“If ye love wealth better than liberty, the tranquility of servitude than the animated contest of freedom, go from us in peace. We ask not your counsels or arms. Crouch down and lick the hands which feed you. May your chains sit lightly upon you, and may posterity forget that you were our countrymen!” – Samuel Adams

Medicaid abuse routinely ignored by sociocrats

Ambulance

Drudge links to a story today of a Buffalo, NY case in which a local resident uses the ambulance service as a taxi to go to the hospital when he doesn’t feel well.

Scott Graham is reported to have been taken to the hospital by ambulance several times per week and even twice per day for a total of over 600 trips in the past three years and at an estimated cost of nearly 120,000 dollars to local taxpayers!

That’s just for the ride to the hospital mind you, and the actual amount charged was $360,000, of which Medicaid paid about one-third. The balance is paid for by patients and insurance companies that have to pay full fare.

Mr. Graham is reported to have sickle cell disease and is unemployed and uninsured so all his costs are necessarily (by law) either picked up by Medicaid or passed on to patients with insurance or at least responsible enough to pay their bills. (Ever wonder why a Tylenol at the hospital costs $37? Some of the exorbitant charges of hospital care can be attributed to the necessity of hospitals to recoup some of the losses in cases such as this.)

Mr. Graham also admits that he could call a taxi but that he is attended to faster in the ER if he arrives by ambulance. He also knows that when EMS is called through the 911 system that he can’t be refused and can’t be made to pay.

I know nothing of Mr. Graham’s medical history other than his report about having sickle cell disease, so I can’t speak to his case specifically, but every ER doc knows that sickle cell disease is often claimed by drug abusers as a way of getting injections of powerful narcotics pretty much whenever they want. Proving whether or not a patient is actually having an acute sickle attack is costly and time consuming so we often take a patient at his word and give Dilaudid or morphine on demand. Naturally, some find this an easy and cheap way of feeding a narcotic addiction.

This case is not rare. Similar abuse goes on in every ER in the country on a daily basis. It matters not whether it’s a small rural hospital or a big city medical center—we all struggle every day to separate the truly sick and injured from the endless parade of patients only abusing the system for some hidden agenda; sometimes it’s drugs, sometimes it’s insurance fraud, sometimes it’s sympathy of family and friends, sometimes it’s ignorance, sometimes it’s malingering, sometimes it’s loneliness and sometimes it’s just boredom. In almost all such cases the bill is being paid by someone other than the patient, usually Medicaid or “no pay” (which is really “you pay”).

It is also a fact that it is these patients that represent the greatest liability when it comes to frivolous lawsuits, so you can understand why doctors often order an expensive battery of tests for what seems a straightforward medical complaint. A headache in your doctor’s office is a headache, but in the ER with a patient who would sue at the drop of a hat it’s a brain aneurysm or sub-arachnoid hemorrhage until proven otherwise by a $3000 CT scan.

Just how much all of this misuse of emergency departments costs us nationally is very difficult to say, but most ER docs and nurses would put the number somewhere close to half of all charges generated from the emergency department. It is much higher in many inner-city medical centers.

The high cost of health care has been talked about for some time but especially in the past few years. In virtually all discussions I’ve heard or read the issue of patient abuse is rarely even mentioned, yet it is certainly a significant contributor to ever rising health care costs. As long as the normal market forces that would ordinarily hold such behavior in check are circumvented there is little hope of truly getting a handle on the problem.

The story goes on to report that “2 On Your Side contacted Medicaid to have them look into the number of times Graham used an ambulance. Medicaid appeared more interested in how we got the information, rather than how much it cost taxpayers to pick him up.”

That is consistent with my experience as well. The agencies responsible for administering these programs seem uninterested in identifying and cracking down on obvious abuse. I have contacted Medicaid many times about obvious abuse only to be told that “We’ll look into it.” And then nothing more is done.

Social welfare programs get their funding and job security not by rooting out recipients that use the services inappropriately but by maximizing their rolls and the amount of money they control. Attempting to clean up their programs would only undermine their claims of usefulness and expanding budgets.

