White Coat Underground

More health care problems that no one talks about

Posted by PalMD on August 30, 2009
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From time to time we see an article (usually from LA) about hospital patients being “dumped” on street corners. I don’t know how wide-spread this problem is, but the systemic problem that leads to this is common and serious.

Most American hospitals are required to render emergency care to anyone who comes in the door. In practice, this means hospitals provide a great deal of uncompensated care. For example, if some guy with a couple of bullet holes is dumped in front of the ER by his “friends”, the hospital is required to stabilize him. But let’s say they then wish to transfer his care because he’s uninsured, or for any other reason. Who will accept him? You can’t just dump him in the ER of a public hospital—it’s wrong from both a legal and moral perspective. In practice, patients like this are cared for until discharge, sometimes for days, sometimes for months. Sometimes hospitals will receive public funds to compensate them for this type of care, but it’s never enough.

Lack of universal insurance encourages a choice between economically unwise behavior and morally repugnant behavior. Hospitals have to choose to cut services or close their doors if uncompensated costs rise too steeply, hurting employees and the people in the hospital’s catchment area. And those who are the most vulnerable are left to either burden the hospital, or risk being dumped on the street. If the patient is well enough to leave the hospital but not well enough to care for themselves, there’s no safety net. The hospital must keep them as a “border”. No nursing home would accept someone without means to pay, and our society has no good backup plan. Sometimes, Medicaid can cover patients like this, but often they cannot.

Our system, as it stands, actually encourages immoral behavior. How proud does that make you?

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Comments

  1. #1 CRM-114
    August 30, 2009

    In California, ERs have another tactic which works for walk-ins assumed not to be insured. The staff sees everybody else ahead of the suspected indigent, and that means everyone else, even the ones that arrive over the next twenty-four hours. The poor sap either leaves on their own or if he’s there much too long the cops come for him.

    I passed a gallstone in the eight hours I sat in the waiting room, quickly bring down my pulse from 240 to 75. The emergency over, I walked home.

    It doesn’t matter what the laws are because they will never be enforced against for-profit hospitals. Nobody is going to jail, no matter what they do.

  2. #2 BaldApe
    August 30, 2009

    If a safety net for those who can’t pay for minimal health care is the only thing we get out of health care reform, I will be impressed.

    Sadly, that will likely be the last thing to go through.

    But fat cats whose employers are “too big to fail” get carte blanche.

    I like to be in America!
    O.K. by me in America!
    Ev’rything free in America
    For a small fee in America!

  3. #3 sli
    August 30, 2009

    Wait, I *did* get dumped from a private ER in California to a public one once they were sure my severe problem (hemorrhaging kidney from an unsuspected tumor) wasn’t going to kill me that day. I guess I just thought that’s what they did!

    The people at county sounded like that sort of thing happens all the time. Their commentary actually irritated me then; I didn’t want to worry about any suckitude of the hospital I’d just left, I wanted the current one to make me better! Which they did, and also directed me to California’s public healthcare option, and now I love them.

    And CRM-114, I believe you. I sat in the private hospital’s ER for about eight hours, and didn’t see a doctor for ten.

  4. #4 D. C. Sessions
    August 30, 2009

    If I were only allowed one small change to our “system” of health care, it would be to have the State explicitly compensate for cases such as you describe. The current approach is just making the hospitals in poor areas more expensive every year, sending people who have a choice elsewhere.

    The result is spiraling failure and cost-shifting to the poorest in our society. I actually know people who argue that this is a good thing.

  5. #5 Kim
    August 30, 2009

    Uncompensated care under EMTALA one of my major wedges when discussing health coverage reform with libertarians. While they’re often not too excited about the idea of hospitals pulling out of cities/neighborhoods due to the cost of uncompensated care, they can sometimes sympathize with the ER doctors and consultants who are legally obliged to offer their services for free. It was also an interesting case to discuss with people who had a woody over the concept of “going Galt” during the election…although perhaps not surprisingly some people who will defend the theoretical non-medical $250k/yr earner’s right to a lower marginal tax bracket will turn right around with a “fuck the doctors”.

    @CRM-114: There is a 6 hour timer on waiting in the ER where I volunteer, so what you are extrapolating from your experience is certainly not a California-wide policy. The order in which people are seen has to do with the acuity of their issues rather than arrival order. If you walked into a busy high-acuity ER with indeterminate abdominal pain and no apparent signs of distress, yeah, I imagine you’d sit for quite a while. My own experience with walking into a California ER during a gall stone attack is that I was in a room with a toradol injection and a page out to the surgeon on call before I knew what hit me. But (quite by accident) I walked into a community ER within a few miles of Stanford where I may well have been the most acute patient at that moment. If I had decided like a self-important idiot that my pain and cold sweat deserved a drive to Stanford, I surely would’ve waited a lot longer.

  6. #6 Kim
    August 30, 2009

    Err, not to imply *you’re* a self-important idiot, but a noticeable percentage of my neighbors in this region of the state are. ;-)

  7. #7 military wife
    August 30, 2009

    Wait, I *did* get dumped from a private ER in California to a public one once they were sure my severe problem (hemorrhaging kidney from an unsuspected tumor) wasn’t going to kill me that day. I guess I just thought that’s what they did!

    Well, did you get dumped, or did you get directed to the facility that was better able to serve your needs long term? I got into several arguments with people who wanted to scream about the program that Michelle Obama was (peripherally) involved with at UCMC where they sent patients out to public hospitals and/or community clinics that were better fits for their conditions or their insurance coverage. We have Tri-Care, and I spend quite a bit of time finding providers and facilities that take my insurance every time we move. Some people don’t understand how to navigate these issues, and it’s kind of unfair to accuse hospitals of dumping people when they really just direct them to the correct facility.

    I’ve been sent home from surgery way before I was able to care for myself, but I had family members who could help. Hospitals really aren’t set up to provide custodial care, and with drug resistant infections around in there, it is probably better to be at home if anybody can help you there, right? It’s sad that so many people don’t have friends or family members who can or will care for them, but keeping somebody living in a hospital for an extended period of time isn’t a great solution to that problem, right?

  8. #8 sli
    August 30, 2009

    Well, county certainly fit my insurance (or rather complete lack thereof) needs better. As for whether it fit my condition better, I don’t know, but I certainly have no complaints about the care I received from the public hospital. The reason given for transfer was better standard of care, but some of the things said by personnel–at both hospitals!–suggested otherwise. However, I was obviously not in the best shape to evaluate things at the time, so I don’t blame the other hospital for making what was probably the correct decision. I think it all worked out for the best, I just found it interesting given the discussion in Pal’s post.