Sunday, March 1, 2009

Week Nine Online Challenge

57 million Americans had trouble paying medical bills in 2007. This is up 33% from 2003. In four years, more than 14 million more people went into debt or were contacted by a collection agency about healthcare costs. Hundreds of hospitals nationwide are in the red. These seem like frightening statistics, but historically, numbers like these fail to make meaningful inroads in public policy. My opinion is that unless we link human stories to crises, our minds tend to neglect the seriousness of the problem. And unless concerned citizens (who are nurses, doctors and EMTs) contribute to the local and national conversations, health care reform will remain theoretical.

This week's challenge requires you to put on your activist hat. With emergency care in mind, post a comment that furthers the discussion of health care system reform. Your response could take a couple of forms.
  • Write a case vignette that tugs at the heartstrings of a concerned populace.
  • Respond to last week's news story from the University of Chicago. (A boy was reportedly sent home to follow up at another hospital after he was attacked by a pit bull.)
  • Teach us about a part of the local health care safety net that we can plug patients into.
  • Hypothesize about how the worsening economy may change emergency medicine.
  • How has pre-hospital care been affected by the current health care crisis?
Keep in mind that you don't have to be a Democrat or Republican to be concerned about the health care system. There are plenty of ideas from both sides. In case you are wondering how this fits into a medical ethics class, try to think about your responses using the rights and justice terminology.


  1. It's interesting how the change in the economy and the change in reimbursement is changing Emergency Medicine. As hospitals are facing a tighter bottom line, they are looking at access patterns and sources of referrals. At most hospitals, admissions come from the ED and from clinics. In order to increase insured ED referrals, many hospitals are modernizing, upgrading, and making cosmetic upgrades to the ED. For instance, look at the recent rennovations to Evergreen, Swedish First Hill, and Valley Medical Center. If you have to chose between 3 ED's in the same area, are you going to go to the nice looking one, or the dingy one? This is going to select for insured and put more pressure on other centers that have less revenue.

  2. After reading the article about the pit bull attack it seems like they are mixing apples and oranges. I can understand the theory of redirecting non-emergent cases to local clinics - in light of busy EDs and their increasing use a primary care clinics by the uninsured this plan seems reasonable. However, in practice it sounds as though the patients are getting interrogated regarding their insurance status. An emergent case is an emergent case, despite a patient's level of insurance coverage or lack thereof. Insurance status should be taken out of the equation if their goal truly is to limit non-emergent cases from taking up valuable ED time/resources. In light of the ethics of the situation, selecting patients in the ED on the basis of their insurance status is a breach of justice. Either they are emergent and belong there, or they are non-emergent and don't.

  3. Russel brings up a great point regarding insurance patterns.
    I don't know much about other hospitals, but at Valley in particular, we intentionally refuse to collect insurance information before a patient has been triaged, assigned a bed, and seen by a physician. Only after all this does Registration get the goahead to collect that data.
    This may not be widespread, but I have always appreciated that about Valley. Being a public hospital, it was always nice to know that we really did take insurance status out of the equation.

    Regarding prehospital care... I think the trend is toward tax-supported fire service units either offloading all trnsportation services onto private companies.. or charging patients for transport themselves.
    Most major agencies in the county use private ambulance for BLS and Critical Care transport now, and in Peirce county for ALS transport as well. On the City of Kent's website, it says "The Kent Fire Department does not offer transport to the hospital because we do not have the resources to transport, and respond to all the 9-1-1 calls that we receive."
    In the last few years, smaller agencies (like Maple Valley Fire, have taken to charging patient's insurance companies for hospital transport, because they were over the budget provided by property tax alone. Though to their credit, they state that they will never send anyone to collections for inability to pay.

