Adam Searing hears it frequently. So do doctors and other health care workers across the state.

“I talk to people all the time who say, ‘I don’t have health insurance and I’m putting off doing this or that.’ We go around the state talking to people who say they don’t have coverage and they are putting (medical care) off,” said Searing, project director of the N.C. Justice Center’s Health Access Coalition.

The North Carolina Institute of Medicine estimates that there are at least 1.8 million people in the state with no health insurance, including more than 20 percent of the non-
elderly population.

“The rate of people who have lost their health insurance through their work is the highest rate in the nation so there are a lot of people losing their coverage,” Searing said.

Many in the health care industry believe the recession economy is at least partially responsible for an ongoing trend of individuals delaying visits to a primary care physician, resulting in health conditions that sometimes end with emergency room visits and lengthy hospital stays.

Bad debt climbing

“I know that our bad debt is climbing graphically. There are people who are unable to pay, and it’s not just the indigent. These are people who formerly worked,” said Scott Whisnant, director of governmental relations at New Hanover Regional Medical Center.
Many of the recently laid-off are still covered by federal COBRA insurance, but COBRA  eligibility runs out after a period of time. And some people that still have health insurance avoid seeking medical care because they can’t afford to pay the deductibles, Whisnant said.

“One of the things that worries us is we haven’t seen the worst of it yet,” he said. “(Free) clinics are being overrun by people seeking help.”

Statistics provided by Novant Health’s Brunswick Community Hospital bear out the trend. There were 11,528 emergency department visits between January and mid-July 2008, compared to 11,887 visits over the same time frame this year. The approximately 3 percent increase is representative of the entire Novant Health network, said Amy Myers, Brunswick Community Hospital spokeswoman.

“All of our hospitals are experiencing trends very similar to those figures,” Myers said. “People are delaying care.”

There is evidence to support people who do seek medical treatment are waiting until their condition is more acute. At Brunswick Community Hospital, the average length of stay was 3.31 days from January through July 2008, compared to 3.45 days through 2009 – an increase of about 4 percent.

“Those are not huge numbers, but they are staring to show a trend with the length of stay increasing,” Myers said.

Population growth in the area and demographics reflecting the large retirement community in the area must be factored into the equation, but the economy is also undeniably a factor in the mix, she said.

Scrimping on care

“They may have had a cold and not gone to a physician for treatment and they ended up having an emergency room visit,” Myers said. “People are often delaying care so they are sicker when they come to the hospital. They want to avoid a co-pay at a doctor’s office when they start to get sick and ultimately, they are sicker than they would have been had they been treated earlier.”

Myers said health care professionals are trying to get the word out that avoiding treatment is not the wisest way to save money.
“When the economy gets tougher, people start to cut back and health care is not the place to start with cutbacks,” she said. “We’re really struggling right now to help the community understand.”
Hospitals across the nation are challenged with closing the Medicare and Medicaid payment gap. Reimbursement allocated by the
federal government does not meet expenses, Myers said.

Medicaid cases accounted for just over 19 percent of patients seen in 2008 at Brunswick Community Hospital. This year to date, the figure is nearly 23 percent.

Myers said the figures indicate that people “are appropriately getting signed up for Medicaid” and also there are more people in need of the federal program.

“The hard part of that on the hospital’s part is that the reimbursement for Medicare and Medicaid has decreased over the years,” Myers said.

The situation is similar at New Hanover Regional Medical Center. The issue of health care reform and what national plan may ultimately be adopted is a cause for concern among hospital officials.

“There is a lot of anxiety about it. The plans talk about increasing Medicare and Medicaid,” Whisnant said.

He said the more immediate issue of helping people get the medical care they need is being addressed, to a degree, by local healthcare systems and other providers.

Cape Fear HealthNet is a grant-funded initiative to improve health care for the medically uninsured. Eligible individuals include residents of New Hanover and Brunswick counties who have no health insurance and with a household income at or below 200 percent of the federal poverty level.

“We’re already trying to tackle this but the issue is so large,” Whisnant said.

Facilities like Brunswick Community Hospital do have a financial assistance programs in place. Figures show that charity care at the hospital cost Novant $4.1 million in 2007 and $6 million in 2008, a cost increase of 50 percent. The formula the hospital uses to determine financial assistance eligibility is also based on federal poverty level figures.

Charity case figures for 2009 are not available, but Myers said Novant Health is seeing an 18 percent increase across the board at its health care operations this year.

Other Novant-operated facilities like Forsyth Medical Center in Winston-Salem are trying innovative ways to address the increase in emergency department traffic. One area of the department is configured to “fast-track” certain patients coming there with conditions that might have been treated by a primary care doctor or at an urgent care facility, hospital spokeswoman Freda Springs said.
A doctor and nurse are present. “For relatively minor things, you keep them moving,” Springs said.

On some days, a registered nurse is stationed in the emergency department lobby and screens incoming patients, directing them to an appropriate treatment area.

“It just really moves things along faster,” Springs said.

Reform needed

But bigger factors are in play that will likely reshape the nation’s health care system. A revamped national health care plan would go a long way toward addressing many of the emergency department ills, for instance, Searing said.

More uniformity in treatment would also help, he said.

“There are parts of North Carolina where people get treated really differently for some health care problems,” he said.

“Our main focus in North Carolina is to make sure everybody in the state can afford to buy a health insurance policy,” Searing said.

“Small businesses with employees are one example, but it’s really everybody.”

Federal funds have allowed expanded coverage for children “but not so much for everybody else,” Searing said.

“Now, I think a lot of eyes are on Washington to see what they come up with,” he said.

What is needed, Searing said, are adjusted plans for small businesses, the elimination of charging people with pre-existing health conditions extra money and the availability of a “menu of plans” that suits each individuals.

“Cost control is critical,” said Searing, who supports legislation to rein in insurance companies and pharmaceutical manufacturers.

“In the last 10 years, health care costs have doubled. In the next 10 years, if we’re still on that track they’re going to double again. That’s just not sustainable,” he said. “The only way we will get a handle on these costs is to get everybody into the system and crunch down on some of these inefficiencies.”

One-third of the health care that is delivered is not effective, Searing said. An uninsured person only receives about 40 percent of the health care services an insured person gets, he added.

“North Carolina can not go it alone with health reform,” Searing said. “I think people are going to be healthier, they are going to be happier and they are going to be going to work more and morally, it’s the right thing to do.”

Brunswick Community Hospital is trying to keep pace with the changing demands wrought by the economy and other factors. Hospital officials are currently hammering out details of the 2010 operating budget.

At New Hanover Regional Medical Center, Whisnant said officials realize changes need to be made in the way health care is provided.
Hospitals will play an active role in shaping any health care reform plan.

“The hospital industry as a whole recognizes it has to give something to this plan. The hospitals will welcome a better system but we feel we’re already giving plenty to the system,” Whisnant said.

Meanwhile, a certain level of service must be maintained regardless of the faltering economy, Myers said.

It doesn’t matter what the environment is doing, it matters what we are doing in the environment,” she said. “We can only control certain aspects of that, so we have to look at what we are doing in the environment.”