April 4th, 2009

We could use some oversight here: frequent fliers in the emergency room

Here’s a little tidbit you may have missed:

Just nine people accounted for nearly 2,700 of the emergency room visits in the Austin area during the past six years at a cost of $3 million to taxpayers and others, according to a report. The patients went to hospital emergency rooms 2,678 times from 2003 through 2008, said the report from the nonprofit Integrated Care Collaboration, a group of health care providers who care for low-income and uninsured patients.

“What we’re really trying to do is find out who’s using our emergency rooms … and find solutions,” said Ann Kitchen, executive director of the group, which presented the report last week to the Travis County Healthcare District board.

The average emergency room visit costs $1,000. Hospitals and taxpayers paid the bill through government programs such as Medicare and Medicaid, Kitchen said.

Eight of the nine patients have drug abuse problems, seven were diagnosed with mental health issues and three were homeless.

Let’s do the math. For each of these nine people, this represents an average of one visit to the emergency room every 7.3 days, year-round, for six years. No doubt some went more and some went less, but that’s the average.

Kudos to the folks at Integrated Care Collaboration for at least trying to study these shocking facts and to seek solutions. I wonder, though, why it took them to notice it. Surely the folks at the hospitals involved must have recognized what was going on, with this volume of visits by such a small number of people. Are there not social workers there who might figure out another way to handle this? Is there no way to refer these folks to primary care physicians or the mental health and especially the substance abuse treatment systems? Or is the taxpayer just eternally on the hook, because no one can be turned away if he/she appears at the ER door?

I also wonder how many of these patients were illegal aliens. The article is mum on that fact, so we have no idea whether it was an issue. But considering that the venue was Austin, Texas, it’s a good possibility.

I think this study points out a common problem, which is that a few people can be responsible for a great deal of strain on a system, and that government regulations often tie an organization’s hands even if those who work there might want to implement a more creative—and reasonable—solution.

I’m fairly sure that, when it was decreed that no person without insurance would be turned away from an emergency room, the idea was that ERs would actually be used for emergencies. But creating an entitlement often causes it to be used for purposes never originally envisioned, expanding it beyond all recognition into absurdity.

23 Responses to “We could use some oversight here: frequent fliers in the emergency room”

  1. huan Says:

    the problem with US healthcare is so much more cost than access to care, as this story so clearly illustrates.

  2. Alex Bensky Says:

    kIF we wind up with a single-payer health care system, this will not seem unusual at all.

    Reason # 1,984 that I am no longer a liberal is that I eventually came around to the idea that if you don’t ration something people want, they’re going to try to get as much of it as they can.

  3. Jamie Irons Says:

    Neo, I could tell you ER stories that would absolutely appall you.

    Since about half of my work is in consultation-liaison, I deal with this every day.

    It is important to understand that state and federal regulations play a huge part in making this problem intractable and, as you note, mental health and drug abuse problems (more often than not both of them in the same individual) are involved in most of these cases.

    Social workers are involved, and they do a terrific job. But the communities simply don’t have the resources to handle the patients once they leave the ED.

    For anyone who fantasizes that “universal health care” will ameliorate this problem (or indeed any problem), I have a very large and very beautiful bridge, not twenty miles as the crow flies from where I sit, that I will gladly sell them.

    Jamie Irons

  4. Mark V Wilson Says:

    The Last Psychiatrist has a good critical post on this story and the difficulty with evaluating cost in this context. The summation is this: “Do you think those Austin area ERs will ultimately bill $3M less if they sent those 9 patients to Neptune? Let alone if they got Aetna?” Link here.

  5. vanderleun Says:

    Or is the taxpayer just eternally on the hook, because no one can be turned away if he/she appears at the ER door?

    In a word, yes.

    I also wonder how many of these patients were illegal aliens. The article is mum on that fact…

    It would have to be since the answer cannot be known. Austin is a “sanctuary city” and has been since the late 1990s.

    American Thinker’s Hit and Run Death Story from last November gives the details here:

    http://www.americanthinker.com/2008/11/hitandrun_death_in_a_sanctuary.html

    It would seem that the ruling law in this case is “Emergency Medical Treatment and Active Labor Act of 1985 (EMTALA).” whose effect is detailed here:

    http://www.federalobserver.com/archive.php?aid=9572

  6. Gringo Says:

    Was it not Michelle Obama’s function at the U of Chicago hospital to funnel people who used the U of C’s ER to lower-cost clinics?

  7. Jamie Irons Says:

    Vanderleun is exactly right. EMTALA is the villain here.

    There are so many problems with this law that it is hard to know where to begin.

    But let me just say that recently, when our county shut down its crisis clinic because the county is broke (hey, it’s part of California!), we at my hospital were put at risk, in an obligatory way that we could do nothing about, because of the county’s actions, over which we had no control. It has taken us months to get the situation to where it is only moderately disastrous.

