Limited Access to Primary Care Could Be Crowding Maryland’s Emergency Rooms

Donna Wiltrout, 42, had to be at work by 5 a.m. on a recent Tuesday. But at a few minutes to 11 p.m. Monday, she was sitting on a bed in the hallway of Frederick Memorial Hospital waiting to be seen by a doctor.

“There’s no way I’m going to make it,” she said.

Wiltrout, a school bus driver, said she had driven 20 minutes from her home in Thurmont to Frederick Memorial Tuesday evening with shortness of breath and increasingly severe chest pains.

A few months ago, she sat in the same hallway spot with the same symptoms, she said, but had to leave because the wait had gotten too long — more than five hours.

Wiltrout said she visits her family doctor every three to six months, but she didn’t have a scheduled appointment in the time from her last hospital visit and wasn’t able to add one.

But that Monday, she said, her symptoms were worse.

With a mostly empty waiting room and few ambulance arrivals, she had been waiting for about three hours.

“You have to be dying to be seen here,” she said. “I’m a single mom of two. I can’t be sitting here waiting forever.”

Hospitals are required by federal statute to offer care to anyone who enters their emergency rooms — even if that means beds have to be out in the hallway, in the corner, by the bathroom.

And they’re feeling the pinch. Emergency departments in Maryland are increasingly requesting that EMTs divert their patients in ambulances to other hospitals.

From 2013 to 2014, the number of yellow and red alerts — issued by Maryland hospitals when their emergency departments were overcrowded or when there were no monitored beds available, respectively — increased by 34 percent, according to data maintained by the Maryland Institute for Emergency Medical Services Systems, or MIEMSS, County Hospital Alert Tracking System, a real-time, computerized system that monitors the status of hospitals and EMS systems throughout the state.

John Donohue, chief of field operations for MIEMSS, an independent state agency, said the first thing he does every morning is review diversions or alerts that were recently issued.

“The guidelines given to hospitals on when to issue these alerts are very soft. You can’t tell a hospital when they’re busy and not busy,” he said. “These alerts are a method for us to help hospitals ensure that each patient is cared for better or at least receives care more quickly.”

According to data from the MIEMSS alert tracking system, hospitals in more densely populated areas send yellow or red alerts more often than those in rural areas.

Sinai Hospital of Baltimore sent an average of 251 yellow and red alerts each year from 2010 to 2014, while the average for all hospitals in the state was 66 alerts annually. Queenstown Emergency Center, on the Eastern Shore near Kent Island, however, averaged just over one alert per year.

But the overcrowding is beginning to spill beyond city lines.

Northwest Hospital in Randallstown falls within 20 miles of Baltimore’s city center, which, according to MIEMSS guidelines, is an acceptable distance for EMS diversions.

With 339 alerts, Northwest Hospital had the most in 2014 — almost 50 more than second-place Sinai. Northwest is on a similar track for 2015, with 87 alerts in the first three months of the year.

Sarah Liebovitz, an EMT with Branchville Volunteer Fire Company in College Park, said she knows to check the board that shows all of the hospitals that are on alert before she responds to a call.

But she has had to wait with her ambulance and EMT team at emergency department doors for up to two hours before leaving to respond to another call due to a back-up in the hospital’s emergency department, she said. Depending on their condition, the patient could be taken inside to be treated or remain in the ambulance with them while they wait, she said.

Alert rates are consistently higher in the winter months, something that Donohue said is most likely due to the flu, or winter cold season.

According to the Centers for Disease Control and Prevention, the flu vaccination offered reduced protection this season. The number of alerts from the first three months of 2015 is already greater than the number of alerts for the first half of 2014 in 11 hospitals in the state.

But no one that shows up at the emergency room’s door is turned away, Donohue said, and “priority one patients” — those facing a life-threatening condition — are never diverted.

“Sometimes there’s literally no space to see patients. What do we do? We take care of the patient. We move people around, we prioritize and we just take care of the patient,” said Dr. Joneigh Khaldun, an emergency room physician in Baltimore. “You do the best that you can, but you can imagine how it affects the quality of care. It’s not safe for the patients.”

Khaldun said that most of the patients she sees in the emergency room are there for legitimate reasons. Even stomach pain could be a symptom of appendicitis and merits an emergency room visit, she said.

But Gene Ransom, chief executive officer of MedChi, the Maryland State Medical Society, said that patients considering a trip to the emergency room should think about going to an urgent care facility instead.

“It is important for folks to remember that there are options,” he said. “But there has been an increasing number of folks having trouble finding a primary care physician or forming a relationship with their primary care physician.”

