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ER doctors sue state, say emergency room system near collapse


Emergency room doctors filed a lawsuit today against the state, saying that California’s overstressed emergency healthcare system is on the verge of collapse unless they receive additional funding.

California has seen 85 hospital closures in the last decade. An additional 55 facilities have shut down emergency rooms. The state now ranks last in the country in access to emergency care and is last in emergency rooms per capita with only seven per 1 million people. The national average is 20 emergency rooms per 1 million people.


“Patients are suffering every day,” said Irv Edwards, one of the doctors represented in the lawsuit and president of Emergent Medical Associates, which staffs 12 emergency rooms in Southern California. “There are emergency rooms throughout the state where people, we believe, have died. Some have died in the lobby before they were seen. Some have died shortly after being placed in a bed after having waited in the lobby for hours. Are people truly suffering consequences? Absolutely.”

Emergency room physicians say they have been particularly hard hit by the state’s fiscal problems. Unlike other doctors, who can choose not to accept Medi-Cal patients, emergency rooms cannot deny treatment. They provide care for these patients but are reimbursed at rates they say are half the cost of the treatment. California’s reimbursement rate ranks 43rd in the country, state officials said.

“As we go forward, these emergency room doctors, they can’t any longer take on the financial burden of the state’s obligation to its poor and to its elderly,” said attorney Raymond Boucher, who filed the lawsuit in Los Angeles County Superior Court today.  “This isn’t a joke. This isn’t just a power play. They are on life support.”

Emergency room doctors statewide believe they subsidized more than $100 million in services provided to Medi-Cal patients in 2007 alone, according to the lawsuit.

Tony Cava, a spokesman for the state Department of Health Care Services, declined to comment on the lawsuit until the state has been served with the papers. However, he acknowledged the low reimbursement rate and said more budget cuts may be on the horizon.

A budget proposal calls for cutting an additional $1.1 billion from Medi-Cal by decreasing eligibility and eliminating some optional benefits. Reimbursement rates for doctors also are scheduled to be reduced an additional 1% to 5% on March 1.

Besides overcrowding and threatened quality of care, Edwards said he was also seeing a flight of medical school graduates out of California and a graying of the ranks of emergency room doctors.
“Ever increasingly, I’m hearing the story, ‘I’d love to stay and I love California, but I can’t afford to live here any longer,’ ” Edwards said. “They say, ‘Reimbursement is not competitive with what I’d get in other states, not to mention I can buy a house there for a quarter of the price of a California home.’ ”
Most medical school graduates carry $250,000 to $300,000 in debt and they cannot afford to stay, he said.

“I’m seeing an exodus of providers of emergency medicine and ... a graying of our specialty,” he said. “Fewer and fewer young doctors are wishing to practice in California.”

-- Kimi Yoshino

Photo: Los Angeles Times

Comments () | Archives (67)

My brother is an ER resident and is getting job offers in CA for $350-400K/year (as a brand new doctor). So I ask, how exactly how are these ER doctors hurting??? Compare this to a general internist who is lucky to make $180K/year. If Medi-Cal is decreasing reimbursements then good for them---ER docs are used to making far more than other physicians for comparable training and work. It's about time that things corrected.

At the expense of failure of the State, doctors are not only blamed and sued, but they also lose their sleep, honor, and license, which is far above money.

People only go to an ER if they can't get decent health care elsewhere. It is pretty obvious that universal health insurance is the eventual solution. When the well off have to sit next to the not so lucky, then, maybe we will have the political will to raise taxes to pay for a single payer system. Right from the start a single payer system saves money because it gets rid of all that bureaucratic and HMO redundancy. Maybe taxes won't go up much then.

What's wrong with you guys?

Legalize these immigrants get their employers (which pay them below minimum wage) to pay their health insurance. By the way if these employers had to hire American citizens they'd have to pay there insurance and higher wages, so it is not like the employers don't want them here.

Posted by: ScientistRCool


You are the one with something WRONG with you.

Employers DO NOT HAVE TO provide health insurance (except in Hawaii & Massachusetts.)

Less than 40% of small and medium businesses (those with less than 500 employees) offer any kind of health insurance at all. 62% of companies over 500 employees offer health insurance.

