passage of Affordable Care Act – The Bakersfield Californian

Emergency room visits are up 29 percent in Kern County since 2009 when the Affordable Care Act was passed, running counter to one of the key takeaways from the law: that they would decrease as consumers take advantage of preventive care.

The problem? Insurance doesnt equal health care access and people still dont know when its appropriate to hit the ER, experts say.

Roughly 51 percent of Kern County ER visits between 2009 and 2016 came from patients enrolled in Medi-Cal, the states insurance plan for low-income individuals, according to data from the Office of Statewide Health Planning and Development analyzed by The Californian.

Medi-Cal was expanded under the ACA, meaning more people have an insurance card. But the number of primary care doctors accepting Medi-Cal hasnt kept up with demand, especially in the Central Valley, and people are still going to ERs for basic care.

People are using the emergency room as their primary care office. People havent really had private doctors, so they dont really know how to use insurance, said Dr. Anthony Iton, senior vice president of The California Endowment, a nonprofit foundation that focuses on health care access.

The result is an added strain on emergency departments across the region, resulting in hospital reorganizations and hiring.

And despite the ACA insuring millions, it still costs hospitals money when Medi-Cal patients walk through the door, said Jan Emerson Shea, vice president of external affairs for the California Hospitals Association.

Now the hospitals are getting a little bit of money, but we still lose on average 40 cents on the dollar for every Medi-Cal patient we treat, Emerson Shea said.

The ACA has eased the burden on taxpayer-funded Kern Medical Center of treating uninsured patients in the ER.

The County of Kern paid $47 million in 2009 to cover the costs of uncompensated care at KMC. Today its financially solvent.

When more Californians began enrolling in Medi-Cal, local hospitals started seeing a surge in emergency room visitors. It has impacted every hospital in Kern County.

Here are the stats for 2009 to 2016:

Valley Childrens Hospital in Madera, the specialty care facility for all southern San Joaquin Valley kids, received 46 percent more emergency room patients, totaling more than 114,000 in 2016 and making it the busiest emergency department in the state (see sidebar).

Not all ER visits, however, have come from people experiencing bona fide emergencies, said Ken Keller, chief operations officer for Bakersfield Memorial Hospital.

We have some come in with a small earache, or a cold, or a flu, or something that doesnt really need to be in an emergency room, Keller said. They have this new benefit they didnt have before, and no education or counseling or outreach to those patients to be able to say, Heres how you access the health care system. What they knew was how to get to an emergency room.

So hospitals have taken on the task of educating patients wandering into emergency departments when they really ought to have gone to doctors offices, Keller said.

Bakersfield Memorial Hospital has hired navigators who can counsel patients on how to seek care outside the emergency room, including finding them primary care doctors who work within their insurance plans, Keller said.

The surge also is forcing hospitals to hire more doctors and staff.

We have more physicians here now than at any point in time than we did seven years ago, Keller said, adding the emergency department has been expanded by about one-third, funded primarily through philanthropy, but also through operating revenue. The hospital recently constructed a pediatric emergency department that has not yet opened and reorganized the way it triages patients.

Jimmy Phillips, administrative director of marketing and communications at San Joaquin Community Hospital, called the surge of patients entering emergency rooms who could have been treated by primary care doctors a big frustration.

Recently, the emergency department has been flooded with patients coming in for things like prescription refills, knee or back pain, cuts and scrapes, fevers and even the common cold, Phillips said.

Those patients, who could have been better served at urgent care facilities, make up roughly 70 percent of SJCHs emergency department admittances, Phillips said, adding that because emergency rooms take patients based on severity of condition, they often face longer wait times for the same quality of care.

Scott Thygerson, the chief strategy officer at Kern Medical Center, said the increase in emergency room admittances has less to do with the Affordable Care Act and more to do with the business of health care and local expansion of emergency departments.

San Joaquin, Mercy Southwest, Mercy Downtown and Bakersfield Memorial have all added beds or expanded their departments since 2009, he said.

When you add expansion, youve got to fill expansion, Thygerson said, pointing to heavy advertising campaigns local hospitals have waged in recent years for their emergency departments. Those emergency departments make up roughly half the admits in the hospital, he said.

Its a big front door, and its the only time a patient truly has a choice where they go for care, Thygerson said, adding that theres no simple answer explaining why emergency department admittances have increased, but that the ACA is just one small part.

State reimbursements to doctors for taking Medi-Cal patients are simply too low for them to justify accepting those patients, leading to the surge in ER visits, said Lanhee Chen, a Republican health care strategist and research fellow at Stanford Universitys Hoover Institution.

Doctors wont accept Medi-Cal patients because reimbursements keep getting crushed, Chen said.

Reimbursements for primary care doctors vary depending on the procedure, but California ranks 48th for their rates nationwide.

