Archive for category Indigent Care

Clinic of Last Resort — the ER

erdoorDeath can be caused by not having a car.   If a sick person does not have transportation the effects can be serious.  And, lack of insurance makes the problem worse.

A new study reported in Health Affairs  finds closure of inner-city ER facilities causes more deaths.  Poverty, advanced age, immigrant status, and lack of insurance were correlated with the increased mortality.

Poor people count on the ER as the clinic of last resort — our health system is designed that way — call an urgent care clinic and ask what services are available — “it depends on your insurance” is the answer — “you better go to the ER” is the advice if you have Medicaid or don’t have insurance.

Why wait until the last minute?  Because, there is always hope the health problem will get better, the chest pain will subside, the blood in the stool will stop or the arm weakness will vanish.  Once the heart attack hits, the bleeding is worse,  or the whole side of the body is paralyzed  the chances of death are much higher.

If you don’t have money one of the greatest concerns is NOT getting admitted — how do you get home, how do you pay for outpatient medications and how do you pay for the ambulance ride ($1000)?  The logic is simple: wait until you are REALLY sick.

The ambulance-to ER-to-operating-room is usually a very profitable supply-line of patients, so lots of resources have been lavished to make the system work.  If the ambulance-to-ER system brings diabetes, pressure ulcers and urine infections it drains a hospital’s resources, and finally leads to ER closure.

A good health system would provide transportation, guaranteed urgent care, medications and transportation home for a low-cost package price.  The unloading of the ER might actually save the ER, save patients with true emergencies, and save poor patients who get care earlier.  Wow — and what if that urgent care center was right next to the ER so if there really was an emergency it could be handled.

But no, all that would require planning and a health system where hospitalization was an overhead expense, not a profit center.  So, the only viable solution in the US:   include vouchers for ER visits with Cadillac  purchases or golf club memberships.

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Indigent Care and Accountable Care Organizations

Some Americans just don’t have access to health care.  That statement is hard to understand for many people.  Just get in the car and drive to your doctor’s office.  Or, if you don’t have a doctor where you live then move somewhere else!  People without money may not have a car and may live with relatives who don’t want to move.  It is reminiscent of what Marie Antoinette said about people who did not have bread “Let them eat cake”.

The majority of Americans do have access to health care so why worry about those who do not?  There are three reasons for concern; 1) we don’t like our fellow man to suffer  2) the care for people with poor access is terribly expensive once they do get medical attention.3) we have a system of care for the indigent which is very expensive and does not work well.  Poor people who live in the Mississippi Delta get health care like a third world country and sometimes not even that good.  In fact, a health care system copied from Iran is being used in Mississippi to try to improve access to care.

Just as an experiment, try to make an appointment with a doctor and say you don’t have insurance.  Voila, no appointment.  What if you have a sinus infection and can’t get an appointment with a health care provider?  You go to the emergency room.  Even though you have been admitted many times for heart failure you can’t get an appointment with a doctor so you run out of medication — back to the emergency room.  You have a growth on your breast but can’t get an appointment.  So when it smells bad you go to the emergency room.

One measure of poor quality preventive care and follow up care is the rate of emergency room visits and re-hospitalizations.  Some communities do very poorly by this measure.

When looking at the health care system as a whole providing good access to care is a way to save money.  But, in America we have lost track of those cost savings.  If a hospital, in good faith, tries to prevent readmissions for everyone, poor and rich, they lose income. The community benefits and taxpayers benefit but the organization controlling the situation is penalized.

There is some hope in the idea of an Accountable Care Organization (ACO).  That proposed system of care matches a population to an organization of hospitals and providers for care.  A certain amount is paid per person per year to the ACO (similar to insurance but without the middleman).  The ACO hospitals become overhead expense rather than cash cows and primary care providers that keep patients healthy are golden.  At least the incentives are aligned favorably for Americans but whether the idea will work is yet to be tested on a large scale.  If poor people are included in the ACO, access to care should be improved and cost may come down.  Additionally, an ACO can be held accountable for quality — since health care providers work for the ACO considerable pressure to deliver a quality product can be applied, especially if customers get to choose which ACO to join.

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