This lack of access to primary care is worrying to Maryland Delegate Dr. Clarence Lam, D-Howard and Baltimore Counties, a physician in preventative medicine at the Johns Hopkins Bloomberg School of Public Health.

“Chronic illnesses — like diabetes and heart disease — oftentimes go undiagnosed and undertreated because patients have a difficult time getting to primary care physicians,” said Lam. “(Chronic illnesses) are probably the best kind to be treated in a primary care setting, but they end up squeezing out people in the emergency room who really have emergencies.”

The emergency room is often the first point of entry for new patients, he said, like those with chronic illnesses who forget to take their medications or couldn’t get an appointment with a primary care physician to get a refill.

Also, because of how the medical school system is structured, there are more doctors applying than there are resources to train them, leading to a long-standing shortage of physicians and other healthcare providers, Lam said.

Khaldun, who served as an emergency room physician in New York before coming to Maryland, said the emergency departments in Brooklyn faced the same challenges with overcrowding as those in Baltimore.

But the Maryland health care system is unique.

In other states, doctors and hospitals are reimbursed at the lowest rate for Medicaid patients. Hospitals in Maryland, however, are reimbursed at the same rate for all patients, thanks to the state’s Medicaid waiver.

The waiver is set to expire this year.

State legislators have ensured that funding to maintain the waiver and continue reimbursing doctors serving Medicaid patients at the same rate as doctors serving privately insured individuals is available in the fiscal year 2016 budget, but it is up to Gov. Larry Hogan to determine whether to spend the funds for that purpose.

A study by the New England Journal of Medicine published in January found that increases in Medicaid reimbursements offered to doctors in 2013 and 2014 increased the availability of primary care appointments to Medicaid patients in the 10 states studied. The same increase did not occur for privately insured individuals.

Hospitals in Maryland have been working to develop programs that integrate health care into the community, an important element of the Affordable Care Act, which was signed into law by President Barack Obama in 2010.

Carroll Hospital Center, in rural Westminster, alerted EMTs that they were reaching capacity 25 times in 2014. While far below the state average, that number increased dramatically from the four alerts it issued during all of 2013.

Carroll Hospital Center does not have other hospitals nearby to help when their emergency department gets crowded, said Stephanie Reid, chief nursing officer and vice president of quality. Instead, she said, they have developed a team dedicated to population health clinical integration, programs that are focused on promoting wellness in the communities surrounding the hospital.

“Healthcare now isn’t just in the walls of the hospital, it’s much more out in the community,” said Reid. “All clinical integration efforts aim to keep patients well and help them from being readmitted. I’m sure the patients want that as well.”

Integration programs are about partnership: nurse navigators working with patients after discharge to make lifestyle changes at home; primary care physicians leaving a few appointment times open each day to allow for last-minute appointments; or schools promoting general health and wellness, she said.

The Maryland Community Health Resources Commission was founded in 2005 to expand access to health care services for uninsured and low-income individuals through partnerships among community health resources and hospitals.

This mission has become increasingly relevant in recent years and grants are awarded to programs that are expected to help achieve this goal, including those that expand access to primary care for underserved populations and those that successfully divert individuals from emergency departments to more appropriate care.

Since its inception, the state’s Community Health Resources Commission — an independent state agency with members appointed by the governor — has awarded 143 grants totaling $49.6 million. In 2012, the Maryland General Assembly voted to ensure a budget of no less than $8 million for the commission each fiscal year, and with Hogan’s approval, the commission will be fully funded in fiscal year 2016.

In 2013, $200,000 was awarded to Anne Arundel Health Systems to establish a new medical care center in the Morris H. Blum Senior Apartment Complex in Annapolis, housing for low-income senior citizens.

“The emergency department analyzed their data and isolated emergency department admissions and 911 calls from (the senior apartment complex). They found it was a hotspot,” said Mark Luckner, executive director of the Community Health Resources Commission. “These patients are dual eligible — Medicaid and Medicare — and it made sense to literally bring the medical care to their doorstep.”

The health center has been open in the senior apartment complex for about a year and a half and relationships between the doctors and residents have been formed, helping to reduce emergency department admissions, he said.

Khaldun said that many hospitals have one individual dedicated to assessing bed turnover. While this may improve efficiency, the emergency room will always be an unpredictable place, she said.

“If we get more primary care doctors, it’s not that we won’t need emergency rooms any more,” said Khaldun. “We just need to change the paradigm.”

Back at Frederick Memorial, Wiltrout was checked into a room after about four hours of waiting in the hallway. She said she plans to continue seeing her family doctor on a regular basis and hopes this is the last time she’ll have to see the inside of a hospital’s emergency room.

By Deidre McPhillips