What to do about ER Gomers?

Great Debates
1

This story was in my local paper today…from the AP, but I didn’t have much luck finding an online link. I have summarized parts of the story…and included some quotes. The story is by David Foster of the AP.

Gregory Goins is the ultimate “frequent flier” of hospital ER visits. Since 1996, he has in the Highland Hospital in Oakland, California more than 1200 times…that’s once or twice A DAY. He doesn’t walk in either…he comes in via ambulance calls. His chief complaints are chest pains and shortness of breath. He has “alarmingly” high blood pressure. Usually, the ER staff hook him up to an EKG to confirm that he is within his usual readings and “admonish” him to take his blood-pressure pills. On the way out, Goins tosses his Rx in the trash.

His ER visits (and ambulance rides and hospital stays) have cost taxpayers an estimated $900,000.

The staff formed a committee to try to make his visits less “appealing”…so they now keep him away from exam rooms…give in EKGs in an uncomfortable chair in the triage area etc…

His usual 2 hour turn around time was reduced to 30 minutes…but it only seemed to bring him back for more.

He lives in a group home for developmentally disabled men…where he is also nagged to take his meds.

"Goins says he appreciates what people are doing for him. But he doesn’t see his visits to Highland as something that needs to change. ‘Last year they told me my bill was a quarter-million dollars’, he says ‘I said, So What? I’m sick. Take care of me’ "

I don’t work in the medical field, so I don’t know if this is an unusual case for ER staff…so my first question for those in the know: How common is this kind of a situation (maybe not this extreme…but a person who repeatedly abuses the ER system to a large financial degree)?
A spokesman for the American College of ER Physicians said that “There’s a moral and legal obligation to take EVERY complaint seriously”
Bottom line, is there really any thing that can be done about this, or is it an inevitable price to pay for our system of health care?

2

It is all too common, I’m afraid. Not to this degree, but anybody who works at an ER knows all-to-well the “frequent fliers.”

These range from drug abusers to people who honestly need health care – for instance illegal immigrants who have no other recourse. In Houston, we don’t report to immigration, so our community hospital has become “safe ground” for health care. The problem is that much of this health care could be delivered far more cheaply and far more efficiently at non-tertiary care settings, like community clinics. This goes for many of the “frequent fliers” that we saw at Ben Taub, not just undocumented workers. At the ER, though, it is federal law to treat everyone who is emergent, so we cannot refer to the community clinics.

More ominous are those that abuse the health care system just to get “attention.” These people usually need psych care, but psych care is one of those things that is difficult to provide emergently. An example is a 26 year old woman I had during an Internal Medicine rotation. We picked her up in the ER for a serious complication of diabetes, diabetic ketoacidosis (DKA). This requires emergent care, IV hydration, careful monitoring of blood electrolytes and sugar, and lots of other supportive care.

The first ominous sign was that she told the ER docs that she wanted her central venous line (for IV fluids) in her groin since it hurt less, and she told them that it was easier to get it in on the right than on the left. When I picked her up, I requested her charts from medical records. From them came my second ominous sign “Do you want all of them?” I responded “Of course!” and went to medical records to see that all they had on hand for the past 2 years was a stack of charts around 5 feet tall.

She was diagnosed borderline personality, a psychiatric disorder that requires constant care and therapy and is not very amenable to medication. Every time she got mad at her parents or her husband, she just wouldn’t take her insulin. A few days later, she’d develop DKA and get trucked into the ER. She had been in the community hospital 18 times in the past year and 16 times in the year before, all for DKA or diabetic gastroparesis from DKA.

These kinds of people need psychiatric care, which is a neglected portion of community medicine. They need constant monitoring and a supportive family. When that fails, they resort to hurting themselves for attention. Similarly are those who fake illnesses for attention or to get drugs. These people need something that society has no good way to provide them (drug treatment or psychological support), and therefore they just bounce back to the overburdened ER system since they can’t get help from anywhere else.

3

A fine post, edwino. It’s a difficult question; how do we help those who either refuse to take the help they really need, or don’t have it available to them? It is sooo frustrating, it’s left me in tears at times. Blaming the patient is not a helpful response in most cases. Yes, they bear some responsibility, and have to experience consequences of poor choices if they are going to change, but more often than not, their own choices are pretty constrained by their own illnesses and external circumstances.

These patients come to the office, too. At least to my office. And every time I see them, I cringe. But each time I have to remind myself “hypochondriacs get sick, too.”

Not real helpful as a solution to the problem beagledave highlighted for us, but it helps me cope on a day-to-day basis.

4

“Gomers” are a challenge to those of us trying to get these visits paid for.

Many managed-care companies are requiring authorization for ER visits in the form of notification or referral from a primary care MD. A lot of gomers don’t bother to get that before they come into the ER, so the claims get denied. And since getting a referral is the responsibility of the patient, the charges become the patient’s responsibility. Many patients my doctors saw had huge balances because they’d come into the ER for every ache and pain (my docs have been radiologists) and the ER doc would order X-rays. So the claim is denied, the patient is responsible and then the patient fails to pay the bill. Sample conversation with said patient: “Well, isn’t that why I have insurance?” Me: “Yes, but you had to get a referral first and you didn’t do that.”

