Tuesday, July 20, 2010
One-way ticket
This post by John H. Schumann, FACP, originally appeared at GlassHospital.
Something happened on my job that I'd onlyread about before. Working in the hospital this month, my team has been caring for Mr. M. He was here when we started on service at the beginning of the month, and unless his planned transfer to another facility goes through, he'll be here when we sign off to the next team at the end of the month.
Mr. M is in his fifties. He speaks Spanish. He is an undocumented immigrant from Central America. He came to the U.S. to seek employment, and send money home to his family. He has no family here that can help care for him when he's ready to be discharged from the hospital.
Unfortunately, three months ago, he had a big stroke. He was paralyzed on his right side. He couldn't swallow, walk, or use his hand. He could barely speak.
He's been in the hospital all that time. This won't surprise you, but he doesn't have health insurance.
Even before he had his stroke, his situation was fairly complex, in that he'd developed kidney failure due to his longstanding and poorly treated high blood pressure. Luckily for him, he lives in the dialysis era. Three times per week, he's hooked up to a machine that filters the waste from his blood.
He'd been getting dialysis at a local center before his stroke, because even without insurance there are federal subsidies for people with end stage renal disease (ESRD). This has been in place since 1973.
We continued dialysis for him here at the hospital. He's received physical, occupational, and speech therapy. He needed a stomach tube to help feed him, and we provided it for him. Due to these tube feedings and the great work of our therapists, his overall condition has improved significantly.
He's now able to eat by mouth, and no longer needs to use the feeding tube ("G-tube," we call it, for gastrotomy--it's in his stomach). Also, he can walk without any assistance.
Several weeks ago, we'd have transferred Mr. M to a rehabilitation facility to hasten his return of function. But no facility would accept him without insurance.
Hospitals work feverishly to discharge patients to the appropriate level of care. We want good outcomes for our patients. It suits no one to have patients "bounce back" if we've discharged them too hastily or sent them home when they're not yet ready to care for themselves or there isn't a solid enough plan in place.
Mr. M doesn't have family here that can look after him. His original home is in Central America. Even though he's clinically improved, he's still not 'employable.'
We can't keep him in the hospital forever, though it feels like that to the intern on my team (the one whose job it is to round on Mr. M every day, examining him and formulating his 'daily plan'). There has to be somewhere he can go, right?
If he had a home or family nearby, of course we'd send him there. But he doesn't.
So, our discharge planners have investigated doing the ultimate: sending him home--to his native country.
I will admit, when I read the article linked at the beginning of this post, it made me very skeptical of the practice of sending undocumented immigrants home. After all, we are not the INS. We are the medical establishment. It's our job to care for people, regardless of who they are or where they come from.
But in Mr. M's case, there really doesn't seem to be any alternative. We've provided him with months of first-world, outstanding medical care for free. And given his social situation, there isn't any other reasonable discharge plan for him, as no other facility will take him. Home truly seems to be the only reasonable option.
And before you accuse us of "dumping" him back home, consider the cost of doing so: for a regularly insured patient, it costs next to nothing (there might be a transport fee, but even that is paid usually by insurance) to transfer to a facility.
How much do you think it costs to send someone home, using a "medical escort service?"
If you guessed $50,000, you'd be on the mark. And that's just flying commercial, with a medical escort. If he were sick enough to merit an air ambulance, you can add another $25,000 to the bill.
Only in America! Our entrepreneurial spirit is truly amazing. Where there's a need, the market rises up to meet the demand. For example, this company.
Surely the Health Care Reform legislation that just passed will help future patients like Mr. M, right?
Incorrect. There is no coverage scheme for undocumented individuals in the plan.
John Henning Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university’s human rights program. His blog, GlassHospital, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people that inhabit them.
Labels: Glass Hospital, health care cost, health care reform, hospital costs, uninsured
posted by John Schumann, M.D. at
8:00 AM
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Blog log
Members of the American College of Physicians contribute posts from their own sites to ACP Internist and ACP Hospitalist. Contributors include:
Albert Fuchs, MD
Albert Fuchs, MD, FACP,
graduated from the University of California, Los Angeles School of
Medicine, where he also did his internal medicine training.
