Les Burson is the president of Pinnacle Emergency Group, a team of emergency room physicians that staffs Bakersfield Memorial Hospital.

And he wants more credit — specifically, tax write-offs — for the work he and his colleagues do for free.

“We are a provider of services. We provide the services to staff the ER,” he said. “We contribute quite a bit in free care, and it could be considered a charitable contribution.”

Burson presented his idea at Rep. Kevin McCarthy’s town hall Wednesday night, and McCarthy said it sounded good.

But the problem runs deeper than just what a tax write-off can solve, he said.

Medi-Cal, the state’s program that covers the poor, pays doctors about 10 to 15 cents on the dollar, he said. Medicare pays about 30 cents on the dollar. And private insurance pays only about 10 percent more than Medicare, depending on the contract.

Meanwhile, doctors are waiting in fear of certified letters from attorneys using their “retrospectivescopes” to tell them what they should have done.

Here’s Burson in his own words:

Emergency Physicians that staff the ‘last line of defense for health care’ are feeling quite a bit of ‘angst’ regarding the current health care crisis and the feeling our voices aren’t being heard.

Most of the patients we see either have no insurance or rely on MediCal. Compensation for many of these patients is a very low, deeply discounted rate. No matter how serious the condition they present with, from an earache, to a gunshot wound to the head or a non- compliant diabetic with overwhelming sepsis and multi-organ failure requiring central lines and intubation for ventilatory support, we receive the same capitated or deeply discounted rate as our reimbursement while assuming a huge liability risk for their care.

Typically these are the patients that have ‘government sponsored insurance’ (or no insurance at all) and are typically the ones who can’t get in to see a primary care physician (PCP) or clinic. The PCP, IF they participate in the MediCal program, usually doesn’t see these patients. Instead, they have a ‘mid level provider’ seeing these folks ‘en masse’ because the reimbursement doesn’t pay for their overhead, thus they have to see a huge volume of patients to cover their expenses. As fewer providers agree to accept these inferior reimbursements, they quit participating in the program. Fewer providers, more crowded clinics, delayed or missed appointments mean the patients are sicker, meds aren’t refilled and they end up on our doorstep in the Emergency Department seeking care. These providers/clinics can and do refuse to see patients based on ability to pay, however, with the federally unfunded mandate of EMTALA, we cannot refuse anyone based on ability to pay. EMTALA is a mandate from the government, which says all patients that present to any Emergency Department, must be seen, treated and stabilized regardless of their ability to pay. According to Dr. Edwin Leap, an Emergency Physician in South Carolina, “EMTALA is the government moralizing about compensation and then dodging the responsibility to pay for it. EMTALA has devalued medical care by making it seem free.” Our ‘badge of honor’ in Emergency Medicine is that we never deny anyone health care based on their ability to pay. We are the only ones who day or night see anyone and provide health care; we’re just seeking compensation for this care.

These are the types of patients that President Obama envisions by nationalizing health insurance for the masses, so that even the 46 million patients with no insurance will have the type of coverage that reimburses those of us on the front line 15-20 cents on the dollar for our time, expertise and significant liability risk. This nationalized health care is insurance in name only. WE are their PCP’s, they can’t see their doctor, they can’t get their medications refilled, their clinics schedule them for weeks or months later for follow up or they miss appointments; the patients know that we are their ‘security blanket’; Board Certified professionals available 24/7/365. Patients will continue to use the ED as their ‘care provider’ as they become frustrated over the limited access to care that’s on the horizon if this model is at all similar to the current MediCal system.

There are no provisions in the new Health Care plan for providing health benefits for illegal aliens. But rest assured, when any undocumented individual from any country comes to our ED, we will see and treat them to the best of our ability and not get reimbursed for their care. Another example of the ‘free care’ we provide every day in Emergency Departments across the country, thanks to EMTALA.

Due to budget cuts, when the Governor of California releases prisoners onto the health care scene, where do you think they will end up? At your local HMO clinic or the local doctor’s office? No, they will show up ‘en masse’ to our already overcrowded ED’s. Sure, while they were prisoners, they received the best health care with complaints of chest pain or abdominal pain, they are whisked away to an ED for evaluation, but now out of prison with no means of support, they will end up on our doorstep. EMTALA says their care is ‘on us’.

Tort reform should be a key part of this legislation. Every patient we see is a possible ‘IED’ (Improvised Explosive Device) waiting to blow up in our faces, today, tomorrow or next week. The risk on every patient we see for a possible bad outcome is real and the possibility of a certified letter from a malpractice attorney using the ‘restrospectivescope’ to second-guess our care hovers over our heads daily. All for free or a deeply discounted rate; a rate that we often have to ‘chase’ to get payers we have contracts with to pay us to see their patients and assume this huge risk. Will the government sponsored health plan also be named in the suit? As the government forces us to cut back on tests and procedures, we will be squeezed even more and will have malpractice attorneys questioning us after the fact as to why those tests weren’t ordered.