Low wage jobs do NOT come with health insurance. Employers who pay $8, 9 or 10 and hour do NOT ante up $12,000 a year per employee for a family health insurance plan.

The low-skilled, uneducated illegals would be just as uninsured as they are now - except they could enroll in Medicaid and suck off the public teat.

Uhh... yeah lets deport all of the illegal immigrants in this country starting with Christopher Columbus and the pilgrims. That way only indians and mexicans will once again rule the Americas. All white amaricans were once illigal immigrants in this land because nobody wanted them here in the first place.

I have had the privelge of working in the ED trenches for the past 25 years.

It is a mistake and a oversimplification to ascribe blame to the uninsured, illegal aliens or insurance challenged patients as the cause of ED overcrowding, the failure of Medi-cal or the crumbling of our healthcare infrastructure.
In an article published in the Journal of the American Medical Association (JAMA Vol 300 No. 6 Oct 22/29, 2008) commonly held myths regarding Emergency Care, ED overcrowding as well as inapprorpriate use of ED for primary care by uninsured patients, insurance challenged patients and or illegal aliens was definetively refuted and "debunked". It is categorically NOT TRUE!!!

The problem is not any one class of patients. The problem rest soley with the State of California. Guess what - when you watch 85 hospitals and 55 ED close is it any wonder that there is ED overcrowding and diminished access to care? When the State of CA balances it's fiduciary, governmental and moral resposibilities to provide indigent care - a federally mandated responsibility (EMTALA) by forcing ED physicians (who fall under EMTALA rules and regulations) to provide services at a level of reimbursements that no longer covers the cost of providing care - is it a surprise that the Emergency safety net is frayed, torn and broken nearly beyond repair.

There are those who read this that want to simplify this by ascribing the issues to greed among ED physicians, illegal aliens, the burden of the uninsured or other problems for which there is no solution except to shrug one's shoulders. Nothing could be farther from the truth. ED physicians provide care 24/7/365 - every second counts!!

Emergency Physicians must speak out on these issues as it is a moral and ethical responsibility for all of us on behalf of current and future patients seeking Emergency Care.

The public has been lulled into a false sense of security by shows like "ER". I am here to tell you, there is no romantic interlude or laugh track in California Emergency Departments. There is no shortage of seriously ill patients. Call panels are "dwindling". Resources are becoming more scarce. In the case of a catastrophe - natural or man made THERE IS NO SURGE CAPACITY.

This is not about the insured vs the uninsured. Dating to 1986, when EMTALA (Emergency Medical Treatment and Labor Act) was signed into US Federal law, access to healthcare through the ED became a federally guarenteed RIGHT. Yes another un or underfunded mandate. Access to timely, quality and compassionate Emergency Care is a vanishing resource - regardless of financial status or Countyr of origin.

Please - don't over simplify this issue - it affects all of us deeply and profoundly.

Now is the time to act. Now is the time to demand change. Now is the time that we must demand solutions from or elected officials. We have a narrow window to solve thiis crisis. I pray we act responsibly, and together, putting aside partisan differences to solve a GRAVE PUBLIC HEALTH CRISIS

Illegals are the problem! If you do not believe this, you must agree that at least they are not helping. If your a citizen with no insurance, the hospital will pursue you with collectors and ruin your credit until you pay. If your illegal, you give your "matricula" card, give a fake name/address and get free health care. They all know this. Let's no even discuss schools, welfare, health care, etc. Just a joke!

Isn't illegal immigration down in recent months? Also hearing that a lot of illegals have been moving back south of the border. These problems with state budgets and social spending and layoffs are happening all over the country. LA and southern Cal are just symptoms of these problems. The continued shedding of jobs will contribute to the strain on public health resources, unemployment resources and the like. California ain't the only state in a budget crisis. The blame on illegals is beyond pointless. The problem is bigger than even that... It's amazing what some people will see when they want to.

Yes, let's blame the foreigners, the poor folks, and everyone else for California's problems. But then Arnold Schwarzenegger vetoed a widely supported bill funding ER care. He didn't want hospitals to get repaid from auto accident insurance monies. Thank you, Arnie!!

