Let me see if I understand this correctly. You want the state of Illinois, in the worst economic downturn since the Great Depression, to increase Medicaid payments a bit more than costs of care. At a time when revenue is falling. And the budgets of counties are forced to make deep cuts.
Don’t get me wrong. It’s a nice idea. It just isn’t going to happen. Certainly not now. Maybe never.
As to rewarding PCPs who accept Medicaid patients and make their clinic/office/hospital the patient’s medical home… again, in this economic climate, I’m not sure how any rewards could be built into the system.
Paying within a reasonable cycle? They’ve been trying to do that for years. Clearly there hasn’t been much progress.
In some respects, forcing patients to pick a “medical home” is a good idea. There is so much seeking of care in ERs, we often get patients at Holy Cross who were at St. Bernard’s or Christ or UofC within the last few days for the same or similar complaint. Obviously, this makes continuity of care practically impossible.
(I won’t go into the intrainstitutional barriers to continuity of care… let’s just say the patchwork computer systems now being used make it difficult to go through previous records, except for diagnostics like lab results and radiology. There’s that, at least.)
The big problem is forcing patient’s to use a “medical home” that’s farther from where they live (when many/most don’t have cars, public transit stops at night, and neighborhoods often aren’t safe anyway) kind of defeats the purpose.
As to re-educating people on what is and what is not an appropriate use of an emergency – in other words, teaching them what IS and what ISN’T an emergency – I don’t think it is possible. I remember once, vividly, a 17 year old patient called 911 because his sore throat (for which he’d been seen by us the night before) had not improved. He arrived by ambulance.
The ER doc read him the riot act about abusing public services and how incredibly wasteful it was to use 911 for a sore throat, when real people with real emergencies (oh, heart attacks, strokes, etc.) might need those ambulances. She really gave it to him.
But that kid was back not a week later, complaining that his symptoms hadn’t gone away, they were worse. He also hadn’t filled the RXs for antibiotics he had been given by us. Gee, maybe that was why his symptoms worsened. Ya think? He sure had a bling phone, though.
This is far from the only patient we have seen this way. Last winter we had a guy who left our ER about 3pm, sick, with RXs for appropriate meds and printed discharge instructions (not that we’re ever certain the patients can read them because illiteracy is also a common problem, the local schools being what they are).
He showed back up about four AM that night, looking miserable, with a high fever, chills, the crackhead dried white lines of spit running from the corners or his mouth to his chin, and clearly severely dehydrated. He still had our printed discharge instructions and RXs in his pockets and he showed them to me. I asked him why he hadn’t gone to get the med RXs filled. He said he was walking home and he saw “some of the guys” so he went to go hang out with them. Needless to say, he came up positive for alcohol and multiple drugs… because that’s what he did with “the guys.” He said he didn’t have the money to fill the prescriptions. Which I’m sure he didn’t… by that point.
There are patients who have come back days or weeks past their “return to the ER/Fast Track” instructions (for things like suture/staple removal and wound checks). It’s not politically correct to ask if their school or work commitments prevented them from returning. But it’s strange that the people who have school and work commitments are the ones who *do *show up on the dates specified… and the patients who have no school or work to go to are the ones who show up days or weeks late, when significant scarring or infection has developed.
This is the thinking process (or perhaps lack thereof) we are often battling. There is a total inability to prioritize that which is serious from that which is not. Personally, I’d buy Children’s Tylenol and Children’s Motrin and a thermometer for use with my kids at home rather than furry boots or a designer bag. And of course if I really, really wanted furry boots and a designer bag, I might consider not having children in the first place. But that’s because I was raised by people who would do those things and think that way – and all my friends’ parents were that way, too. I grew up thinking those things are perfectly normal.
But we are dealing with a patient population who suffer no cognitive dissonance whatsoever when making such decisions, because they didn’t grow up with the same “normal” we did. They simply do not understand, and we can not make them understand in their short (though frequent) times spent with us. The ability to make long and short term goals, to schedule appointments and keep them, to recognize and plan for RXs running out and the need for refills or new RXs, to prioritize what’s important to have around the house when you have kids, to differentiate between a true emergency and just a bump on the head – when and how would you develop that in a community with crappy & dangerous schools, full up with violence and drugs, and with no jobs (and for which you’d be unqualified even if there were jobs because you can’t do basic math or read on a very basic level)?
Where would you learn these healthy parenting priorities when your community has high rates of teen pregnancy, violence, and drug use? When kids are being raised by their grandparents and aunts and uncles and friends of the family because their parents are drug addicts who can’t raise them? And how many other kids aren’t being raised at all and just run wild (getting into all kinds of trouble and trauma) because their parents are either absent or dead and so are their grandparents because they died young of preventable diseases? Or because parents simply aren’t home because they have to work one or two jobs just to scrape by, and they can’t find safe, appropriate daycare or after school care?
This patient population lives in the now. I’m not talking about culturally elastic senses of time, I mean there’s little thinking beyond this moment Right Now… and the moment right after this one which will shortly become Right Now. If you look at it from their perspective, there is no point in thinking beyond Right Now. There’s no work to go to. Finishing high school does not qualify you for most jobs any more, because the schools are so bad. There’s few parents and adults equipped to channel the energy of the young into constructive activities. There are few wholesome places to hang out and burn off that energy, except churches… but that implies family members who attend and who bring the kids with.
When you never have anything to do, you don’t develop the thought processes for making and sticking to plans, making goals and achieving them, or prioritizing anything. You can do whatever you want whenever you want because nothing means anything and you know that your life, and the lives of everyone else you know, will never change – because you’ve grown up seeing all the adults around you living exactly the same way.
How can we change this? I don’t know. I can think of a lot of ways that would be fascistic, none of which would respect patient rights, patient autonomy, or the right to refuse treatment. I have wracked my brain to think of other, voluntary ways to change this kind of thinking, but haven’t yet thought of any other ways.
The fact is that the ways these problems manifest in inner city ERs are merely an extension of the economic and social breakdown and dysfunction of these patients’ communities. Those are much bigger problems to solve, and hospitals and ERs are not the systems to solve those. The other systems in place to solve those problems aren’t and don’t; they’re overwhelmed and underfunded (and now, thanks to the economy, they’re probably having their budgets cut… unless they can get some of the stimulus package money).
Head Start would at least give somewhat of a fighting chance – longitudinal studies bear out that kids who attend Head Start programs are more likely to finish high school and more likely to be employed in adulthood, as well as less likely to get pregnant as teens or to do drugs. But how well funded is Head Start? And how to fund a massive expansion of it during an economic downturn? How to make sure all children attend? You can offer it as free daycare – that’s an incentive – but then if there aren’t a ton of local Head Start programs within walking distance or near safe public transit, how do those moms get the kids there?
I would love to solve these problems that result in the poor health and inappropriate ER use of inner-city community hospital ER patients, but I don’t even know where to begin. It all sounds so easy when you’re in school. But when you see the reality of it, day in and day out, it is incredibly discouraging, and you resign yourself to doing health care “damage control” rather than actually improving the health of inner city patients. We work in the ER. That’s all we do. That’s our only sphere of influence. But it is dwarfed by the influence of the community at large, and all of that community’s problems.