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From left to right: Donald Thigpen, Derrick Samuel, and Cary Avey Texas trauma centers provided $180 million in uncompensated care in 2001, according to a study commissioned by Save Our ERs from healthcare consultants Bishop + Associates. Most of the uncompensated care is provided to the medically indigentthose without state aid or thirdparty insurance, who can’t afford to pay for their care themselves. However, a good portion of Texas hospitals’ debt is generated by insurance companies and by the state itself. Health Management Organizations employ strategiesknown as gate-keepingto dodge payments to hospitals. Originally intended simply to control costs, gatekeeping practic es are now notorious for delaying or avoiding legitimate payments to hospitals and physicians. HMOs may require hospitals to obtain prior consent from the liable insurance company before providing a patient with a treatment or service. While the hospital waits for authorization, the untreated patient’s condition may worsen, necessitating yet more expensive stabilization and treatment. If the hospital treats the patient without authorization, the HMO may decline to pay. HMOs are also known to refuse payment for emergency services provided for illnesses that prove not to be life threatening. If the classic symptoms of a heart-attackchest pains, nausea, shortness of breathturn out to be an attack of indigestion, the HMO may not pay for treatment received at an emergency center, since the condition treated was never an “emergency.” Some insurance companies accept charges only to delay payment to physicians for months or even years at a time. The state itself has lately been a poor patron to Texas hospitals. Texas used to draw down federal matching dollars to provide funds to hospitals that served higher than average numbers of uninsured and medically needy patients, but over the last decade that funding has declined steadily. The amount the state reimburses hospitals for treating Medic LIFELINES 0 n Saturday afternoon, six nurses in scrubs man five telephones in an office carousel on the third floor at Ben Taub. The extra nurse, Victoria Chavis, is training a recent hire how to perform emergency room triage over the telephone. As patients call the hotline from home, nurses enter their names and personal information into a computer database. A series of computer menus guide nurses through the triage questioning processWhat are your symptoms? How long has that been going on? How much does it hurt? What medications are you taking? Depending on the answers, nurses may advise patients to care for themselves at home, or see a doctor within a few days; if the case is urgent, they may recommend the patient go to the emergency room, or even call 911. But the main purpose of the Ask Your Nurse Hotlinestarted three years ago by Gateway to Care, now staffed and operated by the LBJ Hospitalis to keep non-emergencies out of the emergency room. As Chavis listens in on an operator’s headset, trainee Sharon Powe fields a call from a woman with pain and swelling in her shoulder. The woman has a history of seizures; it’s possible she fell during one and injured herself, but she doesn’t remember the fall. “Is it red?” Powe asks. “Is there swelling?” The woman says yes to both. “Are you taking any medications for it?” Powe asks. Victoria Chavis, RN “Percoset,” the patient says. “I took two tabs. I’m just falling out right now.” With Chavis’ occasional sotto voce guidance, Powe steers the woman through the rest of the litany of questioning, then recommends that she see a doctor within a few hours. Since this 18 THE TEXAS OBSERVER 11/5/04