Legislators have been working to find solutions. Locally, U.S. Reps. David Valadao, R-Hanford, and Jeff Denham, R-Turlock, have proposed HR 2779, a bill that would field-test the best Medi-Cal reimbursement strategies while incentivizing physicians to work in areas where there are high numbers of Medi-Cal enrollees, like the Central Valley.

Kern County, which has a shortage of providers, high poverty and high infant mortality, is considered to be a medically underserved area by the U.S. Department of Health and Human Services. There arent enough doctors to meet the need.

Here in the valley, we know all too well that possession of an insurance card does not equate to health care services and medical treatment, Valadao said in a statement. By correcting Californias reimbursement method, we can encourage medical professionals to not only set up their practices in the valley, but to provide medical services to all patients, including those who rely on the Medicaid program.

At the state level, Gov. Jerry Brown struck a budget deal with lawmakers last week that set aside $546 million in tobacco tax money for Medi-Cal provider reimbursements roughly half the $1 billion annual estimate of what the measure would generate when voters approved Proposition 56 in 2016.

But even that isnt enough to fix the problem, Chen said.

With the volume of people were talking about with Medicaid, Im not sure that amount of money will be sufficient to deal with the issue. Its not about throwing money at the problem, Chen said. It gets back to the systemic challenges of Medicaid.

Youve got a program that does not have a benefit structure that incentivizes beneficiaries to stay healthy. Its about treating them once theyre sick, and thats not an effective way to manage a population.

A more permanent solution, said The California Endowments Dr. Iton, would be to look at a statewide policy and plan to increase the number of primary care doctors in rural areas of the state where demand is growing.

He suggested the state pay a geographical premium for Medi-Cal reimbursements where theres a dearth of doctors, and create scholarships and incentives for family practice specialties in rural areas while building residency programs that could lure young doctors to practice in the areas where they were educated.

They need sufficient resources infused to match the scale of the problem, Iton said. Right now, were not anywhere close to matching the scale of the problem.

Harold Pierce can be reached at 661-395-7404. Follow him on Twitter: @RoldyPierce.

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‘It’s a big frustration’: Local hospital emergency rooms overwhelmed since passage of Affordable Care Act – The Bakersfield Californian


Hospital nurse ‘critical’ after being stabbed by patient in Emergency … – WCVB Boston


Police said a hospital nurse was seriously injured by a patient with a knife, who then fled after the attack.

The incident happened around 10:15 a.m. Wednesday inside the emergency room at Harrington Hospital in Southbridge.

According to the hospital, the employee was seriously injured by a patient wielding a knife who then fled the emergency room.

Authorities said patient cornered her in a small room and stabbed her.

Conor ORegan, 24, was arrested shortly after the incident at his home, the Worcester County District Attorney’s Office said.

The nurse was immediately treated in the emergency room, stabilized and then flown to UMass Hospital, authorities said. The nurse, who was not immediately identified, was in critical but stable condition.

The hospital said patient admissions to the emergency department was being restricted while authorities investigated the incident.

“Our thoughts and prayers are with our employee and her family at this time,” a hospital spokesperson said in a statement.


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Hospital nurse ‘critical’ after being stabbed by patient in Emergency … – WCVB Boston


Tip No. 1 For Taking Charge Of Mass. Health Care Costs: Avoid The ER – WBUR

wbur (Open Grid Scheduler / Grid Engine/Flickr)

If you’re wondering why health care costs so much in the U.S., here’s one little piece of the answer: emergency room visits.

Forty-two percent of emergency room visits in Massachusetts in 2015 were for problems that could have been treated by a primary care doctor, according to the state’s Health Policy Commission. This state agency, which is charged with driving down costs, says a 5 percent cut in avoidable emergency room trips would save $12 million a year; 10 percent fewer such visits would save $24 million.

That extra spending is passed on to all of us in the form of higher health insurance premiums. Andgoing to an emergency room for non-urgent care is often not the best move.

“If its not a true emergency, youre going to wait for hours in the emergency room, its not the best practice for coordinated care, and you run the risk of having a lot of tests that might not have been necessary if you saw your regular provider,” saidSarah Sadownik, deputy director of the research and cost trends team at the Health Policy Commission.

The commission is breaking down some of the ways we in Massachusetts could save money without doing ourselves any harm. We’ll be posting many of these tips as they are released.

What’s your guess about the most common reason your neighbors go to an emergency department (ED)? Here’s the answer, by zip code:

Statewide, the top five reasons are: sinus problems (sinusitis), stomach pain (that’s my work zip code), rashes and skin conditions, acid reflux and bronchitis.

I go to the ED on weekends or after 5 p.m. when the office of my wonderful doctor is closed. But it looks like most people go during office hours.

Sometimes we go to the emergency room because we can’t tell if our symptoms signal a common problem or something more serious.

