State moves to reduce use of ERs

Massachusetts officials will give $4 million this year to community health centers in a new effort to steer patients with routine illnesses away from crowded hospital emergency rooms.

Twenty-one health centers in Boston and 11 other cities will use the money to open on additional nights and on weekends and pay for education campaigns to encourage patients to seek care at health centers rather than emergency rooms, for the flu, fever, sprains, backaches, nausea, rashes, cuts, and minor broken bones.

The health centers also will expand capacity during regular hours, because data show that some patients go to the ER even when health centers are open.

"We need to give people better access to primary care," said Amy Lischko, the state's commissioner of health care finance and policy. She said unnecessary emergency room treatment contributes to high health care costs and long waits, and doesn't provide patients with coordinated care from a doctor who knows their history.

Former governor Mitt Romney's administration approved the new program last fall, and the administration of Governor Deval Patrick has embraced it.

But interviews with patients suggest that some with minor problems might still go to emergency rooms. Moreover, many emergency room physicians said the initiative doesn't address the most pressing problem: back ups of seriously ill patients who need to be admitted to the hospital.

The sickest patients can wait hours -- even a day or longer -- on gurneys in the emergency room, a situation caused in part by the elimination of nearly 40 percent of the state's hospital beds in the last two decades.

Hospitals are taking other measures to attack this problem, such as discharging patients from rooms more quickly to free up beds. And several legislators have filed bills that would require public health officials to establish guidelines for how long patients should have to wait in the emergency room for a bed, and to track hospital performance.

"People with minor problems are easy to take care of; they're quick and uncomplicated and are not high-resource users," said Dr. Ron Walls, chairman of Brigham and Women's Hospital's emergency department. Redirecting patients with routine problems to community health centers, he said, will shorten their waits, but may not provide relief for sicker patients.

Doctors also disagree about whether the initiative will reduce costs.

A new state report said that the average charge for an emergency room visit that could be handled by a primary care doctor was $976 in fiscal 2005. That compares with $200 to $300 at a health center. (Both hospitals and health centers significantly reduce these charges when they negotiate with insurers.) But some studies have shown that it may be cheaper overall to treat patients with minor problems in emergency rooms, which have to stay open anyway, than to pay for a large-scale expansion of primary care services.

About 40 percent of visits to Massachusetts emergency rooms in fiscal 2005 were for non emergency conditions or emergencies that could have been treated by a primary care doctor, such as a baby with a 102-degree fever, according to the new report from the Executive Office of Health and Human Services.

The state's figures do not include patients who are admitted to the hospital after arriving at the emergency room, however. If these very sick patients are included, ER doctors estimate that about 20 or 25 percent of all patients who go to the emergency room could be treated instead in a doctors' office or health center.

Massachusetts and other states have been grappling with long emergency room waits for at least a decade. Little is known about how states compare with each other, but one study of 12 communities indicates that Boston residents use the emergency room more often than average. In 2003, there were 36 ER visits for every 100 Bostonians, compared with about 32 visits for every 100 US residents, according to the Center for Studying Health System Change, a research organization in Washington, D.C. The reasons for Boston's higher rate are unclear, but many doctors say it's the consequence of a shortage of primary care physicians.

The state's health centers, which care for about 700,000 Massachusetts residents, also are increasingly stretched. And that situation may worsen as the new law requiring all residents to have health insurance goes into effect this year.

Walls said he often asks patients with minor problems why they came to the emergency room, despite the long waits, and they "usually have a good reason," he said.

Interviews with patients in the overflowing Brigham emergency department one night last week suggest that community health centers will face major challenges in changing behavior because of the complex array of reasons that lead patients to the hospital.

At 6:15 p.m., 19 people filled the waiting room; all 44 treatment "bays" were full, and eight of the sickest patients lay on gurneys in a corridor, stuck in limbo until hospital rooms opened up. Nurse Jean Hickey, the care facilitator that night, said that up to one-third of these 71 patients appeared to have relatively minor problems that might be treatable elsewhere.

Matilde Fernandez, for example, woke up with a sharp pain in her stomach. At 8:30 a.m., she had called the Brookside Community Health Center in Jamaica Plain, but her doctor, who was working a half-day, was booked. The health center offered her an appointment with another doctor, but she decided to go to the emergency room because she thought she'd need an ultrasound and other tests that the health center does not provide. "They'd have to send her somewhere for another appointment to diagnose her," said Fernandez's son, Daniel, 15.

So, they drove to the Brigham at about 1 p.m., and at 7, Fernandez, 39, still lay in an emergency room bed waiting for the results of a blood test. She said it was worth the wait to have all the tests done at once in one place.

Some insurers also place fewer restrictions on the ordering of expensive tests in the emergency room than they do in doctors' offices.

Walls said he hears the one-stop-shopping rationale from many patients. "If they need an X-ray, they'll get it, they'll get whatever they need," he said. "And they know they will have the answer when they walk out."

It may be challenging for health centers that don't offer radiology and extensive lab services to attract these patients. But at least one, the Whittier Street Health Center in Roxbury, plans to increase its array of onsite lab tests and will expand the hours radiologists interpret X-rays from 25 to 67 a week.

These changes, as well as staying open weeknights until 9 and all day Saturday, and adding more staff members, will allow the center to start providing care for low-level traumas such as cuts that require stitches and casts for minor broken bones, said center president Frederica Williams.

An analysis of Brigham emergency room visits in fiscal 2006, she said, showed that 3,000 were by Roxbury residents with minor complaints. "That doesn't even include people going for urgent care," Williams said. "So there's a lot of potential."

Neighborhood Health Plan, which is overseeing the state grants to health centers and will track results, said that about 40 percent of emergency department visits by its members are for non-emergencies.

Back at the Brigham ER, another patient, Charmaine Roberts, had arrived at 5 p.m. with a "shocking, needle-like" pain in her side. Roberts was worried about an ectopic pregnancy, which can be dangerous if allowed to develop. Roberts, whose family is uninsured, said she never considered going to a community health center because she assumed that she'd have to pay up front and that she wouldn't be seen unless she had a regular doctor.

Community health centers usually charge low-income uninsured patients small fees to see a doctor. Getting the message out to patients that treatment in a health center won't cost them a lot will be a challenge, as will countering the belief that hospital care is higher quality.

Some health centers have waged marketing campaigns while expanding hours in the past, efforts that have yielded limited success. So several are refining their strategies this time. HealthFirst Family Care Center in Fall River, for example, recently hired a case worker who will get reports from nearby hospitals after health center patients show up in the emergency room with minor problems, and then meet with or call these patients.

Liz Kowalczyk can be reached at kowalczyk@globe.com.