ER visits are inordinately costly, but are generally the only way for homeless people to receive care (behavioral, chronic health conditions, etc).
I'm having difficulty finding the source, but I've read that individual "frequent fliers" have consumed hundreds of thousands of dollars of emergency services without receiving substantive care that would improve their situation.
Why is an ER fundamentally so much more expensive than another office visit?
Just an anecdote, I don’t see any late night “urgent care” places anymore. If they were sufficiently less expensive than ERs, it seems like insurance companies would incentivize them to have longer hours. Otherwise, after 9pm, you have to go to ER.
> Why is an ER fundamentally so much more expensive than another office visit?
Two main reasons: you need to use personnel, equipment, and rooms that can offer the highest levels of care. And you need to pay for having a facility staffed to handle worst case loading (with triage) 24/7.
You also tend to have pretty exhaustive testing on the "emergent" side to make sure everything is immediately OK prior to discharge.
Right, and ERs also charge high prices to insured patients in an attempt to recoup losses from treating uninsured patients (including those with serious chronic mental disorders).
Even here in Canada where all citizens generally have insurance ER visits are still far more expensive then if a patient visits a primary care provider or has has any sort of care before the issue takes them to the ER
This has vastly less to do with the cost than the level of care they have to be prepared to provide. I get that people really want to beat the medical cost horse, but it’s sometimes helpful to understand it, first. People use the ED as a PCP across the spectrum because they don’t know better, because they can’t find other options, and sometimes because they don’t have other options - and all of those things tend to cost the hospital, state or insurer vastly more than the patient.
Further, tacking on “serious chronic mental disorders” is basically a non-sequitur and could’ve been replaced with “diabetes” or “broken legs” or “tooth pain”.
They are significantly less expensive - there are also massive doctor/nurse shortages, among other issues. Insurers, especially in the MA space but also in the ACA market, spend a significant amount of time trying to educate ED users about UCCs.
If your local urgent care can’t find a doctor or NP willing to be on call late, they can’t stay open late. Given the shortages, expect the problem to get worse.
Urgent care is never going to be staffed and equipped the same as an ER. It's not an ER. If you get shot, the ambulance isn't going to take you to an urgent care.
Checkout this 2015 article: "San Francisco Firefighters Become Unintended Safety Net for the Homeless"
> With a budget of more than $330 million, the San Francisco Fire Department responded to more than 136,000 incidents last year — about 28,000 of them fires and other nonmedical calls for service, plus just under 12,000 false alarms.
The police and emergency responders can be called, but are unable to take any action to help a clearly mentally ill individual unless they are a danger to themselves and others. The same is true for doctors/hospitals/emergency rooms.
It is common for an individual to have 20 or 30 public service calls before they are admitted and start to receive guided treatment. Even individuals with caring and attentive families can and will fail to be treated, with damage to their mental state, or at a minimum long costly delays to their recovery.
Without getting too much into the details of a personal experience in San Francisco (decades ago), I can say that a person can act extremely crazy and threatening, have a history of serious mental illness and it was effectively impossible to get the police to intervene until the person became violent or made threats that make coherent sense. I am not a lawyer, or an expert on mental illness, but everyone in this situation thought the person was really scary and threatening, just not in a way where they said something like "I am going to attack you". Ultimately a few days later that person did assault a stranger and got taken into medical care. But we couldn't get the police to do anything before that point.
I don't blame the police, they followed the law. But in a case like that, where a person seemed very dangerous (and ultimately was), had a history of severe mental illness, was off their meds.. it seems like you need a way to intervene before the ill person does something dangerous.
1) very temporary ‘fixes’ to what are almost always conditions caused by some kind of chronic situation - often bad environments, toxic families, serious psychiatric and drug problems, major life events which don’t just go away, ongoing manipulation or emotional abuse by someone near the person, etc. often many of these things all at once.
2) very traumatizing on their own with severe long term legal and monetary consequences. Practically speaking, people lose a significant amount of rights they never get back (including the right to own firearms [https://www.atf.gov/file/58791/download], the right to adopt kids, hold many jobs, etc.) the moment they get a 5150. Getting a 5150 is one of the few ways one could lose custody of their child for good, at least in California. If someone has a legitimate history of psychosis or other serious mental health conditions, that’s all probably a good idea and legitimate! there is also a history of abusive folks using things like 5150’s to abuse and target folks they are trying to control (like abusive parents, ex spouses, etc).
Getting thrown in a psychiatric hospital against one’s will is not a pleasant or comfortable situation for anyone, let alone someone going through a psychotic episode. But the best society has come up with so far, and definitely better than them stabbing random strangers on the street (or themselves), or being thrown in genpop. Usually, anyway.
It’s a short term ‘fix’ for what is often (but not always!) a serious long term problem. Which is better than nothing!
Emergency and Long term involuntary commitment has a long and storied history of being seriously abused to steal people’s assets and manipulate/control folks who clearly were not crazy or a danger to themselves or others by any real definition.
It’s also a necessary tool when attempting to manage serious mental health issues in the population.
In both of these cases though, do you really want to set the bar so that it doesn’t require a clear, documented by a third party and actual/present danger to someone before it gets used?
Because I guarantee if you do, it will be used by angry spouses, controlling parents, political/business opponents or leaders, etc. against sane people all the time. More than it already is, anyway.
Which is often.
SF has a serious problem. Actually using 5150’s more isn’t likely to help though as most of the people getting them likely already have gotten them before. It’s a revolving door.
They get screwed up enough to warrant an emergency hold. They get help, temporarily stabilize, and within a week are back to the same situation. Eventually, they go psychotic again, and rinse repeat until they die or figure out how to get out of the cycle. Many die.
Well, "they are admitted and start to receive guided treatment".
Unfortunately the police will tell you bluntly: "It's not against the law to be crazy"
More unfortunately, medical personnel have told me that unless a treatment regimen with appropriate medication starts, the brain will deteriorate and chances of a full recovery disappear.
> Well, "they are admitted and start to receive guided treatment
Unless there's a separate medical system for the homeless/ mentally ill - I just don't see how it'd work. The American healthcare system is fucked, and cannot be unfucked for just the homeless (who can't pay). Most people are happy to ignore the state of affairs until there's an untreated schizophrenic hanging out in front of their favourite Avocado Toast joint.
Unless mental illness is criminalized, police have no business detaining the mentally ill or forcing them into treatment.
The problem is that "the homeless" start out as normal people - they have rational minds, have jobs/insurance and contribute to society. They can pay for treatment. Unfortunately they can have clear signs of deteriorating mental health and the system will not touch them. Then they lose their rationality, their jobs, their insurance and transition from contributing to society to burdening it.
This doesn't require a separate medical system, it requires prompt intervention/treatment at the beginning of the illness, not after many many visits.
> This doesn't require a separate medical system, it requires prompt intervention/treatment at the beginning of the illness, not after many many visits.
I fully agree. The same goes for cancer, dental health and countless other diseases and ailments. The solution is having a stronger social safety net - but America appears not to want that, so here we are.
They are a large portion of ER cases and ambulance calls. If you go to an ER in an urban area, especially late at night, there's always a few crazy people raving in some sort of episode.
Instead of getting the treatment they need, they end up tying up ER resources? Either because of continual crisis with no proper diagnosis, or just lack of health insurance to find/afford any other options
I'm not saying you're right or wrong, but why do you believe that?