We used to assume that most of the people who visit an emergency room were uninsured. But that doesn’t seem to have been the case before the state expanded health coverage and is likely even less true now. Here’s the most recentcomparison we could find.

I’m surprised cost is not a factor for more people. An emergency room visit is more expensive than going to see your doctoror visiting urgent care facilities, which are often open on evenings and weekends. So what’s missing from this analysis? What are your reasons for going to the Emergency Department?

If you want more juicy details about avoidable ED visits, try this. And if you’re up for a deep dive into the reasons Massachusetts has some of the highest health care costs in the country, and maybe the world here’s the HPC’s most recent cost trends report.

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Tip No. 1 For Taking Charge Of Mass. Health Care Costs: Avoid The ER – WBUR


How to navigate a bustling emergency room – The Seattle Times

A visit to the emergency room is a stressful experience, especially as wait times can easily exceed several hours. Heres how to make sure you and your loved ones have appropriate care.

Complaints about emergency room care are legion, with stories of distress frequently voiced both by patients and by the relatives and friends who accompany them to the ER. Sometimes these complaints are warranted, as when patients with abdominal pain wait unattended in the ER for hours until their appendix bursts. But more often than not, they stem from a misunderstanding of how emergency rooms operate and how patients themselves can be helpful.

Among the laments Ive heard: I was there four hours before I saw a doctor. Nurses, doctors and orderlies kept scurrying past my cubicle, but no one paid any attention to me. I couldnt get anyone to bring me a drink of water. I was observed for hours, but no one would tell me if or when I might be admitted to the hospital.

And if you do need to be admitted, expect to wait some more in the emergency room until a bed is available in the appropriate unit.

Each year some 120 million Americans go to an emergency room, a number that increases annually even as more hospitals close their ERs (there are now 22 percent fewer than 20 years ago). According to the Centers for Disease Control and Prevention, the average wait time before seeing a physician is 55 minutes, but the wait could easily exceed several hours on a busy night or weekend.

The most important fact every ER visitor should know is that true medical emergencies patients with a potentially life-threatening problem like a heart attack, stroke, respiratory distress or uncontrolled bleeding take precedence over a broken bone, headache or stomach pain.

A triage nurse will evaluate the severity of your problem and assign you a priority number. Expect to wait if your life is not hanging in the balance, and dont complain if someone who came in hours after you is seen first. As one nurse put it, Waiting is good. It means youre not going to die.

However, if you are waiting to be seen and your symptoms get worse or new ones develop, let the admitting desk know. ERs do not want people vomiting or passing out in the waiting room. But there is little to gain from exaggerating your symptoms youll confuse the diagnosis and may be subjected to needless tests in order to be seen sooner.

Also important to know: If faced with a true emergency, call 911. The responding ambulance will take you to the nearest hospital equipped to deal with your problem. Dont follow the example of two friends of mine who walked themselves to the hospital while in the throes of a heart attack. And dont drive or have someone drive you. If you come by ambulance, you will be evaluated and given emergency treatment immediately, even before reaching the hospital. But if your problem turns out to be less than urgent, once there youll be sent to the back of the line.

If a doctor sends you to the emergency room, ask the office to call ahead and provide important background information.

But think twice before heading to the ER for less-than-urgent problems. If your doctor is not accessible, minor ailments like a bad cold, sore throat, earache, eye infection, back pain or a cut needing stitches are best treated in an urgent care facility, now common in most cities. These days many chain drugstores have clinics staffed by medically trained personnel who can treat many minor problems, although not a bad cut or wound, and suggest more specialized care or follow-up when needed. (Do ask first about cost and insurance coverage.)

In addition, some hospitals, including most hospitals in Connecticut, have a fast-track emergency room for treating patients with less serious problems and getting them out quickly.

Assuming that an emergency room is your best option, there are many things you can do to make the visit more efficient and less anxiety-provoking. Along with your insurance card, keep a card in your wallet or a list on your phone with all the medications and supplements you take and any allergies or chronic health problems you have. If available, also take copies of recent laboratory or diagnostic test results.

Try to have someone come with you or meet you at the ER who can serve as your advocate and helpmate. A friend who recently spent many hours in the ER with an elderly woman who had fallen and broken her nose was able to get her a needed drink, refill her ice pack, find out when she might be admitted and offer moral support.

Once assigned an ER cubicle, learn the names of the nurse and doctor in charge of your case since they are the best ones to ask for help, including pain relief, and may be the only ones who know if its safe for you to eat or drink something.

Although it is normal to be stressed and anxious when seeking emergency care, try to practice self-calming measures like deep breathing or meditation. This can help to minimize your symptoms and counter a tendency to become hostile, which would not endear you to the ER staff and may even result in less, rather than more, attention paid to your case.

When you are ready to be discharged, make sure you understand the instructions for the continuing or follow-up care you may need and request a number to call if your condition worsens later.

How to navigate a bustling emergency room – The Seattle Times