It's so easy to say mexicans, and people from all over the world who came to US are the reason of our problems, hey look at our Mayor!! he is not a native American! This a Federal Crisis!!!! a failure in our policies...

Where is the $84 per year homeowner surcharge going that was designated to keep ER care available in Los Angeles County? Many ERs have closed down since the bill was passed, but we still are charged.


I'm an ED physician for 5 years. I have not heard of any jobs paying that much in Southern Cal, let alone to new docs. You can make those types of salaries after having partnered in a group, or if you run a group and make money off of everyone else, like Irv Edwards. Take your brother's numbers with a grain of salt.

-ed md

The anti-immigrant tone in this discussion board is eerily reminiscent of the time leading up to Kristallnacht in Nazi Germany (c. 1938.) I just dread the day when California nativist start pulling Hispanic-complexion individuals/ familiies from their homes and workplaces, and start beating them on the streets. I am a student of history, and this is not farfetched!

Now, for the record:

Approximately 60% of the federal budget (or some $1.6 trillion last year) is reserved for entitlements (social security, medicare, medicaid, etc.) -- not a single penny of which is reserved for illegal immigrants, even though many of them will have paid into this through payroll withholdings. If you are really concerned about what is breaking government budgets (and raising our national debt to catastrophic levels) your sick, hospital-ridden, native-born granny is more likely to be contributing to this problem than the typical illegal immigrant. If economics is the key motivation for your anger, then direct it to the appropriate demographic -- old, native-born retirees on social security and medicare. However, if your motivation is raw xenophobia, then I'm afraid nothing short of Kristallnacht, or heaven-forbid a Himmler-esque "final solution" will satisfy your anger.

way to go dems! this is the legilature that has been running this state, they are incapable of managing our money yet we pay nealy the most in all taxes in the country. there is no justifing this in any way. yes, and part of it is illegals, but it is more than that too. its just a complete missmanagment. but looking at who people vote for, the problem will never go away, so basically we should just accept this as a change for the future and pay as much tax as we can untill we lose our jobs. people need to just accept this b/c they will never take a look at who they keep electing over and over and who makes up our legilature here in california. what gets me is so called, "educated people" are the most dumb when it comes to this, they are more interested in putting provoktive leftist bumper stickers on their suvs.

ScientistRCool: "if these employers had to hire American citizens they'd have to pay there insurance and higher wages, so it is not like the employers don't want them here." // Guess again. There is no law that mandates employers provide healthcare or anything above minimum wage (which isn't enough to cover non-group healthcare premiums).

Illegal immigration is not the issue here. Sure, people without health insurance contribute to the problem of overcrowding. But, would you as a doctor refuse to treat any child with a entirely curable condition (take a 4 year old girl with an acute asthmatic attack) and potentially save her life because her parents cannot pay you for the simple treatment? I doubt many people would be so heartless.

The real problem in the emergency department is patients seeking non-emergency medical care. EMTALA essentially says that no one can be refused care, regardless of their illness. At the same time, it does nothing in the way of guaranteeing any sort of reimbursement, Furthermore, physicians are so afraid of being sued they will order a complete workup on anyone just to limit the possibility of being sued. Given past court cases I don't blame them.

Take it a step further to the 911 system. Paramedics/EMT's routinely take patients into the ER for non-emergent conditions ( See - "G-tube pulled" "I ran out of pain medication'). Unfortunately, ambulances often become glorified tax-cabs with a fast pass into the ER.

The system is a joke.

Re: Rebbecca - A quick Google, AMA or any other search will quickly reveal the starting salary is nowhere near the figures you have quoted. I'm not sure where you get your numbers but I've worked with Attending Physicians at Trauma I centers who aren't making that much in California.

But, I digress. Is salary really the issue here? Personally, the real issue is whether or not when my mother has a stroke she can be treated quickly and effectively. Whether she will receive the treatment to save her life , or die because of an unsupported, overcrowded, over regulated and ineffective system.

If all of America's illegal immigrants were granted citizenship, and every citizen in America had universal healthcare, this wouldn't be a problem.

You racist tools.

Wait a minute. First you guys say it can involve a wait of 6 hours or more to see a doctor at the ER, then you tell me there are hordes of people who are there just because it is more convenient. (More convenient than what? Than jumping off a bridge?)

