Tuesday, March 22, 2016

You can't Always get what you Want

I read a story in the Los Angeles Times recently. As I read, Mick Jagger (Some of the younger generation may only remember this name from Kesha's TiK ToK) came to mind. He and the rolling stones released a 1969 hit You Can't Always Get What You Want. The Lyrics include the refrain

You can't always get what you want
You can't always get what you want
You can't always get what you want
But if you try sometime you find
You get what you need 

The Story in the Times is about a 79 year old man who "tripped on a crack and fell to the ground" in 2013 on a "sidewalk in West Los Angeles." He was surprised when "an ambulance appeared suddenly." He did not call an ambulance. He was not bleeding on the street, or calling out for help. He said that "three men came out, checked my ID, laid me on a cart, pushed me into the van and took me to the emergency room." This may seem to be what anyone would want, or at least what anyone would need.

However, this man "said he didn't want to go to the ER." and if he had wanted to go, he said he "could have taken a cab costing less than $10." So, there is what he needed, which may have been a hand in getting back up following the fall. What he got was a bill for $250.00. Being as that was three years ago, one might dismiss it as a lesson learned, and move on. But this gentleman is currently fighting a bill collector who is seeking the $250.00. That sum is significant. 

According to a spokesperson for the Los Angeles Fire Department, this is not common. He says that ambulance rides can "easily top $1,000." In fact a GAO report in 2012 says that "an ambulance ride nationwide can range from $224 to $2,204." There are variables such as distance and the level of medical care rendered during the trip. But such qualifications (your mileage may vary) are not uncommon with reports of averages or data aggregations.

According to an ambulance company manager quoted in the story, "most private ambulance companies follow the lead of doctors and hospitals and routinely price their services as high as possible in hopes of receiving a bigger reimbursement from insurance companies." A representative for Los Angeles County confirmed that this practice occurs. This is the theory that you ask for twice as much as you want and then you can take a 50% reduction and still walk away happy. And, even better, maybe someone makes the mistake of paying the bill at the claimed amount and you get "free money." 

Overall ambulance charges are not an insignificant contributor to the costs of medical care. In fact, the story quotes a federal government audit that concluded "Medicare paid roughly $30 million for ambulance rides that apparently resulted in no treatment." These are not the rides that were followed by billing for significant hospital care, as one would expect following a serious motor vehicle accident or fall down the stairs. These ambulance rides were followed by no rendition of medical care. In other words, these patients were apparently transported in an ambulance and then found to need no care, and discharged. 

While the average "urban ambulance ride is 10 miles," some billed "Medicare for trips of more than 100 miles." This reminded me of a lady I knew who suffered a serious heart issue and was taken from her rural home to a regional hospital for care. After a significant heart surgery, and some serious complications, she was discharged by the regional hospital to recover several miles away at a rural hospital. They drove her across the countryside in an ambulance, deteriorating as she went. Arriving at the rural facility, which lacked any expertise in cardiac care, she began a precipitous decline. 

Family members suspected that the regional hospital (RH) personnel had figured out her prognosis (bad) and had concluded that the end was near. they perceive that not wanting her death on their statistics, the RH arranged for her transfer two towns down the rural highway in an ambulance. This was cheerfully described as a transfer to a "swing bed facility." Use of these "small rural hospitals" is purportedly to allow patients to recover "close to family and friends." The link above describes how this allows "you to recover in a hospital setting, versus a nursing home." Of course, neither is likely to have facilities for complex cardiac care. 

Following a heart surgery, I am not sure that I would be comfortable with a transfer to a "small rural hospital" whose interest in such a case might be focused primarily on filling beds. And, some may harbor doubts that an 88 year old heart surgery patient, under medication, is capable of making an informed decision to abandon the critical care regional hospital in favor of a "small rural hospital" that has a bed to fill. After a cross-county ambulance ride of significant expense, she arrived, but not in good condition.  

Through the next afternoon, her condition declined. As the decline became obvious to the personnel at the rural hospital (again the family believes), the rural hospital decided to transfer her back to the regional hospital. Having spent the better part of 24 hours deteriorating in the new environment, following  a long truck ride, medical expertise concluded that a return  ambulance ride would not do, and a helicopter was dispatched instead. I am told the expense for this was significantly higher than the truck ride the day before. (Riding in a helicopter is on my "bucket list," but I hope to do it over the Grand Canyon or Maui while conscious and coherent).

Following a rural helicopter ride through the black night, her body arrived back where she started, at the regional hospital. Despite these extraordinary transportation efforts of the medical professionals, her soul had, in route, departed to some other destination. There was disagreement as to whether she was even alive when she first entered the helicopter. There was consensus that she never made the decision to engage the helicopter, and there remains some doubt that she ever knew she went on the ambulance ride across country the day before (The forms demonstrate some lines (scribbles), and there are claims she signed the necessary forms, but her family harbors doubt about coherency and competency).  

Back to the Los Angeles story, a spokesperson for Los Angeles County said that "no ambulance can take patients to hospitals against their will." But, she cautioned that ambulance crews can "make judgment calls if a patient is unconscious or unable to effectively communicate." She said that if a patient is "disoriented and not speaking clearly," then the crew can make a decision to transport. This does not sound like the 79 year-old man who claims he told the crew he did not want an ambulance ride. But then the story is focused on his side of the story, and the crew was not interviewed. They may have honestly perceived him differently.

The Times' columnist concluded that perhaps this was just a misunderstanding about transport, noting "there was some confusion the day he got hurt." He believes that it was a favorable outcome that the 79 year-old "was looked after," and that it is "better safe than sorry." Though he only suffered a sprained wrist, the author concludes this was the best, or at lease an acceptable, outcome. In the grand scheme of things, perhaps $250 is not that extreme an amount balanced against a health concern.

Both the 79 year-old with his sprained wrist and the rural octogenarian present questions of consent though. In the Los Angeles story the author perceives it "better safe than sorry," and perhaps there is some logic in that. Found in a posture (down) and environment (city street) that may be inhospitable, perhaps it is best to transport (absent a clear objection) for evaluation and care? 

But it is harder to make that conclusion with the octogenarian who was found in a safe and hospitable critical care hospital environment. Absent a clear expression of assent for transfer to a "small rural hospital," what justifies this transfer? Certainly, expense might be saved. But, in this setting it was not. Any comparative advantage (financial) offered by the rural setting was likely offset that first day by the long ambulance ride. If not, it was most certainly erased by the panicked and urgent helicopter ride back. 

The two stories also illustrate another point. Once you become the patient, you may lose the ability to chart your own course (it could happen to any of us on a sidewalk or otherwise innocuous spot). You may then find yourself at the mercy of a system that is driven by considerations and motivations that you do not understand, and may not even perceive. Just remember "you can't always get what you want,"

And despite Mick Jagger's reassurance, despite the effort you invest ("try sometime") you may not even "get what you need." Perhaps we must all hope that if it is us in that situation, there will be someone there for us, family member or friend, who will be able and willing to look out for our best interest?


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