WhiteCoat

Emergency Care – Where’s The Line?

rat-under-yellow-lines-in-streetThe University of Chicago case is getting a lot of press and is polarizing the people on either side of the argument about Dontae Adams’ care.

Read about it at one of my previous posts, at ShadowFax’s place, over at Kevin’s blog, or at Scalpel’s blog. The Chicago Tribune is getting a lot of play out of the controversy. It has published several articles already and just put up another one last night.

Just by the sheer number of people writing about the topic, you should be able to tell that the outcome of this topic is going to help define how medical care will be provided in the future.

On one side of this issue is Dontae Adams and his mother.

Dontae happened to be in the wrong place at the wrong time. He was bitten in the mouth by a pit bull and had a large cut on his lip. It is obvious that he needed medical care. Dontae’s mother took him to the emergency department at the University of Chicago where she alleges that they began asking her about their insurance soon after they arrived. Dontae’s mom works and he has medical coverage through the Illinois Medicare program.

Stop here for a minute.

If you read through the comment boards at the Chicago Tribune web site, they are rife with people who criticize indigent/uninsured patients who may or may not be citizens of this country for “clogging up the emergency department” by going there for “routine” care. It’s easy to look down on someone is viewed as “abusing the system.”
So let me ask you this: Suppose you lost your job tomorrow and had no insurance. Suppose you had to take a minimum wage job at WalMart to keep food on the table for your kids and you weren’t eligible for health insurance. What would you do for medical care?
If you called a random doctor’s office and told them you needed an appointment for “routine” care and could only pay a small amount of cash, what are the chances that you’d get seen that same day? What are the chances that you’d be seen at all? Our family has good insurance, my daughter needs to see a specialist, and the earliest appointment is 4 months away.
Let’s say you’re living on a fixed income and want to pay for your doctor’s visits in cash. How can you afford to spend well over a hundred dollars for a single doctor’s office visit?
Ah, but there are free clinics all over the place, right? In the rural hospital where I moonlight, the closest free clinic is about 40 miles away and has very strict criteria on who it will treat at no cost. Cook County, IL, where the University of Chicago is located, is in the midst of a budget crunch and has closed down many free clinics. See articles HERE, HERE, and HERE.

There’s also an issue of whether or not the care some people seek in the emergency department is “necessary.” Clearly, much of the care that emergency physicians provide is not “emergent.” But I can say that because I have had eight years of medical training plus all the continuing medical education each year. Going to the emergency department to get an excuse for missing work, or trying to get a three day government-paid babysitter for grandma so you can leave on a trip is one thing, but in general, we have to give the benefit of the doubt to the patients.

Back to Dontae.

According to federal EMTALA laws, patients must receive a medical screening examination when they present to an emergency department seeking care. If an emergency medical condition is found, the condition must be stabilized or the patient must be transferred. If no emergency medical condition exists, the hospital’s duty under EMTALA ends.

From what I’ve read in the newspapers, according to EMTALA, Dontae’s injury was not an “emergency medical condition,” so the University of Chicago did not have a legal duty to treat Dontae once the emergency physicians determined that no emergency medical condition existed.

Now let’s look at things from the other side of the coin: Outside of federal EMTALA laws, what services should hospitals and physicians be “required” to provide?

Some believe that medical providers should be on the hook for everything. Expand EMTALA laws to require that patients receive everything they ask for. We need to provide for all of a patient’s needs. Whether it’s cardiac stents, kidney dialysis, Vicodin prescriptions, Lasik surgery, hair plugs, or a sex change operation, all medical care should be free to everyone. Sound silly? That’s the way our system is headed. If you think that some things should be free, but others should not, then you’re engaging in the same thought process that the University of Chicago used when it discharged Dontae Adams. Where ever you draw the line between free and not free, someone who would have to pay is going to criticize you for your decision.

That “free care” medical system is akin to expecting government to provide services with no one paying income taxes, expecting cities to provide services without anyone paying property taxes, expecting newspapers to run all of your advertisements for free (and to be delivered for free, too), or expecting professional medical societies to stay solvent without charging membership fees.

If we head down the free-for-all route in medicine, then why have insurance? If hospitals are required to provide all services to everyone regardless of the ability to pay, there’s no need to have any insurance. Hospitals can’t refuse care and all we have to do is show up at the front door to have access to the latest and greatest medical technology.

That’s a great idea, except for one problem: Who’s paying for it?

Medical care isn’t cheap. Government reimbursements for medical care are shrinking or nonexistent. New York pays a whopping $17.50 to physicians who provide lifesaving care to patients in the emergency department. California’s whole medical system is in shambles. Very few patients can afford huge medical bills. That leaves the physicians and hospitals holding the bag.

