Too broke for the ER, patients flee

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Too broke for the ER, patients flee

Recession forces many to leave ‘against medical advice,’ doctors say

In hindsight, maybe Jesse Ashlock shouldn’t have walked out of the New York emergency room last summer, only a couple hours after being knocked unconscious in a Brooklyn bicycle crash.
Medical crews told him he needed a blood test, chest X-rays and probably a CT scan to check for head injuries. And he certainly should have had treatment for major road rash, including raw scrapes on his face, neck and hands.
But the 31-year-old editor for a design magazine was between jobs, briefly without health insurance and afraid of being stuck with a sky-high hospital bill. The doctor on duty dismissed Ashlock’s questions about cost, telling him she was “a physician, not an accountant,” he said.

So Ashlock stalked out of Woodhull Hospital without treatment, becoming part of a small but growing number of patients turning down emergency care because they fear they can’t afford it.
“I’ve heard all kinds of horror stories … I could easily imagine it being $5,000,” said Ashlock. “I was worried about having a concussion and worried about going to sleep, but I was fine.”
Even as rising unemployment strips people of health insurance, sending many to emergency departments for care, doctors on the front lines say the lingering recession is also prompting an unexpected outcome.
More patients, they say, are refusing potentially costly procedures ranging from tests to confirm heart attacks to overnight stays to monitor dangerous infections.
“I have definitely seen an increase in this problem,” said Dr. Sara L. Laskey, who works in the emergency department of MetroHealth Medical Center in Cleveland, Ohio. “They’re really making conscious decisions about what they do and don’t want done.”
Just last month, Laskey saw a woman with bronchitis and pneumonia with life-threatening oxygen levels who refused hospital admission because she had no insurance. Even when Laskey arranged for her to have an oxygen kit to take home, the woman turned it down because of the cost.
“She refused, saying she would share her husband’s oxygen,” Laskey said. “Ultimately she left without the oxygen or an admission.”
Discharged ‘against medical advice’
Increasingly, such cases are raising ethical dilemmas for doctors, forcing them either to persuade patients to agree to treatment or else to discharge them “against medical advice.” That’s a formal designation that signifies a patient is knowingly disregarding a doctor’s guidelines.
About 119.2 million visits were logged in U.S. emergency departments in 2006, according to a report last year by the federal Centers for Disease Control and Prevention. Of those, about 1.5 million, or 1.3 percent, ended with discharges against medical advice, or AMA. Doctors believe those numbers are both underreported and growing.
“Even without the recession it goes on all the time, but it probably goes on more now,” Dr. Neal K. Chawla, who works at a stand-alone emergency clinic run by Inova Fairfax Hospital in Falls Church, Va.
“It’s like, ‘OK, I’m not dying of a heart attack, let me go home,’ ” he said. “I have similar conversations two or three times a day.”
Just this month, Chawla, a spokesperson for the American College of Emergency Physicians, said he argued with a man who refused hospitalization to drain a large abscess on his buttocks; another man who declined admission for an infected kidney stone; a woman with low-risk chest pain who didn’t want to pay for further cardiac exams; and a patient with acute appendicitis who needed emergency surgery but didn’t want to pay for an ambulance.
“He called his mother to drive him over,” Chawla said.
Some patients can be convinced to submit to care, but others can’t, said Dr. David J. Alfandre, a researcher with the National Center for Ethics in Health Care run by the U.S. Department of Veterans Affairs.
“Everyone has a right to decide what’s done with their body,” said Alfandre, who reviewed studies of discharges against medical advice in a report for the Mayo Clinic Proceedings in March. “The hard part is ensuring that the patient understands the risks and benefits.”
Rates of hospital discharges against medical advice are about the same as for emergency rooms: between 1 percent and 2 percent, Alfandre found. Of some 39.4 million hospital discharges in 2006, about 390,000 were classified as AMA, according to statistics from the federal Agency for Healthcare Research and Quality.
Overall discharges grew by 14 percent between 1997 and 2006, but AMA discharges, the smallest category, jumped by 48 percent in that period.
“Early leavers,” as they’re sometimes known, are most often men on state-sponsored Medicaid or with no health insurance who have serious social and financial concerns, research shows. About 21 percent of people discharged against advice had no insurance, compared to about 7 percent of routine discharges, according to AHRQ. …

man got to luv a care system

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[Sarcasm]Our health care system is great the way it is[/sarcasm]

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I would hate to be a doctor in some of those situations. When you know how bad a situation can be, but can’t do anything about it. Terrible…

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France’s model healthcare system