Sadly, many of these people tended to fall into two categories: the elderly, who were lonely and craved the attention from the ER staff; and nervous mothers who rushed their kids in for every cut and scrape. (At the risk of getting into it with Qadgop, I should point out that I usually read not only the rad’s report but the ER notes, as well. Them ER guys can be brutal!)

And as edwino pointed out, many of these people would be best served with other forms of care, such as elder care or psychiatric care. Insurance companies can (and do) also help out by educating their customers on appropriate places for treatment; doctor’s offices or urgent care centers for less-severe problems versus ER care.

Robin

5

I appreciate the response of you folks in the health care field. One of my first reactions was

“$900,000”?..think of all the health care services that could be supplied to the dis-enfranchised for $900,000 that this guy is sucking up, for no real (apparently) health gain"

The need for community based mental health care does seem to be key here…I frankly don’t how we would accomplish that need…and apply it to this kind of scenario.

6

Maybe this is a dumb question, but, uh, MsRobyn…

If it’s two in the morning, and I think I have appendicitis or some other emergency occurs which requires me to go to the ER, how am I supposed to get my doctor’s authorization first? Find his home phone and have him call me in? Or do the HMO’s only require referrals during regular business hours?

Not trying to be snippy if it seems that way; I’m actually not feeling too well at the moment and am somewhat short-tempered, but I assure you there’s nothing personal to my question. I highly respect anyone willing to work in the public health sector.

7

It’s actually not a dumb question. What you do is call the insurance company to tell them you went to the ER. With some insurances, the admissions clerk will call a 1-800 automated authorization line.

Robin

8

900 large is a LOT of money. Most of us with private insurance have a million-dollar maximum lifetime limit. I certainly have never had a patient account go that high.

While private physicians have the option of “firing” a patient for non-compliance (there’s a procedure that has to be followed, but it is an option), a public hospital can’t get away with that. They are required to treat all patients, regardless of whether they’re abusing the resources or not.

I’m not familiar with the particulars of this case, but it sounds like the group home is somewhat at fault for not ensuring that Mr. Goins takes his medication. He is developmentally disabled, and possibly does not associate his non-compliance with his frequent hospital visits. It may also be that the staff at the group home is calling the ambulance on his behalf instead of ensuring compliance, as some institutions are wont to do.

Robin

9

I agree with Ms Robyn that it sounds like the group home is not doing a good job here. It occurs to me that if it’s beyond the capabilities of the group home’s staff to handle this situation, maybe this guy should not be in a group home? Maybe he needs to be in an institution? If I were a taxpayer in that jurisdiction, I’d want to know why this has been allowed to go on for so long. $900,000.00 down the drain?

10

There is little incentive for the hospital to do anything about it. First, the $900K probably represents charges rather than actual cost. Those charges are cost shifted to you and me and the HMO. Why should the hospital stick it’s neck out to deny care to a wino clutching his chest claiming chest pain when all he really wants is a warm, dry place to sleep? The one day the wino isn’t malingering will be the day that hospital denies or delays care and gets sued. Not good odds these days.

Get Outta My ER

11

As I indicated earlier in the thread, Mr Goins (and I didn’t say he was a wino), already has a warm dry place to sleep: A group home for the developmentally disabled.

12

My apologies to Mr Goins and his family. I was trying to paint a picture from the prospective of someone with intimate knowlege of the business end of health care delivery. In my experience, the bulk of the frequent flying malingering ER abusers are intoxicated street people. I was in no way accusing Mr Goins of any substance abuse.

13

Nope. Here’s a link to the story: http://www.pe.com/topstories/10002935_PE_NEWS_ner09a.html

The part in particular that makes my blood boil is: "Emergency-room staff hook him up to an electrocardiograph, confirm that he’s within his usual readings, and admonish him to take his blood-pressure pills.

On the way out, Goins tosses his prescriptions into the trash."

How can the group home make sure he takes his meds when he throws them out before leaving?

This guy is obviously a danger to himself and should be locked up. And at a significant savings I might add. It may sound like it’s not compassionate, but I don’t believe what this guy is doing is helping much. As health costs rise (because of things like this as well as others), health insurance becomes more expensive, and more people will go without it, just because this guy wants attention.

14

Now that I’ve read the article, it makes more sense to me.

This man has learned to manipulate the system for his own ends. I believe, from the actions he’s demonstrating, that his non-compliance is to ensure that he will need the attention of the ER.

It still doesn’t change my opinion that the group home is somewhat at fault. If Mr Goins refuses to follow the rules of the home, he should be found more suitable lodgings. Maybe a more restrictive environment such as a nursing home or long-term psychiatric facility would be more appropriate than this group home.

I also think he is a candidate for case management, in which a specially trained nurse, social worker and doctor confer and make recommendations on the best way to help him.

Yes, I know that resources such as bed space in institutions is limited, as are money and staff. But let’s be honest. Most hospital districts can’t afford to carry the burden of these patients. In a perfect world, there would be adequate funding for health care for everyone, but it’s not, and there’s not. And until we get serious about solving the social problems of mental illness and start funding small, community-based clinics, the problem will not go away, plain and simple.

Robin