I had seen Suzie before. And before and before and before and before. Emergency room staff call people like Suzie frequent fliers, and they do not apply the word kindly. Frequent fliers are the bane of emergency room physicians, and of impatient – excuse me, inpatient – medicine. They come in to the ER complaining of this or that weekly, sometimes daily. Always the same complaint, and usually the standard ER workup shows nothing. The obvious thing to do in such situations, to send the patient home with an appointment to see a clinic doctor in a few days, almost never works. The patient comes back to the ER in a few days with the same complaint. When asked about the doctor’s appointment, the patient says variably, “I forgot,” or “the doctor was out of town,” or “what appointment?”
These patients are unbelievably common. So common that I feel completely confident that if I slapped a $100 bill on a desk and preceded to call every ER doctor in the nation on a bet that every ER has a Suzie, 6 months and 10,000 calls later that bill would still be sitting there. There are no exceptions. Every ER has a Suzie. If there is an ER without a Suzie, there is a Suzie in the vicinity trying to find that ER.
I found Suzie on the hospital floor a few months back, admitted to my care. The ER doc put her in with the diagnosis of dehydration and abdominal pain. The nursing staff said as soon as she arrived on the floor she asked for IV pain medication. Then a friend slipped her a box of fried chicken and she ate that, despite orders that she stay on a liquid diet.
Suzie is an ER doctor’s nightmare because she really has something wrong with her. She has a chronic disease that leads to chronic abdominal pain as well as recurrent infections. It is not possible to dismiss Suzie out of hand. And yet, Suzie is in the emergency room so often that it is also not possible to attribute every complaint to the disease. She comes in complaining of a fever and has no measurable fever. She says she has been vomiting for a week and does not vomit as long as she is observed.
The morning I got Suzie as an admission I talked to the ER doctor, and he confessed that the real reason he admitted her is because she had been to the ER five times in four days. Even though he could find nothing wrong with her, he felt he couldn’t keep sending her away. I can understand that. Although insurance companies give us hell for it, not knowing for certain what is going on is an appropriate reason for hospital admission. You can only write off a patient complaint so many times.
Though I had seen Suzie many times when I was on call for other doctors, this was the first time she had been admitted to me. When I pulled her file up on the computer, I saw that in the previous 8 weeks she had been to the emergency room 32 times, and admitted twice. In that same time, she had been to only one clinic visit.
When I examined Suzie on the floor I found a young woman who did not appear to be in any distress. I asked her why she had been to the emergency room so many times. Her calm response was: “I was hurting.” Why not see your regular doctor? “I was in too much pain and thought I needed to be in the hospital.”
As I said, Suzie has a real medical problem. It is not my job to blow her off. On the other hand, her choices are driving her medical care in a direction she has no right to take them in. Suzie is choosing hospital care over every other type of medical care, and doing this over the objections of all of her doctors. I would never advise a patient of mine to go to the ER 32 times in two months. If a patient came to see me that often, I might admit her once to rule out serious problems, then refer her to specialists who can better manage her. In fact, Suzie had a appointment with a specialist in Jackson, someone who has specific knowledge and experience with her illness. I discharged her two weeks before that appointment date, and I don’t know if she ever kept the appointment. I hope so, but her track record for keeping outpatient appointments is too poor for me to be hopeful that this will be a long term solution.
A solution, though, is what we need. Suzie, and patients like her, cost hospitals millions of dollars a year. Insurance companies will not pay for 32 ER visits in two months. Suzie has Medicaid, which does not pay well even on a good day; but Medicaid usually has caps on the number of ER visits it will cover in a year. When a patient exceeds that, the bill goes to the patient. Suzie is disabled, meaning she has no money. If we are to assume that each ER visit generated $1000 in charges (a pretty sure bet), and that Medicaid paid none of it because Suzie had used up her ER benefit a long time ago (also a pretty sure bet), the hospital has a bill of over $30,000 it cannot collect. $30,000 is close to a full-time employee’s annual salary. It would not take too many Suzies to put a hospital in serious financial trouble.
Unfortunately, the law is on Suzie’s side. The ER cannot turn her away. Nor can it order her to pay up front. The law says emergency rooms must treat all patients in need. Once the ER verifies that the patient does not have a life-threatening condition, it can discharge the patient at will, but it has to evaluate her. Suzie can come to the ER three times in a day and the ER must at least examine her each time.
There is a solution to this problem, though admittedly it is a long shot. The hospital should contact Suzie and make a deal with her. The deal is this: Every January 1 the hospital will create a bank account in Suzie’s name with $500 in it. Each time Suzie goes to the ER, $25 is deducted. At the end of the year, Suzie gets whatever is left.
