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Wednesday, July 22, 2009

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Forgive me if my comments below seem a tad cranky, but the kid has been very unstable lately, and we know from experience how completely inadequate the local ERs and availability of psych beds are.

Tho I don't like physical pain either, and I admire your stoicism ,Dr X, I wish ER use were just about physical stuff. With us, the ER is where we will have to go in a crisis of the kid's, to preserve life. The resort of desperation. The two times in a year (eight years ago) we went were after calling police to put a psychotic child raging out of control onto a stretcher--the police were gentle, kind and calmer than distraught parents, us. Also stronger. There aren't walk in clinics for psychiatric emergencies or psychiatrists or psychologists around here who return calls in a timely manner in a crisis.

However, for the more typical types of ER use? Where we live, there's a reasonable walk-in clinic now, open on weekends. That's where we'd go for anything but a life and death crisis. The doctors aren't the greatest, and are pill-happy, but if it were the evening or weekend and we couldn't see the regular MD, that would be it.

I wouldn't call the ambulance but would drive a family member to the ER, if absolutely necessary (except for spinal cord injury, heart attack, stroke, or acute psychosis) as our local EMS duns you for hundreds of dollars and you pay it all if the threatened heart attack turns out to be something else and you are not admitted. We have health insurance with a 5000 deductible and very high copays. So I would only use the ER if kid were homicidal or suicidal and it was too dangerous to keep him at home.

It's the hypochondriacs and the uninsured in our community who mostly use the ER. They are not always the poorest. Then our rates for insurance go up and we feel it as our copays are percentages of the cost...

Our local hospital also periodically institutes draconian surcharges on the bills of the insured (not reimbursable by insurance) "to cover the uninsured" then magnanimously hands out our money to grateful poor people. Not that we are asked. I'd rather give charity directly. One reason why we would go to the hospital in a bad neighborhood, next town over, as they don't practice such mugging of paying patients.

But when we were in the country over the weekend and spouse cut chin open on wrecking bar (hundred year old trim snapped as he was ripping it out)we didn't know a doctor in the area and couldn't find a walk in clinic open on a Saturday night, so apologetically went to the ER 15 miles away, thinking stitches were needed. Those plastic thingummys did it, but the staff there said there actually wasn't anywhere else we could have gone at that hour, or day of the week. Then again, when we are up there (rural, mountainous part of New England), if anybody had a heart attack or stroke, they would be a goner as an ambulance would never get to them in time let alone get them to the hospital quickly enough to save their brain, tho perhaps the body might be saved...

I think the main way to lessen excessive ER use is to have strict copays, even for the uninsured. With the exception of the homeless, everybody can come up with a $50 charge levied in the next month (one could hold their cellphone for ransom until the bill was paid?). It's only a fraction of the cost, but people who are used to getting it for free would feel it.

That homeless guy being visited by Michelle Obama could have a Blackberry,and I see daily that the TItle 8 subsidized residents of our town all have Iphones and other elaborate phones, which could be put up for collateral. Debatably, if one can afford an Iphone and data plan, one might afford to pay something towards even exorbitant private health insurance? It's a question of priorities...

R,

I wouldn't include psychiatric emergencies among the cases I was talking about. The ER is often the only place to go. And if you need hospitalization, it is usually the only way to be admitted if you have a psychiatrist to arrange for admission.

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