How a Broken Health Care System Harms us All

January 15, 2018

A recent case of a patient left in the cold in Baltimore is not an aberration, it's a symptom of a larger problem with this country's health care system.

A disoriented patient in Baltimore found by a passerby sitting in a wheelchair clothed in only a hospital gown appalls physicians and non-physicians alike. Yet these types of occurrences are not uncommon in our broken health care system.

Given the recent attacks on the Affordable Care Act and likely further rolling back of Medicaid and Medicare, this kind of patient dumping will only get worse. Incidents such as this highlight the need for a system overhaul. Patients requiring acute care need access and I am reminded that our expensive acute care system is not even the best venue for care for many of our patients.

One evening, I received an admission request from the emergency room. Listening to the history provided, I knew that an acute inpatient facility was inappropriate. The elderly woman in the emergency room had no acute medical condition,-no injury, no acute mental status changes, no illness. She had dementia and her family, who had been caring for her at home with no outside help, dropped her off in the emergency room and left.

I tried to explain to the ER physician that I had no resaon to admit this patient. Utilization management would be quick to call me and explain that the patient did not meet admission criteria and we would likely not be paid. He argued back that he could not simply discharge a demented elderly woman onto the street. Of course, he was right. She met no admission criteria, but I had no choice but to admit her, there was nowhere else for her to go.

Her family, likely burnt out from caring for her with minimal or no services, reached their limit. She couldn’t stay in the emergency room, but bringing her up to an acute floor would tax an already overburdened nursing staff, take a bed from a patient who needs an acute bed, and ultimately not offer the type of care this patient actually needs.

From previous experience, I know that procuring the maintenance and respite care needed to keep her home with her family costs more than most families can afford. This is especially true of families in my poor, urban communities. Even with all available resources, caring for a demented family member strains even the most altruistic individuals.

Obtaining nursing home placement for patients with dementia can be equally challenging and time consuming.  Most private payers do not cover nursing home care. So while we wait for weeks or months for families to figure out the financials, for the patient to qualify for Medicaid, and an appropriate nursing home to accept the patient, they sit in a hospital bed. Administration will call every day asking about length of stay and what the team is doing to get the patient out of the hospital.
During this time the patient will be potentially exposed to any number of infections and other nosocomial conditions. She will be in an unfamiliar, scary environment increasing likelihood of behavioral issues that decrease her chances of a nursing home offering a bed.
Our current system fails many patients and families in these situations. Rarely do families have access to resources to care for elderly relatives, especially demented patients, at home. Even when money can be found, the number of competent caregivers available is limited. Nursing home care is expensive and can be cumbersome to access.

Again, competent care can even be challenging to find as these facilities and overtaxed staff may find themselves lacking resources as well. So these patients ping pong in a system ill-equipped to help them or their families. These scenarios are not limited to merely our demented elderly, but can be seen in patients seeking timely mental health treatment and other chronic conditions that should have been able to be managed in a non-acute setting.

This country needs a health care system that affords families the resources to access help, allows physicians to provide appropriate care, and identifies appropriate facilities for patients. Our current system focuses almost solely on episode-based acute illnesses and injuries and, as such, our emergency rooms and hospitals are generally designed to care for these conditions, not the chronic, often debilitating illnesses.

A strong primary-care presence can help patients and their families before situations become dire and desperate. A system with robust social services and ample case managers and social workers to help navigate could bring patients both the non-medical and medical care they need. A payment system not weighed down with excessive administrative costs and inefficiencies would allow physicians and other members of the health care team to provide appropriate, necessary care in a timely fashion and appropriate venue. No patient should be left in the cold.