By Paul V. Dutton | August 11, 2007
MANY advocates of a universal healthcare system in the United States look to Canada for their model. While the Canadian healthcare system has much to recommend it, there’s another model that has been too long neglected. That is the healthcare system in France.
Although the French system faces many challenges, the World Health Organization rated it the best in the world in 2001 because of its universal coverage, responsive healthcare providers, patient and provider freedoms, and the health and longevity of the country’s population. The United States ranked 37.
The French system is also not inexpensive. At $3,500 per capita it is one of the most costly in Europe, yet that is still far less than the $6,100 per person in the United States.
An understanding of how France came to its healthcare system would be instructive in any renewed debate in the United States.
That’s because the French share Americans’ distaste for restrictions on patient choice and they insist on autonomous private practitioners rather than a British-style national health service, which the French dismiss as “socialized medicine.” Virtually all physicians in France participate in the nation’s public health insurance, Sécurité Sociale.
Their freedoms of diagnosis and therapy are protected in ways that would make their managed-care-controlled US counterparts envious. However, the average American physician earns more than five times the average US wage while the average French physician makes only about two times the average earnings of his or her compatriots. But the lower income of French physicians is allayed by two factors. Practice liability is greatly diminished by a tort-averse legal system, and medical schools, although extremely competitive to enter, are tuition-free. Thus, French physicians enter their careers with little if any debt and pay much lower malpractice insurance premiums.
Nor do France’s doctors face the high nonmedical personnel payroll expenses that burden American physicians. Sécurité Sociale has created a standardized and speedy system for physician billing and patient reimbursement using electronic funds.
It’s not uncommon to visit a French medical office and see no nonmedical personnel. What a concept. No back office army of billing specialists who do daily battle with insurers’ arcane and constantly changing rules of payment.
Moreover, in contrast to Canada and Britain, there are no waiting lists for elective procedures and patients need not seek pre-authorizations. In other words, like in the United States, “rationing” is not a word that leaves the lips of hopeful politicians. How might the French case inform the US debate over healthcare reform?
National health insurance in France stands upon two grand historical bargains – the first with doctors and a second with insurers.
Doctors only agreed to participate in compulsory health insurance if the law protected a patient’s choice of practitioner and guaranteed physicians’ control over medical decision-making. Given their current frustrations, America’s doctors might finally be convinced to throw their support behind universal health insurance if it protected their professional judgment and created a sane system of billing and reimbursement.
French legislators also overcame insurance industry resistance by permitting the nation’s already existing insurers to administer its new healthcare funds. Private health insurers are also central to the system as supplemental insurers who cover patient expenses that are not paid for by Sécurité Sociale. Indeed, nearly 90 percent of the French population possesses such coverage, making France home to a booming private health insurance market.
The French system strongly discourages the kind of experience rating that occurs in the United States, making it more difficult for insurers to deny coverage for preexisting conditions or to those who are not in good health. In fact, in France, the sicker you are, the more coverage, care, and treatment you get. Would American insurance companies cut a comparable deal?
Like all healthcare systems, the French confront ongoing problems. Today French reformers’ number one priority is to move health insurance financing away from payroll and wage levies because they hamper employers’ willingness to hire. Instead, France is turning toward broad taxes on earned and unearned income alike to pay for healthcare.
American advocates of mandates on employers to provide health insurance should take note. The link between employment and health security is a historical artifact whose disadvantages now far outweigh its advantages. Economists estimate that between 25 and 45 percent of the US labor force is now job-locked. That is, employees make career decisions based on their need to maintain affordable health coverage or avoid exclusion based on a preexisting condition.
Perhaps it’s time for us to take a closer look at French ideas about healthcare reform. They could become an import far less “foreign” and “unfriendly” than many here might initially imagine.
Paul V. Dutton is associate professor of history at Northern Arizona University and author of “Differential Diagnoses: A Comparative History of Health Care Problems and Solutions in the United States and France,” which will be published in September. http://cache.boston.com/bonzai-fba/File-Based_Image_Resource/dingbat_story_end_icon.gif

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US infant mortality rate now worse than 28 other countries

By Patrick O’Connor
18 October 2008

[LEFT]A report issued Wednesday by the Centers for Disease Control and Prevention (CDC) documents how the infant mortality rate in the United States is growing in relation to other countries. The study, “Recent Trends in Infant Mortality in the United States,” found that at least 28 other countries now have lower death rates for infants in the first year of life.

The US’s relative position has declined steadily. In 1960, it had the 12th lowest infant mortality rate, but by 1990 had dropped to 23rd place, and by 2004—the latest year of the CDC’s comparative world figures on living standards—the US ranked 29th. The most recent study, published in July and titled “The Measure of America,” estimated that the US is now in 34th place.

The CDC report found that there was no improvement in the incidence of US infant deaths between 2000 and 2005, a “plateau in the US infant mortality rate represent[ing] the first period of sustained lack of decline in the US infant mortality rate since the 1950s.” This “has generated concern among researchers and policy makers,” the report noted.

For the year 2000, the infant mortality rate was 6.89 per 1,000, a rate that remained stagnant for five years before declining slightly to 6.71 between 2005 and 2006.

The CDC noted: “The impact of child mortality is considerable: there are more than 28,000 deaths to children under 1 year of age each year in the United States.”

Several countries in Scandinavia (Sweden, Norway, Finland) and East Asia (Japan, Hong Kong, Singapore) have an infant mortality rate below 3.5, almost half the US rate. The CDC’s 2004 rankings placed the US in a tie with Poland and Slovakia, and only marginally ahead of Puerto Rico and Chile. The US was behind every developed country in North America, Western Europe, and Australasia, as well as Cuba, Hungary, Israel, and the Czech Republic.

