Too broke for the ER, patients flee

[one...two...tree 2,762]

Jesse Ashlock of Brooklyn, N.Y., was knocked unconscious in a bicycle accident last July that also left him scraped and bruised.

Recession forces many to leave 'against medical advice,' doctors say

By JoNel Aleccia

Health writer

msnbc.com

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.

'If they leave the ER now, they're likely to go back'

People who leave against advice are at higher risk for ending up back in the hospital, or for becoming seriously ill or dying, Alfandre said. Asthma patients who leave AMA are about four times more likely to be readmitted, his review showed. General medical patients are about seven times more likely to wind up again in the hospital.

"Patients should be told, 'If they leave the ER now, they're likely to go back,' " Alfandre said.

Several emergency department doctors said they see many more reluctant patients than they ever sign out against medical advice.

"If it's a really dumb decision, I'll sign them out AMA," Chawla said. "Cardiac is one of the big ones. We're very cautious about the heart."

Other doctors said even when they don't sign patients out against advice, they do have detailed conversations about the value of certain tests and procedures.

"In my mind, that's not necessarily a bad thing. Testing is out of control," said Dr. Jeffrey Sankoff, who works in the emergency department at the Denver Health Medical Center in Colorado. "I think it's good we're having those conversations about risks and benefits."

Those talks can help direct patients to solutions less dire than refusing treatment. Most hospitals provide charity care, though the amounts and conditions vary widely. Many also offer help connecting patients with services such as Medicaid. And most hospitals will set up payment plans, if nothing else, to allow patients to manage the bills.

No care, but billed anyway?

Not every doctor is so proactive, however. In Jesse Ashlock's case, no one stopped him as he stripped off an X-ray vest, put on his shirt and strode out of the emergency room, still bleeding from the scrapes on his face and hands.

"I think the frustration is that they didn't want to discuss the cost," he said of his decision to leave.

Adding what he regards as insult to injury, Ashlock later received a bill for $618.67, which he still hasn't paid. He called Woodhull Hospital officials to ask why he was being charged for services he didn't receive, but the bill still stands.

It covered the cost of his evaluation, according to a spokeswoman for the New York City Health and Hospitals Corp., which operates the hospital. After being contacted by msnbc.com, hospital officials contacted Ashlock to resolve his bill, said Pamela McDonnell, HHC's director of media relations.

In the end, Ashlock said he'll probably pay the bill in installments so it won't damage his credit. And he's grateful overall that his injuries from the bicycle accident have healed, leaving only small scars.

"You just have to look on the bright side. I'm walking around and talking to you," he said. "Still, $600 is a lot of money."

http://www.msnbc.msn.com/id/30628634/

Edited May 11, 2009 by Col. 'Bat' Guano

[Niels Bohr 72]

It's very sad really.

[Peikko 1,575]

It is, sad and totally unnecessary, but I just don't see this government making enough changes to really make a difference. It's my biggest gripe about living in the US to be honest, the stupid nature of the health business.

[Mr. Big Dog 10,747]

Propaganda of the worst kind. Everyone knows that the US has the best health care in the world. Or so some would argue...

[w¡n9Nµ7 §£@¥€r 123]

[Niels Bohr 72]

No doubt that Health Care is excellent. But, Health Insurance is not.

[Kathryn41 3,205]

True story - a friend of mine in Michigan about 10 years ago fell through some rotten steps on a friend's back porch. He broke his leg - could feel the shin bone 'move' and got a bad gash on his cheek. He had no insurance and even though he was working couldn't afford any medical treatment - he was basically only able to pay his child support and the bare minimum for his own daily needs. He made a splint for his leg and taped it really tight until the bone 'healed' and he iced the wound on his cheek and sewed it up himself with a needle and thread. The leg did indeed heal as did his cheek. I was appalled that such actions were necessary but it was the only treatment he could afford.

Edited May 11, 2009 by Kathryn41

[Nagishkaw 510]

True story - a friend of mine in Michigan about 10 years ago fell through some rotten steps on a friend's back porch. He broke his leg - could feel the shin bone 'move' and got a bad gash on his cheek. He had no insurance and even though he was working couldn't afford any medical treatment - he was basically only able to pay his child support and the bare minimum for his own daily needs. He mad a splint for his leg and taped it really tight until the bone 'healed' and he iced the wound on his cheek and sewed it up himself with a needle and thread. The leg did indeed heal as did his cheek. I was appalled that such actions were necessary but it was the only treatment he could afford.

0mg!

[Pinocchio Liberal 268]

True story - a friend of mine in Michigan about 10 years ago fell through some rotten steps on a friend's back porch. He broke his leg - could feel the shin bone 'move' and got a bad gash on his cheek. He had no insurance and even though he was working couldn't afford any medical treatment - he was basically only able to pay his child support and the bare minimum for his own daily needs. He mad a splint for his leg and taped it really tight until the bone 'healed' and he iced the wound on his cheek and sewed it up himself with a needle and thread. The leg did indeed heal as did his cheek. I was appalled that such actions were necessary but it was the only treatment he could afford.

Prolly a dead beat dad who didnt want to get busted for not paying child support, is prolly more like it.

[DeadPoolX 9]

True story - a friend of mine in Michigan about 10 years ago fell through some rotten steps on a friend's back porch. He broke his leg - could feel the shin bone 'move' and got a bad gash on his cheek. He had no insurance and even though he was working couldn't afford any medical treatment - he was basically only able to pay his child support and the bare minimum for his own daily needs. He mad a splint for his leg and taped it really tight until the bone 'healed' and he iced the wound on his cheek and sewed it up himself with a needle and thread. The leg did indeed heal as did his cheek. I was appalled that such actions were necessary but it was the only treatment he could afford.

