aka American ER Doc Gone Walkabout… 013
OK, so this isn’t directly about Oz: I’m here in the USofA for this case, but it offers quite a contrast between two systems.
A 47 year old presents to an ER because of a couple months of constipation, bloody mucoid stools the diameter of a pencil, and a non-intentional 10 kg weight loss.
We know the diagnosis, confirmed by a CT – sigmoid carcinoma.
We know it’s in the US, and deduce that he has no health insurance – otherwise, why would he be in an ER for this chronic problem?
So, now it gets pretty less-developed world-ish. He’s seen by surgery, and has no “emergency” – he isn’t actively exsanguinating, and he doesn’t have a high-grade obstruction. So, “no, thanks” says surgery.
He’s discharged from the ER with instructions to “find a PCP (GP in Anglo-Australasian) to refer you to a surgeon, or find a surgeon to do the surgery and an oncologist for treatment planning.” Several weeks later, having been “non-compliant” in med-speak, and not having found a surgeon to do the procedure for whatever the guy could pay, he completely obstructs and has a subtotal colectomy at another hospital. The surgeon who got to do the colectomy does not send a letter to the original hospital with the usual: “Thank you for referring this interesting patient”. The letter is more of the tone: “Are you guys f#@king nuts?”
The case was discussed at an M&M in the States: Some physicians (the “suits” – is that term used in Oz?) lauded the actions of the ER in protecting the hospital and the Department of Surgery from unreimbursable costs. Thankfully, others were appalled and distressed that our colleagues could send this man out the door. As ER Docs, we sometimes find fantasy problems requiring admission in far less egregious cases — I think a blood draw from a running IV line might have given us a Hemoglobin of about 55 and prompted an admit for transfusion. Reportedly, M&M discussion was vigorous (kinda like the Julia and Tony show at question time! – sorry, if you’re an American reader and have never watched Julia Gillard, the prime minister, and Tony Abbott, the opposition leader, go at it in Australian parliament, you’re missing a great show). I’m more discouraged that some would support this kind of case management, than I am by the failure of the young doctor to find a way, no matter how much lying was involved, to get him admitted and treated.
I can’t imagine something like this happening in Launceston, or any other part of Australia – correct me if I’m wrong.
About 44 million Americans have no health insurance and can face this sort of treatment. American law requires ER’s to examine all persons who come to the ER, but does not require treatment if no immediate life or limb threat is found: thus CT scan for diagnosis, but no treatment.
And, now we sit back and wait for a few months while the US Supreme Court rules on whether to undo all the political hard work done 2 years ago to try to establish a framework for universal (well, except for about 11 million) health care cover in the United States.
So any of you thinking of trying American ER’s, prepare yourselves.
BTW – any jobs open for me in OZ? Every time I write one of these columns, I get the urge to book a flight back.
Honestly, I keep trying to come up with commentaries on the medical practice differences and they just aren’t that great: pacer vs isoprenaline drip for bradycardia, size of opioid prescriptions, aggressiveness of use of imaging technology, etc. But the health care system and financial stuff I find much more interesting for compare and contrast.
Later, Mates.
About Rick Abbott
He might have died from his bowel obstruction, but at least his “civil rights” weren’t compromised by the government spending his tax dollars on universal healthcare.
Those tax dollars were much better spent on the civil rights of the people in the middle east who his government is bombing and shooting.
Ahh well at least he has a right to a gun!
Interesting, as a US emergency physician practicing in Australia, I also see that the medicine is mostly similar. While your story on the surface certainly makes the US system look horrible, I could paint similar picture about a more benign, but much more common problem that I see in Australia. And that is the young to middle age females that I see recurrently in the ED for pain control for their biliary colic while they wait the 6 months to a year for surgery in the public system. Logically, you would think in the US fee only system this would be a much more common (especially with US obesity rates). Yet, that was not my experience in many years of practice. I found when patients would come in for multiple visits for colic that I could find a surgeon who would take care of the problem, usually within a couple of days. That was regardless of ability to pay. The other thing that I think is better in the US is working in a small hospital the EMTALA law is your friend. I have a few horror stories working in a small hospital in Aus trying to get higher level care for a specialty we don’t have. In the US, threaten EMTALA reporting, and the transfer system magically corrects all its faults. Not so in Australia.
I’m not here to completely defend the US system. But, this picture that people who are having significant medical issues that haven’t yet met the level of acute emergency are always thrown out without medical care is just not true. There are examples like the one above, but there are many more of physicians stepping up and caring for patients, payment or not.
My perception of the difference is that although the Ozzie person may have to wait and suffer through multiple bouts of biliary colic while waiting (even longer for a total hip -- I did a bicycle race with a guy who had been waiting for 18 months -- couldn’t walk very well, but was still tough in the bike race), in the US, an uninsured person may have no real end in sight: Seen in the ER, they are given instructions to establish care with a PCP (GP) and get referred to a surgeon, or try to establish care directly with a surgeon. If they go to a large private system (say Kaiser -- for you Ozzies, a “non-profit” corporate medical care system), they are told that they can’t be cared for because they are not a member. It seems that over the years, the guys in smaller groups have progressively gotten more tight fisted -- “If the really profitable groups like Kaiser (yea, I know that Kaiser is a “non-profit -- it’s a tax distinction only) won’t care for a non-member, why should I provide free care even though I don’t work on a membership basis?” So, the person with biliary colic waits, in limbo with no clear idea where they will eventually get their gall bag out. Even if they find a surgeon who is a “good guy” and will do it for free, or for a reasonable price, then they have to find a hospital or surgery center willing to do it for some feasible facility charge -- generally larger than the surgeon’s fee.
The ability to get specialist care for the uninsured tends to be very location dependent: In Boulder, a very rich town with relatively few indigent patients, it wasn’t as tough to get care for the indigent -- though still a challenge for something that wasn’t emergent. At University Hospital, where the indigent population is large, getting something non-emergent done is truly unusual. In OZ, total hips might be a 1-2 year wait, but for many in the US, the wait is eternal.
And, as you note, with anything emergent, there is no issue -- the EMTALA hammer waits, ready to fall. (For the Ozzies: EMTALA (the Emergency Medical Treatment and Active Labor Act) is federal legislation designed to prevent “dumping” of indigent patients from one hospital to another -- but is worded such that any “discharged” patient is protected, not just those sent to a different hospital.) So, even if you’re not a good guy that wants to care for anybody and everybody, you have to provide life and limb saving care, or face substantial penalties. Once you’ve decided that it’s biliary colic, not cholecystitis, though, the patient may be YOYO (You’re On Your Own).
Interestingly, some of the poorest folks that I care for are on the Indian Reservation, but because the Indian Health Service is a system of care, there is no differentiation between those with and without insurance. Even if I have to transfer them to a private hospital off the Rez, the IHS covers the cost. Emergent or not.
I’m glad that you mentioned transfers -- an interesting circumstance with a few comments to be made. I’ll save that for a separate post.
Thanks for the comments.