It's not the uninsured. It's not illegal immigrants.
The Californians most likely to crowd hospital emergency rooms — often with fevers or infections that could be treated elsewhere — are insured by the government and born in the United States, according to a new statewide study.
For every 100 people on Medi-Cal, 47 visits were made to emergency rooms in 2005, according to the Public Policy Institute of California. For every 100 people covered by Medicare, 46 visits were made to ERs. Californians without any insurance made 31 visits for every 100 people.
The report also challenged the perception that illegal immigrants are more likely to use the emergency room as a doctor's office, taking advantage of the federal law that compels the staff to treat anyone who walks in the door. It said about 12 percent of noncitizens reported they were likely to use an emergency room in 2005, compared to about 14 percent of people born in the United States.
Experts debate how much the tr ends contribute to the crowding of hospital ERs in Ventura County. The facilities are already so packed that ambulances were diverted from different hospitals for 7,400 hours last year, the equivalent of 308 days.
Others worry about increasing the financial burdens on hospitals that have closed some 70 emergency rooms in the state in the past decade.
To the people waiting in a county-run clinic in a Simi Valley strip mall, the numbers are a symptom of a healthcare system that pushes patients to rely on emergency care.
The homeless, uninsured woman sitting in a corner with a hand over her face walked into the clinic at 8:50 a.m. because of blurry vision and back pain. Carla Krisatis will be seen shortly after 11 a.m. A similar wait a couple of months ago sent her first to a Moorpark clinic that was also packed and finally to the Simi Valley Hospital emergency room, where she finally found treatment.
"At this point, I'm ready to go back there," Krisatis said as she waited.
The county healthcare system is designed to keep patients with routine conditions out of emergency rooms by emphasizing the use of clinics, urgent care centers and a special program for the uninsured. County officials say the clinics are seeing record numbers of people, while visits to the emergency room at Ventura County Medical Center have remained relatively flat.
But some of the people waiting in Simi Valley say they go to emergency rooms often, usually because they think it's their only or best choice.
Jakki Baker's 3-year-old daughter, Shaylee, developed a 103-degree fever on a Saturday during flu season when the county clinic was closed. They waited for five hours in the emergency room at Los Robles Hospital & Medical Center in Thousand Oaks. Then a doctor told Baker to take her daughter home, give her Tylenol and fluids.
"It's ridiculous. I hate the emergency room. I try to avoid it like the plague," Baker said.
All about money
About 37 percent of the emergency room patients in Ventura County last year were insured by Medicare or Medi-Cal, according to the Office of Statewide Health Planning and Development. About 16 percent of ER patients were uninsured.
People on Medi-Cal are also the group most likely to use the emergency room for routine conditions that could be treated in a doctor's office or clinic, according to the report by the Public Policy Institute. It said about 44 percent of all California emergency room visits in 2005 could have been seen outside the ER.
Some Ventura County physicians think the trends are on the upswing, with emergency rooms continuing to see more insured people who can't get doctor's appointments. And it won't just be people covered by Medi-Cal and Medicare, said Dr. Jim Hornstein.
"The bottom line is they're the canary in the mine shaft," said the Ventura family doctor. "They're the first ones who can't get in."
Hornstein points an accusing finger at a primary care doctor shortage created in part by the reality that specialists make more money. Practices f or existing family care and internal care doctors are jam-packed with patients. Anyone new has trouble getting in the door.
The shortage has hit Medi-Cal beneficiaries first because of money. Fewer than half of the state's doctors accept Medi-Cal because the reimbursement rate is so low, according to the California Medical Association.
"I'd have gone broke a long time ago if I took Medi-Cal," said Dr. Ted Hole, another Ventura family practice doctor.
"They pay maybe $20 for an office visit. My overhead per visit is $40. How can you do that?"
Hole said private insurance companies also don't pay doctors enough to motivate them to see patients on weekends.
He said doctors get paid the same whether they see patients or refer them to the ER.
So they send them to the hospital.
Doctors want to provide the best care they can for patients, Hole said. But like people in every other profession, they are also trying to make a living.
"There is no aspect of medicine that is not somehow related to reimbursement," he said.
Many are wary of authority
Hospitals are barred by law from asking emergency room patients about immigration status. Public Policy Institute researchers acknowledged the population's healthcare visits are hard to track.
Still, they used the California Health Interview Survey to conclude that a greater percentage of people born in the United States were likely to use the emergency room than are naturalized citizens. Both groups were more likely to rely on emergency care than noncitizens.
"Are immigrants going to the emergency room? Yes. Are they going at a higher rate than others? No," said the study's co- author, Shannon McConville.
Some observers argue that illegal immigrants rely on community clinics and live in secrecy, worried that any public exposure could result in deportation.
"People who are desperately poor and come from a very different culture and speak a language that no one else speaks are very wary of authority figures in any setting," said Susan Haverland, leader of an outreach program that works with Mexican farmworkers who speak the indigenous language of Mixtecan.
Filled to saturation
In Ventura County, the busiest emergency room last year was the Ventura County Medical Center, with about 42,003 patients, according to state records. St. John's Regional Medical Center in Oxnard was the second busiest, with 40,911 patients.
When ERs reach capacity, ambulances carrying all but the most critically ill patients are diverted to other hospitals.
That happens often in Ventura County, with ambulances diverted from three different hospitals — Los Robles in Thousand Oaks, Simi Valley Hospital and St. John's in Oxnard — for more than 1,000 hours each last year.
