City clinics' burden spills over to ERs

The Baltimore Sun

A growing number of Baltimore residents are being treated in hospitals for illnesses that could be prevented with routine medical care, a new study has found. The health commissioner says the data show "a fundamental failure" of the city's health system.

City residents are being hospitalized or treated in emergency rooms for such conditions as asthma and high blood pressure at rates that are roughly twice those in surrounding counties and statewide, according to the Rand Corp. study.

Baltimore's health commissioner, Dr. Joshua M. Sharfstein, says the problem is the inevitable result of clinics that are stretched to capacity and a shortage of primary care doctors to serve the poor.

"Our city's hospitals are the envy of the world," Sharfstein said. "But in the shadow of the hospitals, the clinics are overburdened. It's not one or the other, it's got to be both. We want the best hospital in the world, but we also want a better primary care."

The report was commissioned by the city Health Department with funding by Baltimore's Straus Foundation in an effort to determine how reliant city residents have become on hospital care.

Researchers analyzed 2000-2007 hospital discharge data from the Maryland Health Services Cost Review Commission to determine the rate of emergency room visits and hospitalizations for conditions that often can be prevented if people see doctors regularly. They examined the figures by age group, sections of the city and common conditions.

Among the findings: More than 800 children were hospitalized last year for asthma attacks, nearly 1,000 people ages 40 to 64 were admitted for diabetes, and roughly 1,900 people 65 and older were hospitalized with dehydration.

In comparing the figures, researchers were surprised by how high Baltimore's hospitalization rates were compared with those of Washington, which has a similar proportion of low-income residents without health insurance.

For example, last year in Washington, 28 per 1,000 residents were admitted to hospitals for conditions that could have been avoided. In Baltimore, the figure was 42 per 1,000 residents.

Still, the challenges in reforming the primary care system in each city are similar, said Dr. Nicole Lurie, a professor of policy analysis at Rand and one of the study's authors.

"I think the community will to really create a comprehensive system access for underserved populations has been a historic struggle," she said. "One of the things that reports like this we hope will do is shine a light on that and stimulate a community-wide commitment to get there."

Lurie stressed that while the study suggests that a lack of access to primary care is a problem, it does not explain the whole story. Neither does the report indicate what needs to be fixed.

"This is a snapshot of what the problem is," she said. "It doesn't tell us the degree to which [patients] have primary care doctors, the degree to which they can't afford their medicine or whether primary care is available and people feel they are not treated well so they don't go."

Other experts say the study highlights a long-known shortage of primary care options in inner cities. Dr. Leiyu Shi, a professor of health policy at the Johns Hopkins Bloomberg School of Public Health, said community health centers need more funding and doctors must be given financial incentives to treat low-income patients.

Shi said the long-term solution should start in medical schools, by pushing students to become primary care doctors rather than pursuing more lucrative specialties.

"This is something that is repeatedly being observed over the last decade," he said. "And this trend is getting worse now because of the economic recession and the lack of investment in the primary care system of our country."

Sharfstein said he plans to use the study's findings to hold public hearings next year to seek ways to improve access. Reform would not only help keep city residents healthy but would also avoid costly hospitalizations and emergency room visits, he said.

"This shows that the state is spending many millions of dollars each year on hospital care that could be avoided with better access to outpatient services," he said.

For now, busy city emergency rooms are filling gaps in care, said Dr. Kayvan Rafei, head of pediatric emergency medicine at University of Maryland Medical Center, who oversees an emergency department program for children with asthma. The program was launched in 2003 after physicians noticed a surging number of visits from children with asthma, many of whom had never been diagnosed.

Doctors used to treat asthma attacks, then urge parents to follow up with their child's primary care doctor. But the follow-up rarely happened.

"Studies have shown in inner-city populations like what we serve, less than 6 percent of children follow up with a primary care provider within a week of coming to the ER," he said. "We recognized this was a problem and we needed to do things differently."

Now, ER doctors send letters to the children's primary care physicians notifying them of an emergency room visit. Parents are educated on the intricacies of asthma and given a months-long plan on how to help their child manage the condition. And some doctors will prescribe asthma medicine before the family leaves the hospital.

Rafei acknowledges that emergency room doctors have taken on the role of primary care physicians. And while the situation is not ideal, he says, it is grounded in the reality that people seek routine care at hospitals.

They also are flocking to health clinics around the city, many of which are struggling to cope with that demand.

Baltimore Medical System, a nonprofit that operates five health centers in the city and two in Baltimore County, has a staff of 37 primary care doctors to care for roughly 47,000 patients - about 600 of whom visit on a given day, said CEO Jay Wolvovsky.

While the health centers receive federal funding, about 75 percent of the charity care the system provides it pays for on its own, he said. Wolvovsky said next year's budget is tight, and he projects that Baltimore Medical System might only break even.

"The problem for us is expanding capacity," he said. "There are some grants, but there is only so far an organization like ours can expand and stay viable."

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