Obviously no one in their senses goes to an ER unless (a) it really is an emergency, and/or (b) they really don't have any other alternatives.

Before we all conclude that the problem is all the "illegals" I'd like to see some numbers. It's easy to say all that, but it might not be true. Prove it.

Remember, there are lots of citizens here who don't speak English either, so you can't judge by what language people speak. I spend a month every year (legally) in the Netherlands and I don't speak Dutch. Does that mean they ought to take me out and shoot me?

If we wish to take the burden off emergency rooms we will need (1) medical / medicare co-pay, and we should reduce the burden of competition by allowing any pharmacy to employee on-site licensed health-care providers. We should eliminate the need for doctor's prescriptions except for drugs which are likely to be abused. Of course, in order to achieve any of this, in the words of William Shakespeare, first we kill all the lawyers.

My friend is an ER doc and agrees that the illegal aliens are a major problem.
Everyone is afraid to say it for fear of being called racist. The LA times will never write a good story on this.

People who aren't here legally should have to pay for what they get. period.

the immigrant bashing won't get you anywhere. having undocumented immigrants here (from all over) increases the bottom line for corporate america, always seeking to increase that dividend for shareholders. i'm a capitalist in many ways, and if i'm willing to pay someone measley wages in order to increase my profit in the short term, someone else will pay in the long term. look at wal-mart - training their employees on how to gain public assistance benefits - instead of taking money from the billions in profits to help pay for their health insurance. if undocumented immigrants, an esitmated 12 million in the u.s., spend an average of $10 per week on you name it, how much do you believe they (we) are contributing to this economy?

Doctors are not supposed to ask for visas or citizenship papers. They are there to help people and save lives. California's population has grown and ER's have closed leaving a huge service gap. Raymond Boucher is one of the finest, brightest lawyers and this is a public interest court case. We need to solve this problem collectively as a society. The California legislature has unfairly ignored and demoted this issue and shirked their obligation to keep public safety and health as a true core mission of government. We should all understand that this is not a court case about personal profit or greed, but a case of great social importance to all Californians.

When you have Medical you think your medical care is "free" because you never pay aything and never get a bill. The ranks of those on medicaid are exploding because it is human nature that if something is "free" you are going to try to get some of it. Couple that with a society of winers who believes they should be taken care of and a governemnt/media complex unwilling to step up and say enough is enough...well, you see what we get. We are becoming a socialist country and there is no way to stop it. THose comments advocating universal coverage are advocating medicaid for all.....GREAT.

The people commenting here, and calling those that bring up the logical point that, since there is a huge population that 1. pays absolutely NOTHING for the services provided by the state and hospitals because they are ILLEGAL, and 2. that those people, on average, take MORE advantage of those service than tax-paying, LAW-ABIDING citizens, are truly the racist ones.

You are trying to pretend their is not probelm with illegals, simply becuase of their race. That is racial differentiation (treating people different due simply to their race). THAT is racist.

Living on Modesto (farm country), when there are 10 hour waiting times in the ER's ONLY DURING PICKING SEASON, it is not too hard to see the problem. Also, when hospitals have to hire bilingual staff, simply because, during the picking season, once again, the large majority of the non-paying, mooching "customers" cannot even understand basic English, then the real problem is pretty difficult to ignore. So, don't try and pretend the BILLIONS billions being stolen from our tax-paying citizenry, simply to pay for illegals that do not pull their weight. It is both insults the intelligence of any thinking person that has done their homework and understands this issue, and makes you look like a fool, and probably someone that is making money off those illegals, one way or the other.

I have worked as an emergency physician for 17 years. Here is the problem: EMTALA, a federal mandated law requiring all hospitals to provide an emergency medical screen to all patients, is not funded by the federal govt. What business in American is required to provide a service by law without being reimbursed for their services? Also, comparing the internist and emergency physician compensation is not comparing apples to apples. There jobs are not even close. The best way to compare compensation between these two professionals is reimbursement per patient. This would shed light on what is fair and not fair. The typical ER doc in this country performs half of their work at night, on weekends and holidays. The ER never sleeps.

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