This stands the whole situation on its head. Suddenly, Suzie has a financial incentive to see her doctor instead of going to the ER. Like every patient on private insurance, it now costs Suzie to go to the ER. The hospital has to pay $500 each year, but this is a small price to pay to eliminate $30,000 in unpaid bills.
I intend to run this idea by the CEO of the hospital, but I am almost certain he will shoot it down. His reasons will be: (1) If we do this for her we will have to do this for many others; (2) Technically, we are paying her to stay away, and this will look very bad if the hospital should ever be sued; (3) She could start going to other ERs and then come here to get her money; (4) She could make the same deals with multiple ERs and get rich doing it; (5) The hospital will be suddenly deluged with offers from other patients to get the same deal; (6) Aren’t we rewarding bad behavior here?
None of these objections hold much water. We can take the easy ones first. Just because the hospital enters into a deal like this with one patient, this does not mean it has to offer the same deal to anyone else. This is the hospital’s money, and this amounts to a business decision. I treat all my patients individually. I will give a medication to one patient that I might not even think of writing for another. It all depends on the patient’s needs, and the patient’s reliability.
The problem of the patient simply going to another ER is also without merit. Have the patient sign an agreement promising not to use another ER without notifying the hospital. If the patient breaks that promise, the deal is void. Tracking her activities is possible in the digital age. Medicaid knows where she has been.
Are we rewarding bad behavior? No, what we are really doing is paying for better behavior. It is in Suzie’s interest that she behaves better. She is not benefiting from 4 ER visits a week. Furthermore, in taking up ER resources it can be plausibly argued that Suzie puts other lives at risk. A person can go to jail for repeatedly making bogus 911 calls. The fire department can be late for a real fire if it is busy investigating a false report. This is also true in the emergency room.
This leaves us with the real question, liability. Unfortunately, the practice of providing cash incentives to modify patient behavior has not been tested in court. If a patient were to sit at home with abdominal pain rather than go into the ER for the sake of $25, and then die of a ruptured appendix, an attorney could argue that the hospital is to blame for encouraging the patient to stay at home. And he might win.
But he shouldn’t win. Insurance companies offer incentives to avoid ERs. In a typical plan (the one I had 2 years ago), the copay for an ER visit was $100, for an “urgent care” clinic $50, and for a regular office visit $25. When I am at home on a Sunday with abdominal pain, I have to decide if I hurt badly enough to run to the ER for an extra $75. This is how medicine works in our country: Patients decide what level of care they need based on the degree of pain and the size of the copay. Since insurance companies in effect pay patients not to go to the ER by discounting clinic visits, they are already doing legally what I am proposing we do with Suzie. There is no difference, except that with private insurance the insurer is doing the paying, and in this case, the hospital is. But there’s the rub – laws protect insurers from patient lawsuits. Hospitals and doctors, on the other hand, can be sued for absolutely any reason, justified or not.
Since it costs Suzie $3 to see a doctor in clinic through the Medicare program and nothing to see one in the ER, her choices so far have been rational. The only way to change her behavior is to give her a reason to keep a clinic appointment. Consumers cannot be expected to choose the more expensive of two options on a regular basis. Our roads will never be crowded with hybrid cars until hybrids cost less than internal combustion vehicles. And ERs will never be free of frequent fliers until it costs the patients less money to go somewhere else. Period. That means giving them money to make decisions with.
I stole this idea from a man named Charles Murray. Murray, the reader may recall, first made a name for himself a decade ago with the controversial book The Bell Curve. The Bell Curve was widely abused for arguing that intelligence is genetic and that public policy should be structured with this fact in mind. I do not support the arguments in that book. However, Murray’s more recent book, In Our Hands: A Plan to Replace the Welfare State, has an attractive premise: The government should give every citizen a stipend of $10,000 a year. Financial problems aside, Murray makes a compelling point in arguing that one of the great problems of welfare is that poor people have virtually no incentive to behave responsibly. Poor people, he argues, would make economically responsible decisions if they had a little money to work with.
Our society is built on the principle of supply and demand. But supply and demand only works if the people involved have money. For example, a person who is broke has no incentive to buy car insurance. If he gets into an accident and gets sued, he has no money! In the same way, a poor person has no incentive to invest in good health. If a poor person has diabetes and no health insurance, he can work day and night to pay for his medications and doctor’s visits. This is an investment in health – pay for quality care now and avoid the catastrophic consequences later. But financially, a poor person might be better off doing nothing. Eventually the diabetes would produce a stroke, heart attack, or kidney failure. At that point he qualifies for disability, and health insurance. So, in a distorted way of thinking, he is better off neglecting his health than fighting to keep it.
