Today I was going to finish a post I created about how emergency care in the US is now at a “tipping point.” Before doing so, I scanned some of my favorite blogs. A post by Dr. Wes is so insightful and so timely that I had to incorporate it into what I was writing about.
Dr. Wes coins a new term called the “Bernie Syndrome”, named after Bernie Madoff and his giant Ponzi scheme that took down so many wealthy investors. People got caught up in his scam because no one took the time to look at how Bernie achieved his remarkable results. No one cared. Bernie’s clients just got regular portfolio statements showing how great their investments were going. Meanwhile, behind the scenes, everything was crumbling. Even though Madoff’s business model was collapsing, everyone was still happy because of the rosy statements that Madoff was sending them … that is until the market got so bad that he couldn’t maintain his charade. Suddenly there was nationwide panic as people learned that the real picture was nothing like the picture that Bernie Madoff had painted.
Dr. Wes gives a couple of examples about the “Bernie Syndrome” and healthcare, including the recent SCHIP expansion and lowering Medicare eligibility to age 55 instead of age 65. US citizens suffering from Bernie Syndrome think that the added coverage is great. After all, just like Bernie Madoff’s investors, the public is going to get even more health care – for free – regardless of what the market or the deficit is like. SCHIP expansion will cover more kids. Medicare expansion will cover more seniors. Underneath these wonderful proposals, however, the medical care system in this country is being crushed under its own weight.
Before the Madoff collapse, several industry insiders questioned the returns Bernie Madoff achieved with his investment portfolios. No one seemed to listen – they were too caught up in the grand illusion that Madoff had created.
Now, at least in emergency healthcare, the Ponzi scheme, reinforced by the Bernie Syndrome, is starting to unravel.
George Bush embodied the Madoff Mentality when he told business leaders during a 2007 speech in Cleveland
“The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America. After all, you just go to an emergency room.”
The transcript of Mr. Bush’s speech used to be here, but for some reason the White House has now removed the text of that speech from its archives.
So patients with Bernie Syndrome now go to the “emergency rooms”. The widely held belief is that if you go to the emergency department, federal law requires the emergency departments to treat you. That widely held belief is only partially true.
EMTALA laws require that every patient be screened for an emergency condition. If no emergency condition is found, the hospital has no duty under EMTALA laws to provide any further care. If an emergency medical condition is found, the hospital is required to stabilize the condition, or, if the hospital cannot provide stabilizing treatment, then the hospital must provide an “appropriate transfer” to another facility that can provide such treatment.
The Ponzi scheme in emergency medical care was working well for a while. Then shrinking reimbursements closed some hospitals. Now unfunded emergency care is taking too much of a bite out of hospital budgets. You see, EMTALA may require that hospitals provide all patients with a screening exam and treatment for an emergency condition, but EMTALA makes no provision on how providers will receive reimbursement for that care. If a patient has no insurance and is not covered any of the social programs, the government won’t be on the hook. If the patient doesn’t have any money, the patient won’t be on the hook. Who is left holding the bag? Health care providers – hospitals and doctors. Hospitals may try to transfer the costs for some of that care back to patients with insurance, but as unemployment increases and the number of insured patients decreases, that shuffling will become unsustainable.
Health care providers are now trying to mitigate their financial risk. Specialists are avoiding EMTALA requirements by refusing to participate in emergency department call schedules. If specialists aren’t on call, they aren’t bound to treat anyone under EMTALA laws. The “free” specialist care has now dried up. In some rural communities, it may require travel of several hundred miles to obtain proper “on call” specialist care.
The latest way in which the Madoff Mentality is affecting emergency medical care is when hospital emergency departments provide the minimum amount of care required under EMTALA and then refer indigent patients to community clinics for further care. If a patient does not have an emergency medical condition, the hospital has no further requirements to treat the patient under EMTALA. EMTALA defines an “emergency medical condition” as
A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in
(i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
(ii) serious impairment to bodily functions, or
(iii) serious dysfunction of any bodily organ or part …
More and more hospitals are now providing an “EMTALA screen” to patients and then referring them to an outpatient clinic if patients do not have an emergency medical condition and cannot pay for their care.
Such was the case with the University of Chicago when it sent a child home last August after the child had been “mauled” by a pit bull. The story was just published in the Chicago Tribune on Friday.
After being bitten in the lip by a stray pit bull, 12 year old Dontae Adams was screened by emergency department staff. Part of his lip was “literally gone” according to Dontae’s mother. He was given antibiotics, morphine, a tetanus shot, and then was told to follow up at the County Hospital within one week. Dontae’s mother took him immediately to Cook County Hospital where he was “quickly admitted for surgery.”
While the case has sparked outrage among the public and among some medical groups, these are the difficult decisions that are being forced by the government’s Madoff Mentality and by those with Bernie Syndrome.
Failure to provide immediate treatment to Dontae’s lip laceration did not place his health in serious jeopardy, did not result in a serious impairment to any bodily functions, and was not likely to result in a serious dysfunction to any bodily organ or part. So technically, it does not appear the University of Chicago violated any EMTALA laws when it evaluated Dontae, provided basic treatment, and referred him to a county hospital.
As the giant healthcare Ponzi scheme starts to unravel, look for more and more hospitals to provide the minimum amount of medical care required under EMTALA and then refer patients without the means to pay for their care to community clinics. Need cancer treatment? Better have a substantial down payment if you go to the ED and want to be admitted. Have a broken bone? Chances are that you’ll get splinted and that you’ll just have to follow up in an outpatient clinic. There, without insurance, you’ll have to bring a down payment as well. Most of the time runny noses and coughs will be sent home from triage unless they have insurance.
For some hospitals, this tactic may be a way to increase profits, but for many hospitals, this policy will be a means to stave off bankruptcy.
We will never have a medical system in which health care is fast, free, and quality.
If you believe otherwise, I suggest that you also be careful on how you invest your retirement funds.
UPDATE FEBRUARY 19, 2009
The American College of Emergency Physicians issued a press release regarding the University of Chicago case.
The Chicago Tribune immediately released an article noting ACEP’s response. The comments section of the Tribune article shows many divergent opinions regarding whether exhaustive medical care should be free to all.