April 3, 2009

Hospital to revisit ER changes amid controversies

Public backlash surrounding the University of Chicago Medical Center emergency room policies and standards of care have escalated in the last two weeks as the Center announced it will reevaluate its plans to reorganize the emergency room, and an unrelated February incident in the ER could jeopardize its ability to serve Medicare patients.

In a memo to faculty and residents last month, President Robert Zimmer announced plans to create a committee to revisit the ER’s policies, which include transferring patients in less urgent condition to other area facilities. Everett Vokes, the newly appointed chair of the medical department, will head the committee and coordinate any shifts in policy.

“Faculty in the Department of Medicine, under the leadership of new chair Dr. Everett Vokes, have been asked specifically to review and refine plans related to changes in the operation of the Emergency Department and the planned reduction of beds in general medicine and in intensive care. As a result of this review, it is likely that the proposed changes will occur in phases and implementation of some changes—though not all—will be delayed slightly,” said University spokeswoman Julie Peterson in an e-mail interview.

Hospital spokesman John Easton has said that early plans to cut 10 of the 31 ER beds have also been shelved.

Discussions about potential reorganization of the emergency room began in the fall, but they took on new importance as the Medical Center faced $100 million in budget cuts this winter, according to Easton.

“So many different but interrelated things were changing so rapidly. The economic downturn forced people to accelerate the pace of change,” he said. But Easton said that Zimmer’s announcement developed out of “a belief that maybe we should slow down and reevaluate.”

The financial constraints are hard to ignore. Compared to peer institutions, the Medical Center relies heavily on Medicaid payments, which Illinois has been slow to provide. This has left it without a “cushion” to fall back on in hard times, according to Willard Manning, a professor in the Harris School of Public Policy and the Biological Sciences Division, who focuses on health economics.

Two national physicians’ organizations publicly criticized the Medical Center’s policy of diverting patients from the emergency room to other area facilities. The American College of Emergency Physicians compared the policy to the illegal practice of “patient dumping,” and expressed concern that the hospital was attempting to jettison its least profitable patients in order to focus on profitable specialty care. A group of nearly 200 faculty members and residents signed a letter to the administration criticizing the policy.

But hospital administrators contend that in addition to cutting costs, the plan will increase community access to healthcare and streamline the ER by encouraging patients to find a more appropriate “medical home” for primary care and non-urgent concerns. According to the Medical Center’s website, about one-third of the patients visiting the ER do so instead of seeing a primary care physician. These visits are costly and contribute to long wait times for urgent cases.

It is not only patients who might be denied care at the Medical Center who have raised concerns. Federal authorities investigated the death of a patient in the emergency waiting area, and subsequently threatened to revoke the Center’s Medicare certification.

On February 3, a 78-year old patient died in the ER waiting area, having waited there for hours without receiving a medical examination or even being checked in.

After receiving a complaint, the Centers for Medicare and Medicaid launched an investigation. An unannounced survey conducted by the Illinois Department of Public Health on February 18 determined that the hospital failed to maintain a central emergency services log, and cited the hospital for failure to provide medical examinations. The inspectors also found additional deficiencies in medical record services and emergency services, according to Medicare spokeswoman Cinthia Michel.

Medical Center Chief Operating Officer Carolyn Wilson said that the incident was not the result of the ER’s organization, but with the way employees followed protocol. “Our ER, like all big-city emergency rooms, is crowded, but proper policies and procedures were in place and staff members may not have followed them,” Wilson said. “Appropriate disciplinary actions are being taken.”

Medicare authorities are currently reviewing a plan of correction, a process that could take a few weeks or longer. The review will be followed by another unannounced inspection.

Wilson said that the Center’s proposed corrections are “robust,” and should be more than sufficient to maintain Medicare Certification.

Losing the Medicare Certification would be highly costly, as over 35 percent of the hospital’s payments come from Medicare. Manning said that while it is not uncommon for hospitals to be cited or inspected by federal authorities, it is unlikely that the hospital would allow the loss of its Medicare certification.

“The consequences are relatively severe—we would lose a lot of money. Clearly the university can’t afford to do that. Very few institutions walk away from Medicare,” Manning said.