    Jamie Irons

  8. lumpy Says:

    Another statistic that should be tracked is how many of those visits the patients made via ambulance, thus increasing the health care costs and stressing the EMS system of the community which provides the service.

  9. PapaMAS Says:

    Neo, absurdity is correct. This is one of those things I always shake my head at. I have a problem going to the ER for routine care. The emergency room is where you should go if your arm is cut off, not when you have a cold. Yet that is just not the way it is these days.

    This caused me a bit of a problem a few years ago. My son broke his arm one fine Friday night so I bundled him into the car and drove to the ER. It was packed and a party atmosphere prevailed! Entire extended families were hanging out and no one was in obvious distress to me. (Granted: I’m not a doctor and the only important thing to me was my son, who was still crying in pain). I was stupefied when the uninterested desk clerk shoved me a waiting number about two dozen spaces away from that currently being seen.

    I tried to make sense of it while sitting down and trying to comfort my boy. We live in a real small town yet it was packed. What were all those people doing there? Seriously, it was like a dang party, not a hospital waiting room.

    Thankfully, the woman who was next in line took pity on us and traded her number for ours. Very decent of her. Still, this should not happen.

  10. njcommuter Says:

    I’m told that if you are brought in by ambulance you get priority attention.

    On the subject of those nine patients who cost society the rest of us so much money: several of them were said to have mental problems. Are we looking here at the cost of deinstitutionalization? Because I can’t think of a better argument for institutionalization. If they need care, and the cost of that care is the income of ten middle class families for a year when they are allowed to wander in and out of the emergency room, should we enslave those families to pay for these people, or should we confine the people to a place where they can get the care they need without hurting the rest of us? Unless we are willing to tattoo these people in day-glo colors with the words “hospital abuser, do not treat” this is the choice we face.

  11. What Does Health Care Cost? « Happy Friday the 13th! Says:

    […] Neo-neocon; here’s her post on frequent fliers in the ER where I found the link in the […]

  12. Tom Says:

    This is one of many end-results of Leftism, remaking reality to fit their vision of how it should really be, not how it in fact is.

    Mental institutions disappeared a generation ago. The long history of “asylums” (truly sanctuaries for the mentally disabled, though often abusive and negligent in practice) was rapidly flushed with the advent of the first anti-psychotics (phenothiazines), coinciding with extrapolation of the civil rights movement to institutionalized psychotics. Thomas Szasz, an academic psychiatrist in Syracuse, was prominent in setting up the antipsychiatry thrust, which holds that all persons (no matter how addled) have the right to control their bodies and what goes into them.

    The end result is psychotic homelessness. Psychotics have the right to refuse drugs and have the right not to be confined in a sanctuary, regardless of the severity of their dysfunctionality.

    Rather than bowing to the evidence, we now have all sorts of fundraising “charitable” non-profits employing people to help the homeless. Constantly we hear the mantra, “Fight to end homelessness!” from them. But of course that is now impossible, no matter how many dollars we give.

    It is all too absurd for words. The Obamites will eventually institutionalize rational objectors, but not the crazies who accost the public, spread infectious disease, refuse their meds, and episodically rape and murder.

  13. neo-neocon Says:

    Tom: Actually, although de-institutionalization was a product of the Left, and people such as Szasz (who believed that mental illness was just a construct and didn’t really exist, and that psychiatrists and psychologists and mental institutions were oppressors of those labeled mentally ill) promoted it, it also fit in with libertarian thought. In fact, Szasz himself purports to be coming from a “classical liberal” (i.e. somewhat libertarian) point of view.

    The original plan envisioned a series of community-based halfway houses for long-term care rather than the mentally ill becoming street people. Of course, the former never happened, and the latter did.

    Putting aside the libertarian aspects of the situation of locking non-criminals up against their will, I wonder whether it would be more expensive to do so versus our present system. I don’t know the answer. But the original de-institutionalization campaign was also an attempt to save money, as I recall.

  14. Tom Says:

    Neo:
    Doesn’t it make you just love academia, that Szasz was a member of the psychiatry dept at Syracuse U.’s School of Medicine, making a career of his assertion that mental illness really doesn’t exist?

    He caught the anti-establishment wave of the ’60s and surfed it with accolades, awards, and income. He tilted against some straw men with his pro-suicide stance, to the tune of, “if we allow the taking of fetal life on demand, as we do, we should allow suicide on demand, too”.

    That he defines himself as a classical liberal just doesn’t cut it with me. Nor you either, I surmise.

