Economics reshaping medical system Money and politics dance awkwardly in care of the poor


PHILADELPHIA - It's just before 7 a.m., and the changing of the guard is beginning at Episcopal Hospital's Emergency Department.

Maddie McKenna, the triage nurse, and Jo Smith, the patient assets representative, take their places in adjoining offices within shouting distance of the nursing station, the department's nerve center.

They will be the first people most patients see this day, once they make it past the locked door and uniformed guard.

McKenna will decide how sick patients are and how quickly they will be seen. Smith will find out if they have insurance. More and more now, since the state revamped its welfare rules, they don't.

It will be a routine day, if there is such a thing in an emergency room in Philadelphia's poorest neighborhood. There will be no made-for-TV moments, no spattering blood, no frenzied efforts to rescue patients from death.

It's a far more subtle drama that has McKenna and Smith working side by side, one in which money and politics dance awkwardly with medical miracles and the myriad social problems of the Badlands.

Dr. Larry Brilliant, the attending physician for this shift, and the rest of the medical staff will try to act as if they aren't doing this dance. No matter what, they will keep asking the big medical questions: What's wrong with this patient? Does he have something that could kill him? Can I keep him alive?

All the while, though, Smith will be asking the question that may determine if Episcopal and other small urban hospitals will survive.

Who will pay?

$1 trillion in expenditures

Annual health expenditures in the United States total more than $1 trillion, nearly 14 percent of the gross domestic product. Working independently, and with no unified plan, forces from all quarters have been slamming on the brakes, throwing hospitals and patients off balance as they react to huge changes.

Lawmakers in Harrisburg, Pa., in an effort to reduce Medicaid expenses, have decided that thousands of able-bodied adults no longer qualify for the state/federal health insurance program for the poor.

And, they decided, those who continued to qualify for Medicaid should join HMOs to save money.

HMO executives, who also wanted to cut costs, had already ruled they wouldn't cover emergency-room treatment for anything less than a true emergency - for poor or rich people.

Long before any of this, lawmakers in Washington decided to protect poor people by making it illegal for emergency rooms to turn them away. At the very least, the staff was required to spend enough time with each case to determine if it was an emergency. The politicians did not require anyone to pay for this.

Episcopal Hospital's Emergency Department is where these decisions come home to roost.

Looking fresh-faced and wide awake for the early hour, Brilliant, an emergency-medicine specialist and the department's director, heads for the nurses' station.

'Do you have insurance?'

Just four years out of residency and still idealistic enough to think money shouldn't matter, Brilliant knows full well many patients won't pay the bill for the care he gives. This day he will head a team of five nurses, a physician assistant and a student physician assistant.

Dr. George Zlupko, the night attending physician, fills him in on the patients still in the ER: a heroin addict suffering from nausea, vomiting and diarrhea; a man who has stepped on a nail; a toddler with breathing problems; a young prisoner who tried to hang himself in jail.

Brilliant goes to the heroin addict, a bony 28-year-old with pale skin and sunken eyes.

The man says he has hepatitis C, a common disease among drug addicts.

The man says he's been trying to get into detox for five days.

"Do you have insurance?" Brilliant asks.

"No. That's the problem."

The man says he has to steal so he can buy street drugs. He's sick, and he doesn't have the energy to do insurance paperwork. Brilliant, a tall, 32-year-old who earned his way through college as a magician, says he can't fill out the forms for the patient. He'll take blood tests to see if the man's hepatitis is flaring up. And he'll call the hospital social worker to arrange drug treatment.

It will be midafternoon when Brilliant learns the man does have active hepatitis and the social worker gets him into an outpatient rehabilitation program.

While Philadelphia has not had a public hospital since Philadelphia General Hospital closed 20 years ago, Episcopal comes close to being one.

More than 80 percent of its patients are covered by Medicaid or Medicare, both of which are being trimmed by cost-conscious politicians.

Only 12 percent have private insurance - a third of the regional average.

Uninsured patients triple

Since the state cut welfare rolls a little more than a year ago, the number of uninsured patients who stayed in the hospital nearly tripled compared with the preceding year, from 147 to 410. The number treated in the Emergency Department and discharged rose 25 percent to 4,273.

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