Colleagues often argue that this is a business. Well, it is a business that is rapidly going bankrupt. I often hear the analogy that if a consumer had a special ‘government card’ (‘MasterCal’) and went to Best Buy to purchase that $1000 television; the government card would allow the consumer to buy that television at Best Buy for $200, and they’d HAVE to give it to them. Or perhaps, the mechanic who tells you it will cost $1000 to replace your transmission; you give him the card and he HAS to do the repair at a loss. How long could any business ‘keep the lights on’ and stay afloat with such a program? Exactly, this is the scenario we all face in the Emergency Department; under-funding for the care we provide. Very few places in the economy do folks provide essentially ‘free’ service as we do in the ED…and it’s ‘the norm’. Health care is not free, it’s paid for by all who pay insurance premiums and by all who pay taxes…’cost shifting’ to pay for a system in need of reform.

We provide several hundred thousand dollars in free care to those with no means every year. We, as a small business that provides staffing for a local ED, cannot write off those expenses, they end up as just services provided for free. Services we provide with no reimbursement is just money that’s not collectible. As a corporation, providing this essentially free service, there should be mechanisms for us to write this off as a loss, as of now, we just provide free care.

Continuing to ‘discount’ our services, cutting back our fees will ultimately lead to fewer motivated folks going to medical schools. Fewer physicians, so even more patients will end up in the ED’s across the country. To quote Dr. Leap, “income represents effort. It represents the time spent in education (12-14 years of post-graduate training), preparation to be the best and time away from your family. It represents your physical activity, your risk of injury, infection, your intellectual struggle to do the right thing; all of these things are worth compensation. So now, for working harder, achieving more, we will be the very ones to finance this initiative by paying higher taxes after we have already paid with our tax dollars for many government subsidies which pay for these patient’s housing, food and now more of the health care that was ‘free’, now it’s reimbursed at 10-15 cents on the dollar.”

As KMC gets ‘into the black’ by closing beds in the ED, leading to lengthy waiting room stays, where do you think those patients end up? Other community ED’s. Their ‘black’ is everyone else’s ‘red’. KMC receives government subsidies to see the very patients they are turning away. DSH funds (Disproportionate Share Hospitals) go to ‘safety net’ hospitals that see a higher, disproportionate number of the uninsured or low-income patients. In fact, all the local Emergency Departments are seeing these patients; we should also be eligible for similar funding.

While it’s a great idea for providing incentives to patients, primary care physicians and insurers to promote ‘wellness’, what about those of us in the trenches of Emergency Medicine that see all of the ‘outliers’ that don’t take care of themselves. Why are we not a part of the equation, where is our voice. We are ‘primary care physicians’ as much as the Family Practice doctor seeing patients in a clinic, office setting, or ‘medical home’.

So now we can ‘trust’ the government for national health care and run it successfully, just as they have with the Postal Service, the VA, or the health care seen on Native American Reservations. Go ask any Veteran or Native American about their health care and the limitless delays they face everyday ‘under government supervision’. Where does ‘the average Joe’ sign up for the same plan as the Senators and Congressman in D.C.; or perhaps the representatives will relinquish theirs and opt for the government’s plan for themselves.

In the recent stimulus packages, the banking industry was given a lifeline and now we’re given an anchor. What’s obvious is that Wall Street, trial attorneys, HMO’s and the insurance industry clearly have more powerful lobbies than those of us in Emergency Medicine.

Over 80 hospitals and 50 Emergency Departments have closed in California over the past 10 years, squeezing the vise of health care on those of us at the end of the health care ‘food chain’ in the Emergency Department. Access to medical care is at a breaking point, and we in Emergency Medicine are at the ‘fracture site’.

A letter similar to this one was sent to over 60 legislators. I received about 10 ‘form’ letters in return. The ‘silence is deafening’ regarding this crisis in Emergency Medicine and the new health care initiatives being proposed.

We are YOUR ‘safety net’ that’s full of holes.

How would you reform the corner of health care where you work? Contribute to our Virtual Roundtable by e-mailing reporter James Geluso.

What do others have to say? Read more:

Health Care Reform Roundtable: Michelle Quiogue

Health Care Reform Roundtable: John Gundzik

What does health care reform mean to you?

Town hall offers some solutions, mostly rhetoric