Certified by the American Board of Internal Medicine, Dr. Fuchs
spent three years as a full-time faculty member at UCLA School of
Medicine before opening his private practice in Beverly Hills in
2000.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned
authority on nutrition, weight management, and the prevention of
chronic disease, and an internationally recognized leader in
integrative medicine and patient-centered care.
DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about
health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more
than a decade and is an Associate Professor of Medicine at an
academic medical center on the East Coast. His time is split
between teaching medical students and residents, and caring for
patients.
Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science,
medicine, health and healing in the 21st century.
FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the
Internal Medicine Residency and Assistant Dean of Scholarship &
Discovery at the Pritzker School of Medicine for the University of
Chicago. Her education and research focus is on resident duty
hours, patient handoffs, medical professionalism, and quality of
hospital care. She is also an academic hospitalist.
Glass
Hospital
John H. Schumann, MD, FACP, provides transparency on the workings
of medical practice and the complexities of hospital care,
illuminates the emotional and cognitive aspects of caregiving and
decision-making from the perspective of an active primary care
physician, and offers behind-the-scenes portraits of hospital
sanctums and the people who inhabit them.
Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the
University of North Carolina School of Medicine, and the Program
Director for the GI & Hepatology Fellowship Program. He
specializes in diseases of the esophagus, with a strong interest in
the diagnosis and treatment of patients who have
difficult-to-manage esophageal problems such as refractory GERD,
heartburn, and chest pain.
I'm dok
ACP Member Mike Aref, MD, PhD, ACP Member, is an academic
hospitalist with an interest in basic and clinical science and
education, with interests in noninvasive monitoring and diagnostic
testing using novel bedside imaging modalities, diagnostic
reasoning, medical informatics, new medical education modalities,
pre-code/code management, palliative care, patient-physician
communication, quality improvement, and quantitative biomedical
imaging.
Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites
for influential health commentary.
MD
Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of
medical practice, including controversies in the doctor-patient
relationship, medical ethics and measuring medical quality. When
he's not writing, he's performing colonoscopies.
Medical
Lessons
Elaine Schattner, MD, ACP Member, shares her ideas on education,
ethics in medicine, health care news and culture. Her views on
medicine are informed by her past experiences in caring for
patients, as a researcher in cancer immunology, and as a patient
who's had breast cancer.
Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a
small community hospital in Connecticut. His blog is a series of
musings on medicine, medical care, the health care system and
medical ethics, in no particular order.
Reflections
of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being
a doctor in a community hospital in Atlanta.
Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in
education, social media and networking, practice management and
evidence-based medicine tools, personal information and knowledge
management.
White Coat Underground
Peter A. Lipson, MD, ACP Member, is a practicing internist and
teaching physician in Southeast Michigan. The blog, which has been
around in various forms since 2007, offers musings on the
intersection of science, medicine, and culture.
ACP Internist and ACP Hospitalist also contribute to and draw upon content from Get Better Health, a network created by Val Jones, MD, to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the clinician's point of view on health care reform, science, research and patient care.
Other blogs of note:
American
Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine
publishes original clinical articles of interest to physicians in
internal medicine and its subspecialities, both in academia and
community-based practice.
Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP
Member, associate program director at New York University Medical
Center's internal medicine residency program. Faculty, residents
and students contribute case studies, mystery quizzes, news,
commentary and more.
db's Medical
Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating
medicine and the health care system.
Interact
MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so
he can create an independent, clinician-reviewed space on the
Internet for physicians to report and comment on the medical news
of the day.
PLoS
Blog
The Public Library of Science's open access materials include a
blog.
White Coat Rants
One of the most popular anonymous blogs written by an emergency
room physician.
1 Comments:
Amazing that it should cost less to send someone home on a flight with an escort than to provide care. Maybe the next round of the health reform -- whenever that will be -- can help a future generation.
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