Improving Access to Care?

To me, the most worrisome sentence in the study citing longer waits in the ED was the following:
“Barriers to routine primary and outpatient care for some Americans may be contributing to ED overcrowding and longer ED waits for all Americans, even those with life-threatening illnesses like AMI.”

This is a topic that bothers me.

People with nonurgent problems are flooding the EDs like never before. In the resulting milieu, the patients who really need “emergent” care are getting lost in the shuffle and are suffering treatment delays. We need to prevent all these people with nonurgent problems from going to the ED so we can focus on the “true” emergencies, right?

Wrong.

A lot of people think that patients with Medicaid “have it made” for healthcare in this country. In one respect, they’re right. Have Medicaid, come to the hospital emergency department and you get same-day care for free. Maybe you have to wait a while, but you get treated. Incidentally, everyone else has access to the same care, it’s just that many times the cost scares people without insurance away from seeking the care.

I admit that there are a lot of people on Medicaid who abuse the system, using their free care to get a $1 prescription for Motrin and concocting stories of excruciating pain in hopes of getting their latest all-expense-paid fix. But there are many more people on Medicaid who are trying to do the right thing and who the “system” ignores. In fact the system makes it harder for these patients to find care.

Sure, Medicaid provides patients with a “card” entitling them to care. But Medicaid also creates financial disincentives for physicians to provide the care. New York pays doctors $17 per ED visit for Medicaid patients? Our 14-year-old babysitter makes more than that! Then Medicaid leaves it up to the patients to fend for themselves.

If you have Medicaid and you have a routine medical problem like diabetes, high blood pressure, or high cholesterol, good luck finding care. Asthma is a classic example. When do people come to the emergency department for asthma complaints? When they’re having an asthma attack. What would the ED staff say if a patient just came in, said they couldn’t find a primary care doctor, and asked for a refill of their asthma medications? “Screw you, buddy – go to a clinic. You’re not having an emergency.”

WordPress lets me review the search terms that lead people to my blog. Almost every day I get hits from people using a search engine who are looking for “doctors who take Medicaid.” They’re trying to find care and sometimes they can’t. When they go to the emergency department with a non-urgent complaint, they’re not going to get the care they need.

No emergency physician is going to give someone monthly prescriptions for high blood pressure medications. No ED performs yearly health screenings. “Treat ‘em and street ‘em.” “Move the meat.” “I’m here to save your ass, not kiss your ass.” If it isn’t an emergency, the patients are going to get referred to a clinic. And the next available appointment at the clinic (if the clinic will take them) will probably be several months in the future. Really what we’re doing is forcing indigent patients to wait until an emergency develops before society believes that it is “OK” to seek emergency care. How much more bass-ackward can we be?

What would YOU do if YOU were in their shoes?

There used to be a patient who would always bring her child in around midnight to 1AM for health care. She had Medicaid and some of the staff used to get mad at her because she would wait until midnight to bring her child in for health problems. No one ever asked her why she brought her kid in at such late hours – except me. Turns out she was a single mom who was taking college classes during the day and working six days a week at night to make ends meet. Her waitressing job got over at 11 PM at which time she would pick her kid up from her cousin’s home. She couldn’t miss school and couldn’t just take off from work at a moment’s notice. None of the doctors in town would take new Medicaid patients. I actually gave her money one time when she mentioned that she was having financial troubles. Maybe I’m a sucker, but I still have more respect for this “system leeching” Medicaid patient than I have for some of the Gucci bag carrying, antibiotic-demanding, self-centered, Blue Cross Blue Shield patients for whom I have cared.

Some people think that keeping the indigent and undocumented immigrant patients out of the ED will “improve” the access to care.

My question is “improve access for whom?”