So, who is looking out for those of us who pay the bills? No one, it seems. Therein lays the root of the problem and it will not be remedied by giving government bureaucrats absolute control over the health care system.

Any attempts to bring health care costs into line must rely on market principles and personal responsibility or be doomed to failure.


Try us out at the new location: American Clarion!


14 Responses to “Medicaid abuse routinely ignored by sociocrats”

  1. Good to see you back in the saddle at Dakota Voice, Dr. Theo. I hope all has been well with you.

    Thank you for pointing out this gross fraud and abuse already taking place in government health care, and explaining how socialists systems dis-incentivize accountability.

  2. “Dr” Theo: How dare you engage in such irresponsible stereotyping – particularly at the expense of the thousands of sickle cell patients who have difficulty as it is getting access to appropriate health care services. What evidence do you have that suggests what “every ER doc” knows about drug-seeking among sickle cell patients? You and I both know that there is very little published research which suggests this: in fact, studies have shown that fewer than 5% of SCD patients show signs of addiction. However, the larger issue – which you conveniently overlook – is the question of WHY individuals like Mr. Graham HAVE TO rely on emergency services for health care – it's because there are virtually no comprehensive health services for adults who live with SCD. I wish you could spend some of your time in this space advocating for the NIH to re-institute and expand its comprehensive sickle cell program instead of irresponsibly stereotyping and furthering negative perceptions of the more than 80,000 sickle cell patients in the US based on the actions of one person. You should be ashamed.

  3. There is a adage in emergency medicine that seems apropos to your comments, Shawn: Ten percent of the population accounts for 90% of ER visits. I think I can say as well that 10% of SCD patients account for 90% or ER visits for acute SC pain and many (I didn't say all!) are addicted to pain meds and use their disease as a way to feed the addiction. You gave the number as 5%, which sounds pretty close to me. That would be half of the SC patients seen in the ER on average.

    What exactly do you want when you advocate for comprehensive health services for SCD? More free care for some at the expense of others? By what moral authority do you think it's OK to take by force from one person to give it to another? There are hundreds of debilitating and painful medical conditions that people live with without a “comprehensive” government program to turn to. They manage to take care of themselves for the most part and don't demand the fruit of other people's labor to provide for them.

    What makes Sickle Cell Disease special, Shawn? Do you have the intestinal fortitude to tell us all why SCD is a special case more deserving than say, gout?

  4. I would like to respond. The “comprehensive health services” needed for SCD is not, as you sarcastically suggest “free care at the expense of others.” The point is that in order for SCD patients to avoid having to seek emergency services, they need to receive adequate care outside of the emergency room (i.e., from a qualified GP/family practitioner). However, most GPs don't know a thing about how to treat SCD or how to spot or handle the many complications that SCD patients suffer from. Most sickle cell clinics only treat pediatric patients. Historically, this is because SCD patients rarely lived to adulthood. Now that many SCD patients are living into their 50s and beyond, sickle cell clinics staffed by knowledgeable and experienced doctors are needed to treat the adult SCD population. Unfortunately, such care currently does not exist in most major cities.

    I would like to respond. The “comprehensive health services” needed for SCD are not, as you sarcastically suggest “free care at the expense of others.” The point I think Shawn was trying to make is that in order for SCD patients to avoid having to seek emergency services, they need to receive adequate care outside of the emergency room (i.e., from a qualified GP/family practitioner). However, most GPs don't know a thing about how to treat SCD or how to spot or handle the many complications that SCD patients suffer from. Most sickle cell clinics only treat pediatric patients. Historically, this is because SCD patients rarely lived to adulthood. Now that many SCD patients are living into their 50s and beyond, sickle cell clinics staffed by knowledgeable and experienced doctors are needed to treat the adult SCD population. Research suggests that when SCD patients receive comprehensive, consistent, coordinated care they can avoid many of the painful crises that result in ER visits. Unfortunately, such care currently does not exist in most major cities.

