Emergency room visits soar in Sonoma County under Obamacare

June 25--Hospital emergency departments in Sonoma County are seeing a dramatic surge in Medi-Cal patients, the result of a provision in former President Barack Obama's landmark health care law that greatly expanded coverage for tens of thousands of poor local residents.

New state data shows Medi-Cal patients made 150 visits each day to area emergency rooms last year, up from 90 visits a day in 2013, the year before the Affordable Care Act lowered eligibility requirements for California's insurance program for low-income residents.

The 67-percent jump in ER visits by Medi-Cal patients over the past three years is troubling to medical professionals because historically a large share of ER visits are for nonemergency medical conditions, such as coughs, headaches, back pain and the flu. More nonemergency patients in the ER means longer waits for those who suffer a real emergency, said Dr. Omar Ferrari, chairman of Memorial Hospital's emergency department.

"There's a serious disconnect between what society believes the function of the emergency department should be and what a large subset of our patients actually use it for," Ferrari said.

A visit to the nearest ER is also much more costly than seeking care at an urgent care center. One often cited study, funded in 2013 by the National Institutes of Health, put the average cost of an ER visit at $1,233.

In contrast, the cost of a visit to one of St. Joseph Health's local urgent care centers is $50, while the new Sutter Health-affiliated walk-in clinic in Petaluma charges uninsured patients a $129 "all-inclusive" fee for each office visit.

Whether it's leading to emergency department overcrowding or adding to the overall cost of health care, medical professionals say the overuse of emergency departments affects everyone.

But county and state officials say aggressive measures taken to beef up the local primary care network and divert Medi-Cal patients toward less expensive modes of treatment are succeeding. In fact, they say, the rate of ER visits per Medi-Cal patient has actually declined after an initial spike the year Obamacare expanded public insurance for the working poor.

Overall, Medi-Cal patients made 54,873 visits to local emergency rooms last year, up from 32,792 in 2013, according to data from the Office of Statewide Health Planning and Development.

Memorial Hospital has borne the brunt of the influx. Last year, the Santa Rosa hospital's emergency department logged 16,921 visits from Medi-Cal patients -- or 46 visits a day -- up from 7,461 visits in 2013, according to state data. The number of emergency visits from uninsured patients remained virtually unchanged at about 4,000 during that period.

Ferrari said there have always been patients who use the emergency department "inappropriately" for conditions that could be treated in an urgent care or primary care setting. But he said there has been a significant uptick in recent years.

Countywide, emergency department visits by patients with private insurance and Medicare also increased between 2014 and 2016, but not nearly as significantly as it did for Medi-Cal patients.

Last year, Medi-Cal patients made 34 percent of all emergency room visits in Sonoma County, up from a quarter of ER visits in 2013. The increase was even sharper at Memorial Hospital, where emergency visits by Medi-Cal patients jumped from 26 percent of all ER visits to 45 percent during the three-year period.

Ferrari said emergency doctors, nurses and other staff pay no attention to a patient's type of insurance -- they must care for anyone brought in, whether they walk through the doors or are brought in by ambulance on a gurney.

But Ferrari said such significant spikes in usage are a serious problem for everyone who relies on emergency beds, which he views as a "precious resource."

"The emergence of emergency department 'superusers' and people using the emergency department for minor complaints puts that resource at risk," he said.

Hospital officials said many of the newly insured under Obamacare are still not connected with a "medical home."

"We work on several fronts to get these individuals connected with a physician for their care needs and to encourage preventive care," said Memorial Hospital spokeswoman Vanessa DeGier.

Jan Shea, a spokeswoman for the California Hospital Association, said there was no significant increase in physicians willing to see Medi-Cal patients following the expansion of Medi-Cal eligibility.

"It is our belief that many newly enrolled Medi-Cal patients are continuing to seek care in (hospital emergency departments) because they cannot access primary care in physician offices and clinics," she said.

One of the key components of Obamacare was a significant expansion in eligibility for Medicaid. That expansion pulled 5 million people into the state's Medi-Cal program between 2013 and 2016, swelling enrollment to 13.5 million people, according to the state Department of Health Care Services.