This is where Murray’s idea makes sense. If you give a person money, suddenly he has a reason to do better. If he gets sick and has to go to the ER for treatment, the hospital can take a piece of that $10,000 stipend. Now the patient has a reason to take care of himself. If he doesn’t, ER visits will take all his spending money.
I most certainly am not poor, and don’t pretend to be. But many of my patients are, and as their doctor I sometimes have to contend with my patients’ problems. From my perspective, limited though it may be, poor people often do not think like people with money. In a capitalist system people are taught to respond to economic stimuli. They price shop for products; they leave jobs or situations that are not profitable to them; they weigh short term expenses like vacations and plasma TVs against long term issues like saving for a new home or for their kids’ college. This difference isn’t simply a matter of education. Poor people, because they have no money, never learn about long term planning. For them, life is about living from moment to moment. A dollar earned is a dollar spent. It is not possible to learn to make economic decisions when you live like that.
I offer two examples from my patient files. A few years ago I cared for a middle-aged women with multiple medical problems, most of them related to anxiety. One day during an office visit she told me that she was stressed out because she had to sell her house. She couldn’t afford the payments. She had inherited the house, with the mortgage, when her mother died a few years earlier. The mortgage was at least 20 years old, meaning she had less than 10 years left and the house would be completely paid off. The monthly mortgage note was $250. I tried to explain to her that she was crazy to sell the house. She would never find a rental for $250. Yes she would have the money from the house once she sold it, but in the long run rent would eat up that money and she would be in worse shape than before. She couldn’t hear that. All she knew was that she couldn’t afford the payments now. Nothing else mattered.
A more recent case: I had a patient tell me that he was going to cancel his Medicare insurance. It cost him over $100 a month, and he couldn’t afford it. I tried to explain to him that he was seeing me in my office 6 times a year, and that plus routine bloodwork could easily cost him that much. A single hospitalization would ruin him financially. But he could not understand that. All he knew was that he got X dollars a month from disability, and Medicare plus his rent left him short each month.
I am not blaming either patient for the decisions they made. Both did what they felt they could afford. But both, because they had no money to work with, were unable to make economically sound decisions. In fact, in poverty, they had no choices to make. So they ate the goose that laid the golden eggs. This is the way poor people behave every day, and in light of this, it is no surprise to me that the poor stay poor most of the time.
If you want people to do better, teach them. Give them decisions to make. Perhaps a patient like Suzie will find it in her interest to be something better than a frequent flier. She might even surprise us and make the right choice, every once in a while.
These patients are unbelievably common. So common that I feel completely confident that if I slapped a $100 bill on a desk and preceded to call every ER doctor in the nation on a bet that every ER has a Suzie, 6 months and 10,000 calls later that bill would still be sitting there. There are no exceptions. Every ER has a Suzie. If there is an ER without a Suzie, there is a Suzie in the vicinity trying to find that ER.
I found Suzie on the hospital floor a few months back, admitted to my care. The ER doc put her in with the diagnosis of dehydration and abdominal pain. The nursing staff said as soon as she arrived on the floor she asked for IV pain medication. Then a friend slipped her a box of fried chicken and she ate that, despite orders that she stay on a liquid diet.
Suzie is an ER doctor’s nightmare because she really has something wrong with her. She has a chronic disease that leads to chronic abdominal pain as well as recurrent infections. It is not possible to dismiss Suzie out of hand. And yet, Suzie is in the emergency room so often that it is also not possible to attribute every complaint to the disease. She comes in complaining of a fever and has no measurable fever. She says she has been vomiting for a week and does not vomit as long as she is observed.
The morning I got Suzie as an admission I talked to the ER doctor, and he confessed that the real reason he admitted her is because she had been to the ER five times in four days. Even though he could find nothing wrong with her, he felt he couldn’t keep sending her away. I can understand that. Although insurance companies give us hell for it, not knowing for certain what is going on is an appropriate reason for hospital admission. You can only write off a patient complaint so many times.
Though I had seen Suzie many times when I was on call for other doctors, this was the first time she had been admitted to me. When I pulled her file up on the computer, I saw that in the previous 8 weeks she had been to the emergency room 32 times, and admitted twice. In that same time, she had been to only one clinic visit.
When I examined Suzie on the floor I found a young woman who did not appear to be in any distress. I asked her why she had been to the emergency room so many times. Her calm response was: “I was hurting.” Why not see your regular doctor? “I was in too much pain and thought I needed to be in the hospital.”