  15. neo-neocon Says:

    Tom: I recall reading the work of Szasz back in college, when it was au courant. He was an iconoclast. But he went much too far, and threw the baby out with the bathwater. I have no idea whether he was actually coming from a libertarian point of view. He did seem to be contrarian more than anything.

  16. Wolla Dalbo Says:

    The local hospital’s ER, in the Washington, D.C. suburbs, is also packed with what looks like half of Nuevo Laredo, including what seemed like their million ill behaved kids, and extended families with grandmothers or perhaps great grandmothers too.

    Two years ago my wife was in a minor car accident, and we went to the ER to have her neck checked, because she had once injured it in a major car crash and still painful skiing injuries to her neck as well. Well, we sat there for close to three hours, the Hispanics and their kids—non in obvious distress—kept getting in to see the doctors and being replaced by yet more Hispanics and their families, but, despite reminding the sullen nurse a few times that we were waiting, we never did get to see a doctor, and eventually we walked out, and saw our own physician the next day, who got my wife into the hospital for some X-rays.

    That year the Hospital, which apparently hadn’t been doing too well financially, reported that it had to take a loss of something like a hundred thousand dollars or more to pay for the treatment of “uninsured patients.”

    We try to avoid that “local hospital” if at all possible now, and go to a more rural hospital that is not so inundated by illegal aliens. Why do I think that most of the Hispanics in that ER were probably illegals—well, all I have to do is look at the estimates for the number of illegals in our area, and at all the empty houses they have walked away from, and the foreclosure and for sale signs in the newly run down neighborhoods formerly packed with them, close by to that hospital.

  17. Tom Says:

    Neo: Szasz is one bit of data that shows most new ideas are bad ideas. But we seize upon them, being so au-courant, as you say.
    I read him on my shrink rotation in a NYState medical school in the ’60s. The shrinks stood in nervous awe, fearing to call him what he was, or at the least was clear to become, a false prophet.

    And a large part of my class became shrinks. Whoa!

  18. camojack Says:

    For those 9 people, much as I’m reluctant to endorse it, I’d recommend the treatment administered to Terry Schiavo…

  19. Lame-R Says:

    While shooting the breeze with an ER doc at a community hospital here in SoCal, he mentioned that they knew the majority of their patients by name since they see them so frequently.

    And apparently many of them do get an ambulance ride in any time they’re not feeling well.

    The hospital bills the state for what they can, then passes on the difference to those of us who actually pay for our medical care.

    Sometime this past year Forbes had an article on specialty clinics versus large hospitals, and an interesting aside was the opposition based on cost: the large hospitals claimed they were bound by law to support a money-pit ER serving the community, whereas the nearby knee or cardiac center didn’t have such a burden so they could charge less for their procedures.

    A fine mess our legislators have created for us.

  20. Wolla Dalbo Says:

    I am afraid that after about the 5th or 6th visit, my solution would be forcible medication and/or forcible enrollment in a long-term residential drug and/or alcohol treatment program to sober them up, or, if they didn’t like that, then a little attitude adjustment behind the clinic.

    Thereafter, they should not be seen or treated unless they were actually bleeding, or had a valid, life-threatening emergency, and had worked at some sort of productive job, so that they could at least pay something towards their care.

    Why a few incorrigibles should be allowed to suck the lifeblood out of a medical system and, thereby, deny treatment to many others with real emergencies is beyond me; this is not mercy, or “caring,” this is insanity.

  21. Tom Says:

    Uhhh, Wolla, you’d be violating their civil rights and Federal law, so what ya gonna do? Not to mention the malpractice lawsuits seeking megabucks. It’s simply much less trouble and much less risk to just call ’em by name and welcome them back, billing whatever taxpayer supported entity “supporting” them.

  22. Wolla Dalbo Says:

    Tom–that’s the problem, of course; that moderation, reason and common sense have been thrown out the window, and what with all of the new found “rights,” “entitlements” and “benefits” that our government, courts and legal system have discovered or created, a few nut jobs, incapable of or, more likely, unwilling to straighten themselves out a little, can so parasitize a treatment facility that they ruin it for others.

  23. Oh, bother Says:

    At the free-standing, privately-owned ER where I worked most recently, we had our share of frequent fliers. Virtually all were drug-seekers. Upon their third presentation they were required to sign a contract stating they would seek the care of a pain management specialist. If they came in again the nurse would contact the specialist to make sure they were following protocol. Only once in about fifty times had the patient actually followed through and seen the pain management doc. The rest? We didn’t see them a fifth time.

    Yes, Gringo, Michelle Obama was paid an amazing amount of money to tell low-income patients to go away. Then her very well-paid job was eliminated by the hospital after the election.

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Previously a lifelong Democrat, born in New York and living in New England, surrounded by liberals on all sides, I've found myself slowly but surely leaving the fold and becoming that dread thing: a neocon.
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