Prolly a dead beat dad who didnt want to get busted for not paying child support, is prolly more like it.

You're not qualified to make that statement. Kathryn knows him, so only she could say whether or not he was a "deadbeat dad." Even if he was, taking such measures are ludicrous.

Edited May 11, 2009 by DeadPoolX

[Kathryn41 3,205]

Nope - not a dead beat dad - kind of the opposite. He was a great father and loved his kids. His ex had an affair and left the marriage so he got the divorce. She abandoned her two sons to run off with the other guy so he was mother and father for the boys for two years until she showed up back in the picture. The divorce gave them joint custody but she didn't see the kids for 2 years since no one knew where she was. When that relationship broke up she showed back up and wanted to see the kids so they negotiated alternating weeks with each parent. She then decided that she wanted full custody - there was a heck of an expensive court case and her lawyers fees were paid by her well-heeled parents - he had to pay his own lawyers' costs. She didn't get full custody - the judge re-set the joint custody but because she wasn't working he also gave a small child support payment to her. So, he was still doing the 50% joint custody, paying for the kids well-being when they were with him and paying her money to help support the time when they were with her plus doing all the driving to drop them off and pick them up on the alternating weeks. I dated the guy for a while and was interviewed by the Friends of the Court when they were trying to decide how best to go with the custody arrangement. When the kids were old enough to decide for themselves they both moved back in with their Dad full time and the child support arrangement stopped. His ex, however, never paid any child support payments to him even though the boys lived with him full time by their own choice.

Edited May 11, 2009 by Kathryn41

[DeadPoolX 9]

Nope - not a dead beat dad - kind of the opposite. He was a great father and loved his kids. His ex had an affair and left the marriage so he got the divorce. She abandoned her two sons to run off with the other guy so he was mother and father for the boys for two years until she showed up back in the picture. The divorce gave them joint custody but she didn't see the kids for 2 years since no one knew where she was. When that relationship broke up she showed back up and wanted to see the kids so they negotiated alternating weeks with each parent. She then decided that she wanted full custody - there was a heck of an expensive court case and her lawyers fees were paid by her well-heeled parents - he had to pay his own lawyers' costs. She didn't get full custody - the judge re-set the joint custody but because she wasn't working he also gave a small child support payment to her. So, he was still doing the 50% joint custody, paying for the kids well-being when they were with him and paying her money to help support the time when they were with her plus doing all the driving to drop them off and pick them up on the alternating weeks. I dated the guy for a while and was interviewed by the Friends of the Court when they were trying to decide how best to go with the custody arrangement. When the kids were old enough to decide for themselves they both moved back in with their Dad full time and the child support arrangement stopped. His ex, however, never paid any child support payments to him even though the boys lived with him full time by their own choice.

I'm just amazed he got joint-custody and then full custody. In the U.S., it's not unusual for the mother to get full custody, even if she's far from fit to take care of the kids.

[Empress of Groovy 373]

True story - a friend of mine in Michigan about 10 years ago fell through some rotten steps on a friend's back porch. He broke his leg - could feel the shin bone 'move' and got a bad gash on his cheek. He had no insurance and even though he was working couldn't afford any medical treatment - he was basically only able to pay his child support and the bare minimum for his own daily needs. He mad a splint for his leg and taped it really tight until the bone 'healed' and he iced the wound on his cheek and sewed it up himself with a needle and thread. The leg did indeed heal as did his cheek. I was appalled that such actions were necessary but it was the only treatment he could afford.

Prolly a dead beat dad who didnt want to get busted for not paying child support, is prolly more like it.

Hitting the Popov already?

[Kathryn41 3,205]

I'm just amazed he got joint-custody and then full custody. In the U.S., it's not unusual for the mother to get full custody, even if she's far from fit to take care of the kids.

He got joint custody - never full custody. The court re-established the joint custody even though the mother sought full custody. Yes, I know - it is usual for the mother to get full custody and the fact that she didn't in both court cases shows the judge recognizing the father's role as the main care-giver to his sons. The court order wasn't changed when the boys turned 14 and moved in with him -the mother wasn't too concerned about parenting her sons so let them go. If she had pushed to keep getting the support payments even though she didn't have the kids he would have gone back to court, but he was trying to save the expense of a court case and didn't pursue full custody legally when he had it practically.

[Ban Hammer 13,360]

still nothing beats this die hard

When a 40-year old man arrived at a hospital asking to see a doctor specializing in "men's troubles", he was shown to a cubicle. There, he gingerly unwrapped three yards of foul smelling, stained gauze from around his #######, which had swollen to twice the size of a grapefruit.

On further inspection, it was discovered that his left testicle was missing completely and, embedded within the swollen, tender and weeping wound, were a number of dark objects which the patient confessed were one inch staple nails from an industrial staple gun.

It transpired that the man spent lunchtimes alone in the workshop, where he regularly enjoyed the sexual thrill of placing his ####### on the moving canvas fan belt of a piece of machinery. One day, the excitement had caused him to lose his concentration and the fan-belt had snatched his ####### into the fly-wheel, throwing him several feet across the floor and removing his left testicle. Rather than go to hospital, he self-administered first aid using a staple gun and then continued work when his colleagues returned. It was two weeks before he got around to visiting the hospital.

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