The Oxnard hospital was saturated more than any other hospital, with about 2,646 hours of ambulance diversion, equal to about 110 days.
St. John's officials say their emergency room was more crowded last year because of the loss of 44 beds resulting from a now-completed construction project aimed at protecting the hospital from mold. The emergency room was also closed for 16 days while the hospital was fumigated for mold.
Like every other hospital, St. John's emergency room receives patients with conditions that could be treated elsewhere, said Lori Bigham, the hospital's vice president of patient care services. But the hospital has a rapid-exam area designed for less severe conditions, meaning the treatment doesn't intrude on the care of more critically ill patients, she said.
Doctors at other emergency rooms say the same thing.
"We do have issues with crowding, but it's not from patients coming in with minor problems," said Dr. David Lebell, assistant emergency room director at Community Memorial Hospital in Ventura. "The crowding comes from the really sick patients, people who have to be admitted."
But any trend that sends more patients into the emergency room contributes to crowding, said Jan Emerson, spokeswoman for the California Hospital Association. If emergency rooms didn't have to deal with minor injuries and illnesses, they would have more resources for people injured in car crashes.
The average wait in a hospital emergency room throughout the state is four hours, she said, noting people wait nearly 11 hours at some hospitals in Los Angeles County.
"You look at overcrowding in the state, and it's getting worse," Emerson said, citing doctors who won't take on-call duty, Medi-Cal cuts and hospital closures that mean surviving emergency rooms have to care for more patients. "It's multifaceted, but avoidable20visits are a contributing factor."
Taking the easy way out
The visits may hurt hospitals most in the pocketbook. Care in an emergency room costs about five times what it would cost in a doctor's office, said Paul Lorenz, deputy director of the Ventura County Health Care Agency.
"It's absolutely the most expensive place to obtain care because hospitals have to run a 24-7 operation," added Emerson, listing the costs of nurses, physicians, laboratories and diagnostic testing.
The Public Policy Institute report calls for more access to healthcare outside of emergency rooms.
Lorenz said the county added a clinic and urgent care facility in Fillmore last year and plans to open urgent care centers in Thousand Oaks and Simi Valley next year. In addition to plans to expand operating hours at clinics in Simi and several other cities, a program is being implemented to cut down on clinic wait times so patients don't turn to emergency rooms ou t of frustration.
"I think over the years we've had significant success in educating the patient population in how to use the emergency room," Lorenz said. "It takes time. It's nothing that's going to happen overnight."
Despite the programs and plans, some of the people waiting at Sierra Vista Clinic in Simi say they still go to emergency rooms.
Jessica Lindsey, a 22-year-old kickboxing instructor on Medi-Cal, has a bladder and kidney infection that means she has to see a doctor every three months to get a new prescription filled. It takes too long to get an appointment, so she goes to the emergency room. "Am I surprised?" she said when told many people do the same thing. "I'm surprised it took people this long to find out you can just go to the hospital."
By Renee Schoof (McClatchy)
WASHINGTON — A new scientific study adds evidence that temperatures in the Northern Hemisphere fluctuated a bit over time, but that the sharp increase during the past few decades is bigger than anything in at least 1,300 years.
The report was published Tuesday in the Proceedings of the National Academy of Sciences. Its conclusion is that temperature increased and decreased a little over the centuries, but the fluctuations were small enough that the line was roughly flat, like the shaft of a horizontal hockey stick. Then, from about 1980 to now, temperature increased sharply, more than any increase before — like the blade of the hockey stick.
For the past 10 years, climate-change skeptics have been calling the hockey stick bogus. Now the scientists who studied the climate record and produced the original hockey-stick graph have done a new study using more data from more sources — and they got the same pattern.
The new study "establishes further evidence that the recent warming isn't just part of a typical cycle," said climatologist Michael Mann , director of the Earth System Science Center at Pennsylvania State University.
"Of course, this alone doesn't establish the cause of that warming — that it must be due to human influences," Mann said. That's left to other scientific studies of the climate.
Forces of nature — changes in the output of the sun's energy and volcanic eruptions — and random variation explain the changes in climate before industrial times, Mann said. But only if human factors are taken into account — particularly the production of long-lasting, heat-trapping gases from burning fossil fuels — can scientists explain the unusually high recent temperature increase, he said.
Mann's group's study collected additional data for the centuries before the mid-19th century, when scientists began recording temperatures.
Their previous study depended on tree rings, and some critics said it was not a reliable way to reconstruct past clim ate over a long period. Mann said that while it's not always true that tree rings aren't reliable, his team decided to conduct a new study that didn't depend on them.
They took data from other natural sources of clues about past climate — corals, ice cores and lake and cave sediments.
"We found we got more or less the same answer," Mann said. The recent temperature increase is an anomaly over 1,300 years without using tree rings, and for 1,700 years if the tree-ring data are used, the study found.
Scientists have observed a warming of about 0.8 degrees Celsius during the past century. Mann said there was a burst of about 0.3 degrees from about 1900 to 1950. Then, in the 1950s to 1970s, temperatures were flat or showed a slight cooling, because heavy particle pollution, which has a cooling effect, masked the heating effect of greenhouse gases, Mann said.
Another, larger increase of temperature has been recorded in the past 30 years, he said, due largely to the increase of greenhouse gases. Particle pollution was reduced as a resul t of clean-air laws in the U.S. and other countries.
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