As I said, Suzie has a real medical problem. It is not my job to blow her off. On the other hand, her choices are driving her medical care in a direction she has no right to take them in. Suzie is choosing hospital care over every other type of medical care, and doing this over the objections of all of her doctors. I would never advise a patient of mine to go to the ER 32 times in two months. If a patient came to see me that often, I might admit her once to rule out serious problems, then refer her to specialists who can better manage her. In fact, Suzie had a appointment with a specialist in Jackson, someone who has specific knowledge and experience with her illness. I discharged her two weeks before that appointment date, and I don’t know if she ever kept the appointment. I hope so, but her track record for keeping outpatient appointments is too poor for me to be hopeful that this will be a long term solution.
A solution, though, is what we need. Suzie, and patients like her, cost hospitals millions of dollars a year. Insurance companies will not pay for 32 ER visits in two months. Suzie has Medicaid, which does not pay well even on a good day; but Medicaid usually has caps on the number of ER visits it will cover in a year. When a patient exceeds that, the bill goes to the patient. Suzie is disabled, meaning she has no money. If we are to assume that each ER visit generated $1000 in charges (a pretty sure bet), and that Medicaid paid none of it because Suzie had used up her ER benefit a long time ago (also a pretty sure bet), the hospital has a bill of over $30,000 it cannot collect. $30,000 is close to a full-time employee’s annual salary. It would not take too many Suzies to put a hospital in serious financial trouble.
Unfortunately, the law is on Suzie’s side. The ER cannot turn her away. Nor can it order her to pay up front. The law says emergency rooms must treat all patients in need. Once the ER verifies that the patient does not have a life-threatening condition, it can discharge the patient at will, but it has to evaluate her. Suzie can come to the ER three times in a day and the ER must at least examine her each time.
There is a solution to this problem, though admittedly it is a long shot. The hospital should contact Suzie and make a deal with her. The deal is this: Every January 1 the hospital will create a bank account in Suzie’s name with $500 in it. Each time Suzie goes to the ER, $25 is deducted. At the end of the year, Suzie gets whatever is left.
This stands the whole situation on its head. Suddenly, Suzie has a financial incentive to see her doctor instead of going to the ER. Like every patient on private insurance, it now costs Suzie to go to the ER. The hospital has to pay $500 each year, but this is a small price to pay to eliminate $30,000 in unpaid bills.
I intend to run this idea by the CEO of the hospital, but I am almost certain he will shoot it down. His reasons will be: (1) If we do this for her we will have to do this for many others; (2) Technically, we are paying her to stay away, and this will look very bad if the hospital should ever be sued; (3) She could start going to other ERs and then come here to get her money; (4) She could make the same deals with multiple ERs and get rich doing it; (5) The hospital will be suddenly deluged with offers from other patients to get the same deal; (6) Aren’t we rewarding bad behavior here?
None of these objections hold much water. We can take the easy ones first. Just because the hospital enters into a deal like this with one patient, this does not mean it has to offer the same deal to anyone else. This is the hospital’s money, and this amounts to a business decision. I treat all my patients individually. I will give a medication to one patient that I might not even think of writing for another. It all depends on the patient’s needs, and the patient’s reliability.
The problem of the patient simply going to another ER is also without merit. Have the patient sign an agreement promising not to use another ER without notifying the hospital. If the patient breaks that promise, the deal is void. Tracking her activities is possible in the digital age. Medicaid knows where she has been.
Are we rewarding bad behavior? No, what we are really doing is paying for better behavior. It is in Suzie’s interest that she behaves better. She is not benefiting from 4 ER visits a week. Furthermore, in taking up ER resources it can be plausibly argued that Suzie puts other lives at risk. A person can go to jail for repeatedly making bogus 911 calls. The fire department can be late for a real fire if it is busy investigating a false report. This is also true in the emergency room.
This leaves us with the real question, liability. Unfortunately, the practice of providing cash incentives to modify patient behavior has not been tested in court. If a patient were to sit at home with abdominal pain rather than go into the ER for the sake of $25, and then die of a ruptured appendix, an attorney could argue that the hospital is to blame for encouraging the patient to stay at home. And he might win.
But he shouldn’t win. Insurance companies offer incentives to avoid ERs. In a typical plan (the one I had 2 years ago), the copay for an ER visit was $100, for an “urgent care” clinic $50, and for a regular office visit $25. When I am at home on a Sunday with abdominal pain, I have to decide if I hurt badly enough to run to the ER for an extra $75. This is how medicine works in our country: Patients decide what level of care they need based on the degree of pain and the size of the copay. Since insurance companies in effect pay patients not to go to the ER by discounting clinic visits, they are already doing legally what I am proposing we do with Suzie. There is no difference, except that with private insurance the insurer is doing the paying, and in this case, the hospital is. But there’s the rub – laws protect insurers from patient lawsuits. Hospitals and doctors, on the other hand, can be sued for absolutely any reason, justified or not.