    Mind you, I agree that what Mr. Graham is doing in New York is an abuse of the system and should not be tolerated. However, your response to Shawn, above, accuses him of asking for special treatment for SCD. SCD patients do not need “special” treatment but they do need “specialized” treatment — treatment by someone who knows what the heck s/he is doing. My husband happens to have SCD and gout. His gout is being handily treated by a rheumatologist who treats gout all the time. His SCD is being treated by a hematologist who specializes in cancer. He may be brilliant, but he doesn’t know anything about SCD. Why? Because all of the SCD doctors in our major metropolitan city only see kids. My husband ended up with a kidney transplant because his award-winning GP missed the signs of kidney failure for several years (high blood pressure, rising creatinine, etc.). Why did he miss it? Because he wasn't aware that SCD commonly results in kidney failure in adult SCD patients. You make a big point out of how “every ER doc knows that sickle cell disease is often claimed by drug abusers as a way of getting injections of powerful narcotics pretty much whenever they want” and then tie your stereotype into a rant about how various folks (presumably whether they have SCD or not) waste valuable health resources. Sure, some jerk in New York, who happens to have sickle cell disease, is abusing the ambulance system. Yeah, that's bad. We should stop that. But since you seem to agree that the vast majority of SCD patients are, in fact NOT drug abusers, please leave SCD out of it. And get off the above commenter’s back—he was a lot more accurate about describing the reality of SCD than you were.

  5. I'm a patient who suffers from SCD and I have only traveled by ambulance twice. SCD is just as important than any other case. I have to say that Mr. Graham has taken it a little too far with calling EMS to take him back and forth to the hospital. I have to agree with the Dr. Theo and Shawn. Mr. Theo, I feel as if some people do abuse the system like Mr. Graham has and continues to do something such as this causes those who live with SCD and take care of themselves have to work harder when it comes down to research or health care. Shawn, I also agree with you some patients such as myself dnt have a drug addiction to the pain medications. If anything I want to be treated like a human being. Yes, I talk about my illness to raise awarness but would never take the system for granted. When I have an attack you can clearly tell and although the attacks are painful I can make it to the ER by car if needed. Also, there are medications that can help him reduce the number of attacks that he may have. Hydroxurea is a medication that I have been on for years and works great maybe his doctors should look into the proper medication to help him with pain when dealing with an attack at home, proper appointments to follow up, and medication to reduce his attacks. I hope you both understand my point of view and thanks for reporting the story Dr. Theo.

  6. Thank you for your comment. Your case is probably typical of the majority
    of SCD patients and I have nothing but empathy and a desire to help people
    like you. The small percentage that use the ERs for recurrent care are the
    outliers and I never meant to suggest otherwise. They are the ones who
    refuse to go to follow-up appointments and refuse any treatment options
    demanding nothing less than more and more opioids for reports of pain
    without any objective findings to substantiate those claims. These same
    patients are often users of alcohol, cigarettes and crack cocaine, all known
    triggers for sickle cell crisis but they refuse to do anything to help
    themselves and repeatedly clog up my ER with demands for more and more
    drugs.

    I don't know if Mr. Graham falls into the category that I just described,
    but with over thirty years in emergency medicine I think I can speak with
    some authority about the situation in general terms.

  7. Your contention that proper treatment for SCD is rare or non-existent is
    simply incorrect. The hospital that I am associated with as well as two
    other large medical centers in my city have clinics and programs for adult
    SC patients. I also believe most internists are adequately trained to care
    for most SC patients, only occasionally needing the help of specialists like
    hematologists.

    My original post was not intended to be a discussion about SCD. Shawn and
    you have taken it in that direction. I was pointing out that abuse of the
    medical system, especially in the ER is rampant and nobody is trying to fix
    it. The government agencies are actually vested in getting and keeping as
    many people as they can on public aid programs and don't give a hoot about
    the waste and abuse. I think you would understand better if you had
    actually read my piece through before commenting.

