President's Page

President's Page
February 2004

Times Change

by Warren E. Lichliter, MD
2004 DCMS President

With Texas Medicine’s recent successes in the legislative and congressional arenas, we have greatly increased our influence and credibility on the state and national levels, and we have been recognized for our success. Now we face a critical problem in our backyard, at the county level.

The delivery of health care in Dallas is in a crisis. The media have reported the problems and practicing physicians certainly are aware of them. The Parkland Health & Hospital System Board of Managers and the Dallas County commissioners have been dealing with the increasing inadequacy of the Parkland budget over the past year. The county hospital has been unable to care for all of the uninsured population or all county residents requiring trauma and emergency care , resulting in great increases in the number of uninsured patients presenting at community hospitals. Indigent and uninsured admissions at Baylor University Medical Center, where I practice, have doubled during the last year. Ten percent of admissions are non-pay and, during one recent weekend, 17 percent of the hospital patients were uninsured.

Many of these patients bring their Parkland clinic card when they present. They know the EMTALA will let them stay for care, and they can see the doctor in 4 to 6 hours rather than the 8 to 10 hours it takes in the Parkland ER. After being discharged, these same patients return because they say that they cannot get an appointment at Parkland or spend an entire day waiting for an appointment.

The increase in uninsured patients results in crowded facilities and delayed access to insured patients. These large numbers of uninsured overwhelm the ability of the hospitals to maintain their level of care and to invest in new technologies, and the physicians’ ability to provide the larger volume of noncompensated care.

The present level is not sustainable. The result may be that hospital systems shut the doors on their emergency rooms. Hospitals may need to drop their involvement in the Biotel trauma delivery system. Physicians are choosing not to practice in Dallas County or are relocating their practices to a surrounding county to avoid ER duties or practice at a hospital that provides high levels of free care, only to get sued relative to that care.

To address this situation, we must define what “uninsured” means in Dallas County. Up to 25 percent of the country’s population has no insurance or inadequate insurance coverage, and Texas and Dallas County surely mirror this rate. At least 50 percent of this population is employed—the so-called “working uninsured”— but their employers don’t offer coverage.
Compounding this is the current system that does not identify these patients when they seek medical attention.

Third, the number of patients who live outside Dallas County but come to Dallas for treatment is significant but, again, poorly defined. This has been a major concern at Parkland, but the major referral hospitals also have seen such an increase.

The end result of these factors is a large amount of uncompensated care that Dallas County citizens pay for directly with hospital district taxes, and indirectly with poor access to care and decreasing numbers of healthcare providers. County residents also pay with higher insurance premiums, a result of the increasing cost to businesses in providing health insurance.

Now that we have defined the crisis, what are we to do?
The “easy” solutions—raising taxes, denying care to illegal aliens, suing surrounding counties for money to pay for their citizens, telling our community hospitals to “take up the slack”—are all inadequate. Systemic changes are needed in healthcare delivery, preventive services, and public health services.

The Parkland Board has already made significant budget cuts to Parkland. In early January, there was widespread fear among the healthcare community that the commissioners were considering authorizing a study of Parkland’s future that might quickly lead to reducing services further. Fortunately, through dialogue with community leaders and DCMS, these fears have been lessened.

In recent months, DCMS leadership has been meeting with all four county commissioners and County Judge Margaret Keliher, as well as community and hospital leaders, to emphasizethe importance of health care for all Dallas citizens and how Parkland impacts that care. Because of these discussions, the Parkland study the Commissioners Court passed on January 6 contained 20 deliverables that were broadened from the 11 in the original draft. The study now includes not only the role of Parkland in the community but the role of the private healthcare system on indigent healthcare delivery to all of Dallas. The impact on public health and preventive services also was included.

Much has happened in the past month. We have laid the framework for working with local politicians and business groups. This is new territory and a new direction for DCMS, but we are learning quickly. Our goal is to develop an effective coalition to influence our local politicians to improve the health of our community. With the support of our 6000 member physicians, it’s within our grasp.

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