That increase is the primary cause of the surge in emergency room visits, department spokesman Anthony Cava said.

While the overall number of emergency visits by Medi-Cal patients has increased sharply, the frequency of use -- measured as the rate of visits per 1,000 Medi-Cal patients -- increased only 7 percent from 2012 to 2016, Cava said. In contrast, the number of Medi-Cal beneficiaries jumped 78 percent during that same period, he said.

He said state data also shows a dramatic decrease in the number of uninsured patients using emergency departments.

"Many of those previously uninsured are now covered by Medi-Cal, which ultimately reduces the devastating financial burden on those least able to afford such care," Cava said in an email.

In the long run, county and state health care officials said they hope unnecessary emergency room usage declines over time. The expansion of primary care offerings, particularly at local health centers, will be a key to making that trend a reality.

Cava said the state is working closely with managed care plans that administer Medi-Cal coverage, such as Partnership HealthPlan of California, on initiatives to reduce emergency department visits. These managed health care plans cover nearly 10.8 million Medi-Cal members across the state.

Initiatives include assigning all managed care enrollees to a primary care provider, such as a community health center, with an emphasis on getting new members to access preventative care. Managed care plans are also required to provide an initial health assessment for all new members, a step designed to establish a personal relationship between medical providers and their patients.

Cava said the long-term benefits of such managed care programs should reduce visits to emergency rooms, when appropriate.

The network of local community clinics, which is where most Medi-Cal patients in the county receive their primary care, underwent significant expansion in the lead-up to the expansion of Medi-Cal under Obamacare. New clinics were built and old ones expanded. Physicians, dentists and nurse practitioners were hired.

The increase in primary care offerings by local clinics helped to reduce wait times for initial visits for new members, but more is needed, said Pedro Toledo, chief administrative officer at Petaluma Health Center.

"What we've experienced in Sonoma County is tens of thousands of people with new coverage and the primary care sector trying to expand to meet that need," Toledo said.

That effort includes building more primary care and urgent care facilities, as well as hiring more primary care physicians, nurse practitioners and physician assistants.

Petaluma Health Center is preparing to build a walk-in urgent care center in 8,000 square feet of space at its medical complex on North McDowell Boulevard. Sutter Health recently opened a walk-in clinic in Petaluma's Deer Creek Village and St. Joseph Medical Group has been increasing its offering of after-hours and walk-in clinics.

Meanwhile, Santa Rosa Community Health Centers is expected to open a $10 million health center, its ninth clinic, at 1300 N. Dutton Ave. by December.

"We know that prevention is way less expensive than emergency room costs," said Barbie Robinson, director of the county health services department. "We hope (for) and want to continue to see a reduction in emergency department visits."

Partnership HealthPlan, the managed care plan that administers care for local Medi-Cal users, has invested close to $4 million in recruiting 147 primary care doctors, nurse practitioners and medical assistants, said Amy Turnipseed, director of policy and program development. The Fairfield-based health plan serves about 560,000 members in 14 Northern California counties, including Sonoma, Mendocino, Lake, Marin, Solano, Yolo, Lassen and Humboldt counties.

About 37 of the 147 providers were hired in Sonoma County alone, Turnipseed said.

Key to providing effective health care, she said, is educating members on the most appropriate use of the local health care system.

"There isn't a single solution to reducing the emergency room utilization," she said. "It requires strong collaboration with our community partners."

One patient seen earlier this month at Memorial Hospital's emergency room embodies the challenge facing health care providers.

The patient, who is covered by Medi-Cal, came to the ER complaining of abdominal pain. It was his 22nd visit to the emergency department, where he has logged 18 CT scans and is given serial abdominal exams every time he comes in. Ferrari said the patient should probably be going to a regular doctor's office instead of the ER.

"He sat in a bed for three hours," Ferrari said. "That's time that somebody's sick kid couldn't get in, and the waits are going up and up and up."

You can reach Staff Writer Martin Espinoza at 707-521-5213 or martin.espinoza@pressdemocrat.com. On Twitter @renofish.

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