  4. I'm glad to have heard a little more about the case in chicago, becausethus far I only knew the basics. I will say that from what I can tell, it appears the care that the child received (being sent away) was inappropriate and I also believe that insurance status should not be the basis for admission, but I consider the efforts of U. chicago admirable
    and practical. I once took care of a patient who came into the ED because he had pain around his nose. It was pretty obvious from
    simple observation that he had a pimple on the inner portion of his nostril and nothing else. He didn't have insurance, and didn't know where else to go. Something like the program at U. chicago may have prevented this
    from happening. I've also heard from some individuals here at Harborview that they either are setting up or have already set up case managers for some of the frequent fliers in the ED. The case managers help find
    appropriate care for these patients outside of the ED in an attempt to find more appropriate care.

  5. I believe Emergency care is going to see a huge increase if insurance is not changed. We are going to get a lot more people with medical problems and have a higher level of non-compliance. Without a major change in how money is exchanged we are going to be looking at a very rough situation and many more hospitals will start to act poorly, as I believe U of C did with the dog bite patient.

    We know that money is the bottom line. It is horrible that in the US we have to pair someone's health (their life) with a price-tag.

  6. I agree with the above comments that insurance should not be the factor that determines whether the patient receives medical care. However, emergent cases aside, if the issue of insurance may jeopardze the quality of care the patient receives or if it's against hospital policy to admit said patients, I think it is appropriate to refer the them to another institution that will be able to better care for them. In addition, handling non-emergent cases in the ER is costly and those cases need to be redirected towards a more appropriate outlet.

    The referral of non-insured patients happens all the time, although I haven't heard of many cases from an ED setting. I'd like to think that the UofC medical team acted in the best interest of the patient, but this certainly seemed to be an emergency case & doesn't seem like the team made the best judgement call.

  7. Several thoughts:
    We are already seeing medical "poster children" of the recession -- people who lost their jobs and can't afford their meds and present hypertensive, hyperglycemic, with worsening CHF or worsening renal failure. Harborview (for now) refills their meds for a month and attempts to create followup care in a system where the earliest primary care appointment for a person without insurance is 3 months in the future. etc. My question is: what degree of strain in the emergency medical system will unravel EMTALA and prompt it to be overturned?

  8. I find Cooper's comment above very intriguing. Instead of trying to fix a system so that the EMTALA legislation could serve its intended purpose, perhaps the situation will become so untenable before the system can be fixed that the emergency medical system will simply be forced to disregard the requirement. Or even more interesting, put its efforts toward overturning it.

    How would emergency departments then determine who to see, who to divert and who to send home? Wouldn't that send the decision right back to the individual hospital's administration? Wouldn't the pressure be even greater to try to attract those with insurance and send away those who cannot pay?

    I think it's interesting that the President seems to believe that health care and energy are two pivotal components of a healthy US economy that cannot wait for the recession to moderate in order to be addressed. It certainly seems like we might be experiencing a moment in history when "the status quo" will simply fail too many people to be allowed to stand.

    As many others have said, the pit bull story seems like a case of a good policy (diversion to the appropriate provider) applied in an inappropriate situation. But everyone seems to be reading more into the policy by saying the decision was made based on the individual's lack of insurance, not just a bad judgement call. I guess I'm not so sure that was the case. It's easy to second-guess decisions with the benefit of hindsight, but hard to always make the right decision initially. I wonder if the U of C deserves the benefit of the doubt.

  9. I get the feeling that real change in the system is NOT going to come from health care providers, hospital administrators, etc...It's these kinds of narratives that appall the general public that are going to stir up changes in the current system.

    As to what Barb asked above, no I really don't believe the University deserves the benefit of the doubt. You said it perfectly they applied adequate and currently accepted policy to an entirely inappropriate situation. Perhaps the nursing staff was feeling the pressure of the expanding hospital policies to eliminate overuse of the ED and acted accordingly. Nonetheless, they did not offer the mother any explanation of what was going on nor did they help her in finding alternative resources. If they are really going to expand current policy, I would assume that this would have to be accompanied by detailed rules and appropriate staff that will determine what constitutes appropriate emergency care...perhaps even a system based on levels of emergency and what possible resources the hospital can shunt the patients to in the meantime.