Infant mortality is a critical indicator of social progress. As the CDC report explains, “Infant mortality is one of the most important indicators of the health of a nation, as it is associated with a variety of factors such as maternal health, quality and access to medical care, socioeconomic conditions, and public health practices.”

This decline in world rankings is another expression of US capitalism’s decay. The gutting of social programs by successive Democrat and Republican administrations over the last four decades has led to an extraordinary social reversion. A tiny layer at the top has enriched itself through the dismantling of all impediments to the accumulation of private wealth and corporate profit, supported by tax cuts and the slashing of investment in critical social infrastructure. That infant mortality rates are now stagnating for the first time in five decades underscores the accelerating character of the social crisis.

The CDC report documented the disparity of infant mortality rates among racial classifications. “Non-Hispanic white,” Latino, and Asian-American children had lower than average rates, while “American Indian or Alaskan Native,” Puerto Rican, and “non-Hispanic black” families had higher rates.

The report noted, however, that the “infant mortality rate did not change significantly for any race/ethnicity group from 2000 to 2005.”

In 2005, African-American infants suffered a death rate of 13.63 per 1,000 births, by far the highest average. The CDC’s 2004 world rankings indicate that a black American baby would have a better chance of survival if born in Russia (which has a rate of 11.5) or Bulgaria (11.7).

The CDC report did not assess infant mortality in relation to social class or family income.

Another study released earlier this month, however, documented this correlation. Published by the Robert Wood Johnson Foundation and titled “America’s Health Starts With Healthy Children: How do States Compare?” the report found: “In almost every state, shortfalls in health are greatest among children in the poorest or least-educated households, but even middle-class children are less healthy than children with greater advantages. Within each racial or ethnic group, a steep income gradient is evident. Children’s general health status improves as family income increases.”

It also reported: “Nationally, and in every state, infant mortality rates increased with decreasing levels of mothers’ education.” The mortality rate for children whose mothers had completed 16 or more years of school was 4.2 deaths per 1,000 births, compared to 7.8 deaths for children whose mothers had completed 11 years or less of school.

The failure to improve the infant death rate between 2000 and 2005 came despite significant advances in medical technology, including care for prematurely born babies.

What the CDC termed “preterm birth”—i.e., those at less than 37 weeks gestation—is a key risk factor for infant mortality. In 2005, 69 percent of all infant deaths occurred to preterm babies. The report stated: “The plateau in the US infant mortality rate from 2000 to 2005 was largely due to the combina­tion of the increase in the percentage of very preterm births and the lack of decline in the infant mortality rate for these births.”

Only those parents who can afford to pay for treatment can be sure that their premature babies will receive the necessary care. Similarly, many families are finding it increasingly difficult to afford the advanced medical treatment which many infants require in their first year. About 45 million Americans, or 15 percent of the population, are now estimated to be without any form of health insurance.

At every level, corporate control over the health care system distorts and undermines the rational provision of medical services. Per capita US health spending was $6,714 in 2006, more than twice the average of other advanced countries. But this spending has failed to improve the population’s health. Infant mortality is one indication of this; another is the extraordinary fact that 41 countries now have a longer life expectancy than does the US.

Official per capita health spending figures are in fact misleading. If the resources invested in genuine medical care and treatment were to be calculated and compared, there is little doubt that the US would rank far below many other countries. A substantial portion of purported American health spending is simply siphoned off as profit by the major health firms, insurance companies, and pharmaceutical interests.

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I’ve done some reading on the French system. It sounds really intriguing. The problem is selling it here because any mention of “French” sends 40% of America into an anti-American tirade.

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I pay enough taxes for poor people to get treated and have kids.

If you want free healthcare, you either:

A) Pay fucking taxes
B) Follow strict guidelines (ie. no drugs, no kids if you don’t make X amount, etc)
C) Know a doctor who is willing to work for free (good luck)

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^^ How old are you?

And what great amount do you spend in taxes?

SPARE ME

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LOL

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We will be paying for the uninsured one way or the other.

Either through higher premiums or taxes. You have no choice.

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1- a hospital will bend over backward to finance a payment plan for a person
2- many people are/may be covered by medicare even if they aren’t explicitly signed up for it
3- youre charged if you leave without treatment or AMA (against medical advice). its like trying to go out to eat, taking a few bites andf thinking you can just leave the restraunt cause you didnt like the food. think again retard. you took a bite. youre getting charged.

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and medical schools, although extremely competitive to enter, are tuition-free.

wat?

I can only imagine how competitive it really is to apply for med school in France.

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When they don’t have to blow half their salary on student loans and malpractice insurance, they don’t need to charge $300 for a 5 minute consultation like they do here. Plus that helps ensure the best and brightest become doctors. The gov’t makes an investment in their future in med school that keeps costs down for decades after.

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cali residents pay next not nothing/nothing for their instate medical schools (and im talking high class… like UC Berk.)… it is INCREDIBLY competitive. free anything is a draw, esp education, and ESP a medical education.