A “provide everything” approach becomes a system where hospitals and doctors are essentially paying for patients to come and receive medical care. That type of system is unsustainable. Providers have gone and will continue to go bankrupt. In addition, the more we lessen the incentive to go into medicine, the less physicians we will have. Who will want to spend twelve years of their life for medical education and take out several hundred thousand dollars in loans just so that they can provide unreimbursed care to anyone that demands it?

Do an internet search about hospital closings. Here’s a list of 50 hospitals that have closed in Illinois since 1980. Here’s another example of a hospital closure this month in Queens, NY. Is the University of Medicine and Dentistry in New Jersey next?

Where do we draw the line between care that must be provided and care that doesn’t have to be provided?

The line is already there. We just have to stop trying to redefine it.

The more we try to force medical providers to provide comprehensive free care for everyone, the closer we get to a system in which fewer and fewer patients have access to any care.

14 Responses to “Emergency Care – Where’s The Line?”

  1. Anonymous says:

    Mom Blogs – Blogs for Moms…

  2. paul says:

    yep. i work at the new receiving hospital for the ambulances that used to go to the 2 hospitals that closed in queens. it seems administration’s strategy for now is to “see how we do” with no changes in staffing or space. the incoming volume has already gone up noticeably.

  3. HyperAl says:

    Amen to that. The President in his speech last night promised healthcare reform by the end of this year. I hope he includes a lot of physicians in the group that will be commenting on this reform bill and not depend on lawyers and politician, mostly,as is always the case in Washington.

    Famous last word before the plane crush on the Hudson, “BRACE YOURSELF FOR IMPACT”. I just hope the result is similar.

  4. toni says:

    It’s not just the “poor” that are without health care anymore. My neighbor just went from a million dollar business to a zero dollar business. His family has been living off the gifts of money from friends and family since Jan First. Not all people are so blessed to have people that will step up and fill the financial gap to allow them to retain their home. They have 5 children. Their home is worth about $560,000 but in this economy isn’t marketable. They have sold off all assets boat, cars, any misc items from prior successful business. The one thing they didn’t retain since Jan First is healthcare for their family of seven! Right now it’s not your typical poor and indigent it’s the average and above average citizen without healthcare. They were paying $800.00 a month for private healthcare for their family a fortune when you have no income coming in to your house. I wish there was more affordable healthcare but I think free healthcare is a myth. It’s not free someone is paying for it. Quite possibly the rest of us who are fortunate to retain a job are going to be paying for everyone else. I think Obama might be living in Eutopia with his grand idea’s of taking care of every american. President Obama’s famous speech,
    “let’s spread the wealth” may take on a more personal meaning in healthcare and I just hope I am wrong. It is one thing to give freely to my neighbor who is hardwording and was in the wrong business when the economy turned sour but quite another to support everybody. Sounds like a nice thing to do but the reality of it might be like biting into a bad apple. I like the idea of cheaper healthcare not free healthcare.

  5. tyro says:

    Toni, I wonder how you can point out folks losing insurance and then say we shouldn’t be taking care of everyone. Spreading the wealth is already occuring; right now, I already subsidize emergency care rather than preventative care for uninsured through my health insurance premiums and my taxes. The money has to come from somewhere, and the more we deny the need for universal health care that is not associated with employment the more people we’ll have with no insurance forced into using already stretched EDs, AND letting their health problems go until they are much more expensive to care for.

    I’m not sure why we hate universal health care so much when both the UK and Canada have it, and we’re somewhat culturally similar. I’d rather pay higher taxes but have a working economy (since GM wouldn’t have to pay for health care) and no worries that I’ll have access. I don’t buy the ‘rationing’ myth as I already have to wait 4 to 5 months for a PMD apointment, or the ‘government will make decisions for doctors’ myth as we already have JCAHO. Seems we have the worst of both worlds.

    Worried about wealth being spread? It’s already happening, IMHO.

    • ER RN says:

      Well I dont want to be taxed to pay for everyone elses health care. I work and I pay for health insurance for my family. Since when is it my responsibility to take care of everyone else in America? Grow up and be responsible for yourself. If you can’t do that then whatever happens to ya happens to ya; NOT MY PROBLEM. Its about time to embrace Darwinism and stop preventing it.

  6. Doc99 says:

    The wealth is being spread all right. The money is going from the Government, Consumers and Employers, not to Doctors, but to the Health Insurance Monopsony.

  7. bwg says:

    You crazy Americans and your crazy healthcare model. I read these blogs daily and still struggle to fathom it out.

