Reporter
State of Emergency
What happens when 130,000 kids lose their taxpayer- funded health insurance? To find out, visit the ER at Children's Medical Center Dallas, where the waiting room is always full and chances are you're footing the bill.
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Spreadsheets aren't the only place where red flags are being hoisted. As recently as 2001, Children's was rated number seven in the country, according to the prestigious rankings in Child magazine. A year later it failed an accreditation survey by the Joint Commission on Accreditation of Healthcare Organizations, scoring below the average for the first time in its history. That same year it was left off of Child's rankings and hasn't been included since. The accreditation score has subsequently been raised to slightly above average, and the hospital fully expects the current survey to go more smoothly. But for an institution that has always prided itself on being state of the art, the 2002 results were a major disappointment. Such problems are difficult to attribute directly to an emergency facility glutted with uninsured patients, but it isn't unreasonable to wonder if the growing number of uninsured kids in Texas has forced one of the state's best hospitals to spread itself too thin.
WHAT IS NOW THE CHILDREN'S MEDICAL CENTER DALLAS has always had an overabundance of good intentions. The hospital is actually the result of four children's facilities joining forces shortly after World War II: a Dallas "baby camp" for kids with gastrointestinal problems, the Bradford Memorial Hospital for Babies, the Richmond Freeman outpatient clinic, and the Children's Hospital of Texas. After the merge, the resulting institution developed a simple, eloquent mission statement: "To make life better for all children."
For most of its first fifty years or so, Children's succeeded, expanding in tidy little increments, each new building block made possible by philanthropy from city fathers or a generous line of credit from the banks some of them ran. The former was always enough without being lavish; the latter was always paid back promptly and in full. Through the years the hospital became a modest pioneer: One of the first pediatric intensive-care units in the nation was opened here in the fifties, and a decade later, Children's started the first pediatric day-surgery program. By the late seventies, the hospital was still a small and somewhat anonymous not-for-profit pediatric facility with one hundred or so beds, 450 employees, 35,000 outpatient visits a year, and $16 million in gross revenue. It was a kind of throwback, an oversized mom-and-pop operation that paid its bills in cash, on time, and never came close to outgrowing its market.
In the eighties Children's began taking advantage of the increased federal funding for teaching hospitals. (Children's has served as a teaching hospital for nearby University of Texas Southwestern Medical School since the mid-sixties.) The new money allowed the hospital to provide exotic services such as organ transplants, sickle cell anemia treatment, and trauma care that could not be found anywhere else in the region. It also allowed the hospital to grow. Since the late eighties, it has almost tripled its bed capacity, and it now fields more than 300,000 outpatient visits a year. Aside from owning the busiest pediatric emergency department in the country, Children's has built one of the largest cystic fibrosis units, and its liver and heart transplant programs are envied for their success rates. The hospital has also treated a number of "celebrity patients," such as the conjoined twins from Egypt who were miraculously separated last year.
All the while, Children's has remained a hospital that treats the indigent and the uninsured. Until recently, that mission was manageable, but with the advent of managed care, both private and public carriers became stingier about doctor's office visits, the medications they covered, specialty referrals, and co-pays. About the only place this wasn't true was in emergency care, where both private and public insurers were traditionally happy to pay nearly 100 percent of the charges. And by the turn of the century, more and more patients who didn't have life-and-death conditions—up to three out of four—began to show up at the Children's ER. So did the number that did not have insurance—up to fifty a day.
While last year's CHIP cuts certainly exacerbated that problem, no one can accuse Children's of being caught by surprise. Ever entrepreneurial, Children's has spent the past decade trying out alternate strategies to handle its increased ER traffic. In 1997 it began diverting less serious cases to First Care, a large new clinic that sits adjacent to the ER on the hospital's second floor. But the plan has turned out to be another example of "If you build it, they will come"; when word spread that First Care also treated the uninsured, it quickly became as crowded and overrun as the emergency room.
Two years later, hospital management tried to redirect patients to its new satellite facilities such as the Physicians for Children at Bachman Lake, in northwest Dallas, an anonymous-looking part of several strip malls along busy Northwest Highway. The Bachman area clinic was its own bold experiment in health care. Staffed by four bilingual doctors, it was designed by Children's management as an alternative to the ER for low-income families. Unlike the ER, though, the clinic demanded that some form of payment be provided, whether Medicaid or CHIP or just cash. When CHIP was fully funded, the clinic flourished during its first two years of operation, serving more than six thousand patients a year and still breaking even, a minor miracle for a facility specializing in treating the working poor. But last year's CHIP cuts siphoned off many of the Bachman clinic's steady clients. Many of them began to stream back to the Children's ER.
Now Children's is running out of options. The growing popularity of the hospital has forced it into a schedule of almost exponential expansion. In just the past four years, the ER has been expanded, and six floors with an additional 132 beds have been stacked onto one of its towers. There may be a point where Children's good intentions don't make sound business sense anymore. Hospital administrators call this a "negative payer mix," meaning that the cost of the uninsured patients becomes a drag on the revenues brought in by the paying ones. This is one reason why Children's has recently become even more aggressive in expanding its satellite facilities. But unlike the Bachman clinic, the envisioned seventy-bed Children's Medical Center Legacy, in Plano, is intended to massage the Dallas area's more affluent suburban communities. Children's latest efforts to deal with the uninsured, in other words, is to increase profits among the insured. "You have to go find where the insured patients are," says the hospital's senior vice president of business development, Patricia Winning. "It's one of the only ways we can continue to help all children."
ONE EVENING THIS PAST SUMMER, I found some of the Children's ER residents hanging around the L-shaped counter. They were joking and grousing about how long it had been since they'd treated anything but a wheezer. Then a call came in from EMS: Paramedics were transporting a ten-year-old girl who'd been riding in the backseat of a car when her brother, who was driving, lost control and rammed through a fence and hit a tree.
A palpable buzz filled the room as doctors and nurses rushed to the rear of the facility, where the ambulance portal is located. The patient arrived, strapped tightly to a gurney. A team of doctors inspected every square inch of her. Vitals were checked; x-rays taken. A social worker hovered about to calm the parents; a chaplain was on call. Surgery was notified to ready an operating room upstairs.
As the attending physician on duty, Abramo was called to the trauma room to look over the girl and pass judgment on the diagnosis of the residents. After a brief consultation, the injury was confirmed. "She's one very lucky little girl," Abramo concluded. "All she has is a broken arm."
More-severe cases have certainly been handled in the Children's ER over the years, but it was still inspiring to witness actual emergency medicine being practiced in the emergency room. It wasn't an hour later, however, that I found Abramo back in another treatment room, examining a young boy who'd hurt his finger while playing. It was hardly even bruised.
"You take them as they come," he said, shrugging. "Sometimes there's no place else to go."
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