Homeland Security's Weak Link by Scott E. Maizel Scott E. Maizel, MD, FACS, of Baltimore is president of the Maryland Chapter of the American College of Surgeons and is actively involved in the current litigation crisis in medical malpractice. The presidential campaign is in full swing with each candidate claiming to be more vigilant, creative and dedicated to preserving our security at home while fighting terrorism abroad. Despite the barrage of words, no candidate seems to be willing to discuss the greatest threat to America's homeland security -- the accelerating deterioration of our nation's health care system. Once the envy of the world, our health care system is under siege at every turn. In years past, if a hospital was able to make a profit at the end of the year it was invested back into the hospital's physical plant, expanding services for the community, hiring more nurses, etc. If physicians were reimbursed their customary charge, they could afford to care for patients unable to pay the fee for service. But the years of "cure at any price" and the financial "excesses" that made care for the uninsured possible, are long over. This has left the American public with a lingering appetite for convenient, error free medical care, but little taste for footing the bill. Legislation was enacted in the late 1990s to ensure the public's access to medical care (the Emergency Medical Treatment and Labor Act -- EMTALA) but there was no provision for the cost of providing it. This was left to the caregivers -- the hospitals and the physicians. A study by the Center for Health Policy Research published in February 2003, estimated that in 2000 care delivered by physicians under the EMTALA mandate resulted in close to $4 billion dollars of bad debt, i.e. services rendered without compensation. Billions more uncompensated care was given by the hospitals. It is not surprising that the American College of Emergency Physicians reports that from 2000 to 2002 the number of emergency departments open in the country fell from 4,148 to 4,037 while during that same period the number of patient visits climbed by more than 7 million. In 2003, the top five busiest emergency departments in Maryland experienced such an increased patient volume that ambulances were forced to bypass their ERs because of overcrowding more than 3,400 hours on average that year for each hospital. Although we have often heard about the 43 million Americans who do not have health insurance this political season, do not believe these patients are going without health care. They are receiving care but it is being delivered free of charge (but not cost) by America's physicians and hospitals largely through emergency departments. And now, in addition to these costs and those of new technology, plant maintenance, personnel, etc., America's health care providers -- physicians, hospitals and nursing homes -- are being pushed to insolvency by skyrocketing medical malpractice liability insurance premiums. Hospitals are forced to choose between hiring nurses, renovating buildings and buying new equipment. Surgeons, emergency physicians and obstetricians, facing this dismal financial reality are quietly leaving the state or retiring. Others, desperate to stay in practice, are considering the possibility of dropping the cost of malpractice insurance completely -- "going bare." New physicians bypass Maryland when they consider where to set up practice. On Sept. 23, the surgeons in Hagerstown announced that because of skyrocketing medical malpractice liability premiums they will stop delivering all but emergency surgical care. This will necessitate transport of patients from that region of the state to hospitals almost 100 miles away. Some lawmakers, failing to hear an "outcry of concern" by patients, choose to believe that no problem exists. Many are unwilling to set aside self interest or traditional political alliances to openly address the problem. The result of this inaction imperils the viability of Maryland's hospitals, drives more surgeons from the state and erodes our emergency preparedness. The reality is that in America there can be no true homeland security if there are no doctors or hospitals available to care for us at the time of a terrorist attack or when our loved ones are hurt, ill or are having a baby. Lawmakers must act now, in a special session, to stop the exodus of surgeons from Maryland by stabilizing malpractice premiums and seeking a long-term solution to the malpractice liability dilemma. A solution that results in better health care for all citizens while ensuring that patient's concerns about their health care are heard and legitimate injury justly compensated. Such solutions do exist. The greatest threat to our security today comes not from a terrorist bomber but from the failure of lawmakers to work together, side by side with all concerned citizens, to courageously address our health care system in crisis. Scott E. Maizel, MD, FACS Originally published on October 15, 2004 on the Gazette President, Maryland Chapter American College of Surgeons 9101 Franklin Square Drive, #110 Baltimore, MD 21237 (410) 574-5720