Since it costs Suzie $3 to see a doctor in clinic through the Medicare program and nothing to see one in the ER, her choices so far have been rational. The only way to change her behavior is to give her a reason to keep a clinic appointment. Consumers cannot be expected to choose the more expensive of two options on a regular basis. Our roads will never be crowded with hybrid cars until hybrids cost less than internal combustion vehicles. And ERs will never be free of frequent fliers until it costs the patients less money to go somewhere else. Period. That means giving them money to make decisions with.
I stole this idea from a man named Charles Murray. Murray, the reader may recall, first made a name for himself a decade ago with the controversial book The Bell Curve. The Bell Curve was widely abused for arguing that intelligence is genetic and that public policy should be structured with this fact in mind. I do not support the arguments in that book. However, Murray’s more recent book, In Our Hands: A Plan to Replace the Welfare State, has an attractive premise: The government should give every citizen a stipend of $10,000 a year. Financial problems aside, Murray makes a compelling point in arguing that one of the great problems of welfare is that poor people have virtually no incentive to behave responsibly. Poor people, he argues, would make economically responsible decisions if they had a little money to work with.
Our society is built on the principle of supply and demand. But supply and demand only works if the people involved have money. For example, a person who is broke has no incentive to buy car insurance. If he gets into an accident and gets sued, he has no money! In the same way, a poor person has no incentive to invest in good health. If a poor person has diabetes and no health insurance, he can work day and night to pay for his medications and doctor’s visits. This is an investment in health – pay for quality care now and avoid the catastrophic consequences later. But financially, a poor person might be better off doing nothing. Eventually the diabetes would produce a stroke, heart attack, or kidney failure. At that point he qualifies for disability, and health insurance. So, in a distorted way of thinking, he is better off neglecting his health than fighting to keep it.
This is where Murray’s idea makes sense. If you give a person money, suddenly he has a reason to do better. If he gets sick and has to go to the ER for treatment, the hospital can take a piece of that $10,000 stipend. Now the patient has a reason to take care of himself. If he doesn’t, ER visits will take all his spending money.
I most certainly am not poor, and don’t pretend to be. But many of my patients are, and as their doctor I sometimes have to contend with my patients’ problems. From my perspective, limited though it may be, poor people often do not think like people with money. In a capitalist system people are taught to respond to economic stimuli. They price shop for products; they leave jobs or situations that are not profitable to them; they weigh short term expenses like vacations and plasma TVs against long term issues like saving for a new home or for their kids’ college. This difference isn’t simply a matter of education. Poor people, because they have no money, never learn about long term planning. For them, life is about living from moment to moment. A dollar earned is a dollar spent. It is not possible to learn to make economic decisions when you live like that.
I offer two examples from my patient files. A few years ago I cared for a middle-aged women with multiple medical problems, most of them related to anxiety. One day during an office visit she told me that she was stressed out because she had to sell her house. She couldn’t afford the payments. She had inherited the house, with the mortgage, when her mother died a few years earlier. The mortgage was at least 20 years old, meaning she had less than 10 years left and the house would be completely paid off. The monthly mortgage note was $250. I tried to explain to her that she was crazy to sell the house. She would never find a rental for $250. Yes she would have the money from the house once she sold it, but in the long run rent would eat up that money and she would be in worse shape than before. She couldn’t hear that. All she knew was that she couldn’t afford the payments now. Nothing else mattered.
A more recent case: I had a patient tell me that he was going to cancel his Medicare insurance. It cost him over $100 a month, and he couldn’t afford it. I tried to explain to him that he was seeing me in my office 6 times a year, and that plus routine bloodwork could easily cost him that much. A single hospitalization would ruin him financially. But he could not understand that. All he knew was that he got X dollars a month from disability, and Medicare plus his rent left him short each month.
I am not blaming either patient for the decisions they made. Both did what they felt they could afford. But both, because they had no money to work with, were unable to make economically sound decisions. In fact, in poverty, they had no choices to make. So they ate the goose that laid the golden eggs. This is the way poor people behave every day, and in light of this, it is no surprise to me that the poor stay poor most of the time.
If you want people to do better, teach them. Give them decisions to make. Perhaps a patient like Suzie will find it in her interest to be something better than a frequent flier. She might even surprise us and make the right choice, every once in a while.