    My daughter got knocked over. An ambulance was called, we were rushed to hospital, she was X rayed, monitored, ECG, blood pressure, regular obs till it was apparent that 10yr old children who are not anticipating impact do indeed bounce, even when thrown about 12ft upon impact…we were then discharged with the usual routine warning signs to look for.

    None of this cost me a penny on the day. My income is taxable, and National Insurance is payable. Both are deducted before I get my monthly wage. Money goes from those deductions to facilitate our healthcare model. Yes it is abused at times. But your system appears open to abuse too, and frankly if more sick people are treated than there are people who abuse then it’s going good.

    However, three things are not (always) covered by the salary contributions….drug prescriptions, depending on imcome, eyecare in terms of spectacles and eye tests, and dental work. Dental work is subsidised if you are fortunate enough to find an NHS dentist but they are few and far between. I can’t grap why my teeth and eyes, which are both firmly located in my body, are not regarded similarly to a broken ankle, or a sleep disorder…

    Surely Dontae’s injury while not immediately life threatening, would result in some significant scarring, which in turn if left untreated might give rise to infection, and if not that, could give rise to scarring which in turn could precipitate low self esteem, depression, etcetera? Here (UK) Dontae would have been assessed, admitted and probably , as it is a facial injury, been treated by a plastic surgeon.

    What do you think will work for the USA? Do you regard our model as a success?

  8. Nurse K says:

    Dontae’s mother took him to the emergency department at the University of Chicago where she alleges that they began asking her about their insurance soon after they arrived. Dontae’s mom works and he has medical coverage through the Illinois Medicare program.

    Um, duhr? Everyone gets asked about insurance information when they arrive; that’s called ‘registration’.

    I assume you meant ‘Medicaid’ BTW.

  9. Carol says:

    Dontae’s mother should not be upset about being questioned about insurance coverage upon their arrival at the hospital. It is standard procedure. Whether she likes it or not, the hospital would like to know how it will be paid. Private insurance pays quickly; Medicare A and B are also quick payors, but Medicaid, paying the least amount of money, very little in fact, can take one to two years to pay for services. Dontae’s mother must realize that in the meantime the hospital has a payroll to meet and bills to be paid, along with property taxes, etc. It amazes me that people pay personally for life insurance, homeowners’ insurance, renters’ insurance, auto insurance, even motorcycle insurance, but they balk at paying for health insurance, the one thing that makes it possible for them to enjoy their homes, vehicles, etc. More and more often I believe that Americans, particularly the 20 to 45-somethings, are permanently ‘stuck on stupid’.

  10. Cindy Anderson says:

    I do not think any emergency room should turn someone away. But I do think we should deport many people here illegally who should be receiving treatment in their own countries and not costing the American taxpayer. I fault our government for not deporting them. And I do fault the many people who can afford health insurance who don’t purchase it and then can’t pay when something catastrophic happens. I am angry that US citizens like myself have had to pay thousands of dollars in healthcare expenses with insurance since I have cancer when these people here illegally usually pay nothing. I have a friend whose brother is a OB in Texas and he said the illegals crossing the border to have anchor babies has bankrupted his hospital since they don’t pay. My daughter had to save up money to pay the birth of her child and she and her husband work very hard. It is not unfair and not right. The largest population of people here illegally live in Mexico which is ranked the 14th developing nation in the world…it is really not a poor nation but the oligarchic form of government refuses to fairly provide for its people. Why don’t we put pressure on the Mexican government to take care of their own…funny, they are very strict on illegal immigration in their own country and do not give immediate citizenship if a child is born there but criticize any US citizen who does not believe we should allow it. And one more thing, my primary doctor is a coptic Christian Egyptian…he left because of much repression of Egyptian Christians in his country. He has waited 10 years to become a US citizen and is one of the finest doctors I know…he saved my life when I had surgery. He takes nothing for free but gives back to the US constantly and feels his citizenship is a privilege not a right. Why should someone like him have to wait 10 years for citizenship while people who break our laws and use our resources expect to receive citizenship while not following our laws. Sorry call me hardhearted..I believe in fairness and justice. But turn anyone sick away in an ER that can not pay, I don’t think that is humane. We must stand strong on our government to deport people here illegally where they can receive treatment in their own country when they need it.

  11. Teresa says:

    Cindy, I’m right there with you except for one thing. If we don’t allow people to be turned away from the ER, then the doctors and facility should be paid by “us” for treatment rendered. I oppose unfunded mandates. If we’re going to impose a duty on someone to treat poor people, then we need to pay for it.

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