Kaiser Permanente filed plans Nov. 20 to expand the emergency department at its South Sacramento hospital, and if you’re looking for a reason why, consider that the number of Medi-Cal enrollees who sought care there more than doubled between 2012 and 2017.
Medi-Cal beneficiaries made up nearly 41 percent of total ED patients seen at Kaiser South Sacramento last year, compared with 27.4 percent in 2012, according to data from the state of California. During the same period there, the number of patients with private insurance coverage dropped to roughly 29 percent of the patient load from 39 percent.
California expanded eligibility for Medi-Cal coverage as part of the Affordable Care Act, and 3.8 million new enrollees have gained health insurance as a result. But emergency service departments around the state are seeing their capacity strained as they try to accommodate a huge influx of patients even as the number of opioid overdose cases have exploded, said Brian Jensen, a regional vice president at the Hospital Council of Northern and Central California.
“There is an increasing use of the emergency departments, since the implementation of the Affordable Care Act,” Jensen said. People “are accessing ERs who previously did not do so unless it was really, really life-threatening. ... It’s ironic because part of the ACA’s objective was getting people centered in receiving primary care in a physician’s office, in a clinic, in some kind of lower-acuity facility, which brings about less cost to the individual and to the system.”
Jensen said he wasn’t surprised to learn that Kaiser is expanding the ER in South Sacramento. The nonprofit hospital company has applied with the city of Sacramento to build a one-story, 41,525-square-foot building addition for the emergency department and, at the same time, to reconfigure the campus entrance.
“Kaiser South Sacramento has one of the busiest emergency departments in the region,” Jensen said, “and they have experienced growth in the number of visits.”
The ER at the South Sacramento hospital appears to have seen more patients last year than any other local hospital, reporting 127,248 visits and admissions to the California Office of Statewide Health Planning and Development. That easily outpaced Dignity Health’s nearby Methodist Hospital, which had a total of 59,082 patients at its ED, and it was greater than the 114,588 patients seen at Kaiser Sacramento on Morse Avenue or the 101,604 reported by Sutter Medical Center, Sacramento.
All Sacramento hospitals posted big increases in ED encounters for Medi-Cal patients between 2012 and 2017, but among the largest were: Kaiser South Sacramento, up 126 percent, Sutter Medical Center’s, up 173 percent; Sutter Roseville Medical Center, up 93 percent; Kaiser Morse, up nearly 137 percent; Mercy Folsom, up 119 percent.
But if these Medi-Cal patients now have insurance, why are they accessing so much care through emergency departments.?
Jensen said it might be simply a matter of habit. So many of these individuals didn’t have access to insurance and used the emergency room as primary-care providers. It’s a matter of re-educating these patients.
Some people simply can’t wait until a provider is available, Jensen said, either because they put off care for chronic conditions and are now having a crisis or because they’re having a psychotic break.
“There’s been a dramatic rise in the need for behavioral health services,” he said. “That includes both mental health and substance abuse services. There are probably a lot of societal factors driving that, but the end result is that there are not enough behavioral health care facilities and providers, individuals who actually do the work, for the needs of this population, so where do they go? They go to the emergency department.”
Sometimes, they go on their own, Jensen said, but at other times, police take them in to see a psychologist to determine whether they should be held for observation for 72 hours.
“In any one of the emergency departments in our region, you’ll see multiple beds at any time of day, maybe 20 at a time, occupied by people who need mental health services,” Jensen said. “We really don’t have an adequate mental health system to handle the increasing demand for services. By default, they are brought to the emergency departments because there are psychotherapists on hand. At least they’re safe, at least they’ll be fed.”
Across the region in 2017, local hospitals treated 190,518 more Medi-Cal enrollees than they did five years earlier. Kaiser’s emergency facilities treated 38 percent of those patients; Dignity, 24 percent; Sutter, 28 percent; and Davis, about 9 percent.
If more Medi-Cal enrollees are seeking care in Kaiser’s emergency rooms, does it mean the HMO giant’s vaunted integrated health system is not working as effectively as other insurers to get Medi-Cal patients to primary-care doctors?
Not necessarily, Jensen said.
“I recently learned that at one of the Kaiser facilities, 40 to 45 percent of their ED visits were from nonmembers,” Jensen said. “I don’t think it would be fair to say that this upswing of people needing behavioral health services are showing up in the Kaiser ED as a result of them not getting the care that they as members...should receive.”