    You and Shawn both talk about “comprehensive, consistent, coordinated care”
    but neither of you have told me how this should be provided–insurance
    companies, private physicians, hospitals, clinics or all the above. OK
    then, who will pay for this care? If some patients only want opioid drugs
    and refuse any other treatment options and referrals what should we do with
    them? Just keep giving them all the drugs they demand or cut them off and
    throw them out on the street untreated?

    The abuse of the medical system by a wide range of patients (see original
    article) drives up the cost of medical care for all of us. The peope who
    are supposed to be monitoring and administering the programs don't care.
    The type of “reform” proposed by The One will only exacerbate the problem
    and drive the costs even higher and the quality down.

  8. Your contention that proper treatment for SCD is rare or non-existent is simply incorrect. The hospital that I am associated with as well as two other large medical centers in my city have clinics and programs for adult SC patients. I also believe most internists are adequately trained to care for the majority of SC patients, only occasionally needing the help of specialists like hematologists.

    My original post was not intended to be a discussion about SCD. Shawn and you have taken it in that direction. I was pointing out that abuse of the medical system, especially in the ER is out of control and nobody is trying to fix it. The government agencies are actually vested in getting and keeping as many people as they can on public aid programs and don't give a hoot about the waste and abuse. I think you would understand better if you had actually read my piece through before commenting.

    You and Shawn both talk about “comprehensive, consistent, coordinated care” but neither of you have told me how this should be provided–insurance companies, private physicians, hospitals, clinics or all the above. OK then, who will pay for this care? If some patients only want opioid drugs and refuse any other treatment options and referrals what should we do with them? Just keep giving them all the drugs they demand or cut them off and throw them out on the street untreated?

    The abuse of the medical system by a wide range of patients (see original article) drives up the cost of medical care for all of us. The peope who are supposed to be monitoring and administering the programs don't care. The type of “reform” proposed by The One will only exacerbate the problem and drive the costs even higher and the quality down.

  9. Dr. Theo: You cannot have it both ways. You cannot backtrack and claim that the small percentage of patients who use ERs for recurrent care are outliers while simultaneously using Scott Graham as the “poster child” for abuse of the system. Let me be clear: what Mr. Graham is doing is wrong. And, in my opinion, you are wrong to insinuate that his actions were a result of his own volition and free will – without taking into account the context in which his behavior occurs. If you had just dealt with the issue of people inappropriately using health care services, I'd have been with you 100%. But you should not use this forum to make such baseless and uninformed claims about SCD – it just furthers negative perceptions of stereotypes towards people who are already maligned, denigrated, and stigmatized.

  10. Professor Bediako, you insist on reading into my post things that I didn't say or imply. I stand by my comments and my assessment of the immense and ongoing abuse that goes on in emergency departments every day. I have also made myself clear as to my experience with drug abusers claiming SCD as a ruse for getting the drugs they desire. Toothache, headache and backache are also common complaints given for the same reason.

    Your advocacy for those suffering with SCD is diminished by your denial of the very real problem that those of us on the front lines have had to contend with for years (and only gets worse with expanding social programs).

    I also noticed that you declined to answer my question about why SCD should be addressed as a special case demanding government programs when many other equally debilitating diseases are not.

  11. I think we can agree on the point that emergency departments are misused everyday. Like you, I want to see fewer people using emergency medical services. Where we disagree is that I do not appreciate your use of a sickle cell patient as the exemplar for what you purport is the root of the problem with emergency services.

    The example of Mr. Graham's case is confusing, misleading, and not clearly related to the broader point that you intended to make about emergency services being misused or overused. You stated that you don't know anything about Mr. Graham's medical history other than his report of having SCD – well, wouldn't you need to know more than his diagnosis in order to make the broad generalization that he was indeed “abusing” emergency services? My point was that if you did indeed know more about SCD (other than how it is often used as a “cover” for drug addicts to get narcotics), you might be able to provide more context to Mr. Graham's behavior…and find another example to more clearly make your point. Your post (and additional comments) insinuate that this behavior is typical of SCD patients – or at least that's how I read it. If it is a misunderstanding on my part, that is totally my shortcoming.

    I'm on the front lines, too, but the difference between you and me (at least on this issue) is that I've actually spent time talking to SCD patients about their experiences with health care – and I understand the context of some of their behavior. In one hospital at which I was affiliated, we couldn't get SCD patients to come to the ER – even when they were in severe pain – because they would be treated with such disrespect by the medical staff that they'd rather suffer at home than face being humiliated by staff who were uninformed and who held stereotypes.

    Finally, I think you are guilty of the same thing you accused me of: I didn't say that SCD should be given special status with a government-funded program; my point – and that of the other commenter – was that specialized health care services are needed for SCD patients that should be provided by an adult hematologist who is knowledgeable of blood disorders and their treatment. If there were such services, then perhaps more people with SCD could remain employed and not have to rely on government I don't care who funds it or how much it costs…

  12. Professor, you continue to miss my point and assume that I have prejudices and motivations that I have not demonstrated. If some SCD patients are treated with skepticism and disrespect in emergency departments perhaps it is because we, the doctors and nurses, have been sensitized by the few that abuse us mercilessly and refuse to follow any responsible care plans that we offer. So who's at fault? I think your frustration is misplaced.

    In your first comment you said, speaking to me “I wish you could spend some of your time in this space advocating for the NIH to re-institute and expand its comprehensive sickle cell program…”

    The last I checked the National Institute of Health was a federal agency and is funded entirely with taxpayer dollars. It would seem, therefore, that what you are advocating is more federal dollars to address a problem that I see as one of personal responsibilities. The 90-95% of SCD patients that do not abuse the system (as you claim) apparently are getting appropriate care somewhere. Why can't we insist the abusers start taking responsibility for themselves or they'll be cut off from further treatments in ERs and other acute care facilities. We do exactly that with people who come to the ER repeatedly for back pain, headaches and toothaches and refuse to follow-up with doctors and dentists to whom they are referred.

    I don't mean to be condescending, but a doctor of education that interviews patients about their ER experiences cannot be said to be on the “front lines.” I might have a 49 year old patient having a heart attack in one room, a child with fever, headache and neck pain that I need to do a lumbar puncture on in another and a young woman hemorrhaging with a miscarriage in yet another room when a young man looking to be right out of a Lil Wayne video storms in and demands that I stop everything and get him a “pain shot” immediately because he has sickle cell disease–no records, no doctor, no objective evidence of acute pain or ischemia. Failure to instantly comply gets me and my nurse screamed at and threatened in the most profane language you've ever heard. That's what I mean by the front lines, Dr. Bediako. Have you had to endure that kind of abuse and pressure night after night? Would you be able to smile and ask what's his drug of choice and how much does he want over and over knowing he'll never keep the follow-up appointment you've spent 30 minutes arranging for him tomorrow?

    Yes, ER doctors and nurses definitely have an attitude about some patients complaining of SC pain, but how could we not. Incidentally, I have worked with several very good black ER docs and they react exactly as I do.

    Finally, it was you that made this discussion all about SCD. It was only incidental to the story that I commented on. It could have been a patient with complaints of recurrent back pain and I would have reported it as such, but it wasn't. It was about a person who claimed to have SCD (we don't know if he does or doesn't) so I felt a responsibility to our readers to put the situation in the context in which the author, me, an ER doc, would assess it.

    I admire and respect the work that you do, Dr. Bediako, but you seem to have a blind spot when it comes to abuse of the medical system and the hard-working doctors and nurses who try to appropriately help all their patients in some very difficult and trying situations.

  13. I guess it's different everywhere.

    Here the people who abuse the medicaid system similar to the one you mention above, then spew “anti-socialized-medicine-government-communist-Obama” retoric in the waiting room.

    I'd like to take “Clueless Rednecks” for $100, Alex.

  14. I guess it's different everywhere.

    Here the people who abuse the medicaid system similar to the one you mention above, then spew “anti-socialized-medicine-government-communist-Obama” retoric in the waiting room.

    I'd like to take “Clueless Rednecks” for $100, Alex.