When a hospital becomes a refuge of last resort, who bears the cost?
Photo credit: (Photo by Loic Venance/AFP via Getty Images)
In spite of my armor of surgical mask and face shield, I know the patient is waiting for me before I enter the hallway of our clinic. I can smell him, a combination of a lack of washing and cigarette smoke. Although I’ve never met him, it doesn’t take long to put the rest of the clues together. He is disheveled, confused and emaciated.
I ask him how things are at home. “OK, doc,” he says, looking out the window. I press on. After a painful game of 20 questions, I realize the following: 1) He used to have a friend who brought him to the grocery store once a week, but this isn’t happening due to COVID-19, and he has no family to help him. 2) He’s eaten one sandwich in the past week and made it last multiple meals. 3) He hasn’t taken his insulin because he can’t see well enough to inject it. 4) He doesn’t think there’s anything wrong with this scenario.
I order lab tests for his diabetes, give him a list of food banks and offer an evaluation for a home health aide, but he lacks the capacity to think through medical decisions and he’s too scared of contracting the coronavirus to let anyone in his home. He leaves the clinic. His tests come back abnormal — glucose high, elevated sodium and other markers of dehydration — but not abnormal enough for inpatient treatment.
He doesn’t pick up his phone when I call him with results, and I end up sending the police to his house to check. They ask me what they should do when they find him. I do the thing I dreaded throughout my training — I call the academic hospital with which I am affiliated and make a request for a “social admission.”
A social admission is an admission to the hospital for a patient with no acute medical need, but for whom no safe discharge arrangements can be made. These patients tend to be elderly, frail or resource-limited, live in unsafe conditions and lack the social support needed for their medical condition. They cannot, of course, be billed as a social admission. Medicare will typically pay for 48 hours of their stay under observation status while a medical workup and placement are investigated. Observation status is technically considered outpatient care and does not count towards the three inpatient days required to qualify for a skilled nursing facility.
Many times, a safe option cannot be arranged in this window, leaving patients in purgatory. The patient (or more frequently, the hospital) is left to eat the cost of an inpatient stay, ultimately driving up costs for other patients. When I was a trainee, we would give a collective eye roll when the ER called us to admit another “91-year-old female with ambulatory dysfunction.” We felt these admissions had little teaching value and should be dealt with outside the hospital.
If sending a patient to the hospital in order to link them to a nursing home or physical therapy and rehabilitation seems inappropriate and circuitous, that is because it absolutely is. Unfortunately, robust programs to support these patients are hard to find. In the same way that police and teachers are left to deal with social factors far beyond their purview, physicians are called upon to act as psychologists and social workers or risk bad outcomes for patients.
This dilemma is magnified under the lens of the coronavirus. Day programs, mental health clinics and home aides have drastically reduced staffing and cut down nursing hours, leaving patients stranded. Patients whose insurance was tied to employment find themselves jobless and unable to afford preventative health services. The social admission is the unfortunate but inevitable side effect of our fragmented, broken health care system; it highlights the crisis of compassion we seem to be facing in America today.
If sending a patient to the hospital in order to link them to a nursing home or physical therapy and rehabilitation seems inappropriate and circuitous, that is because it absolutely is. Unfortunately, robust programs to support these patients are hard to find.
Compassion is built on empathy but involves the additional “wanting to alleviate pain and suffering.” As a society, we leave something to be desired in channeling our empathy into action. Many Americans feel sorry that people are on ventilators in the ICU due to COVID-19, but balk at the temporary discomfort of wearing a mask. We sympathize with the family who has been bankrupted by medical bills, but worry that capitalism will suffer with universal health care. We fail to realize that everyone ultimately pays for the lack of preventative care when patients treat the emergency room as their family doctor because they have nowhere else to go. We have become a society of individuals who compartmentalize our responsibilities and decide that the suffering of others isn’t our problem.
I recently had a patient come into our clinic, where I am an instructor for resident physicians. He could not afford to refrigerate his insulin and suffered from hypoglycemia spells more frequently in the heat. He wanted us to sign energy assistance forms for the state to subsidize the cost of electricity. The resident who initially saw him was upset that the patient had missed multiple appointments and felt strongly that this was abuse of the system — to not show up to take care of your diabetes and then ask for assistance to pay the bills.
I felt a bit differently. Last year, our air conditioner broke in the summer, when I was in my third trimester of pregnancy. I could not sleep and found it difficult to study for my internal medicine boards. I could empathize with the fact that lack of essential services (in my case, a habitable home) worsens a pre-existing condition (pregnancy) and hampers the ability to complete daily tasks. I even forgot the date of one of my prenatal appointments. I had seen countless patients like our diabetic, who wound up in the hospital for costly treatments because society did not have the compassion to address the underlying barriers to care.
Caring for underserved patients with complex social issues has been my biggest source of job satisfaction as well as my biggest stressor. It is disheartening when attempts to help in the clinic are rendered useless by factors beyond one’s grasp. I truly believe in the social responsibility of physicians to consider all the forces acting on a patient's health, but the onus of facing unaddressed systemic barriers to care results in undue pressure and burnout. In my 15-minute time slot for a patient visit, I often have to pick an aspect to address: social barriers or pure “medical issues.” Why should I have to choose?
My social admission was indeed admitted to the hospital — after his social issues, left untreated, became a medical emergency and he collapsed in his home. He was deemed incapable of making medical decisions, became a ward of the state and was placed in a nursing home. While I was happy that he was receiving regular meals and care, I felt unsatisfied. Would he have fared better if he had a team of social workers trained in getting him appropriate resources rather than doctors who had to choose which of his needs was most pressing?
Improved education for physicians on social determinants of health is always helpful, but the solution needs to be broader. We need policy change that places access to health as a right and not a privilege.
So, I wait. For programs and funding to alleviate disparities in care that ultimately hurt the well-being of society. For voters to notice that a lack of funding for preventative medicine means that patients end up in the hospital over and over again, with the bill to prove it. And I have the hospital on speed dial, just in case.
Niharika Sathe, M.D. is an internist and primary care physician in Camden, New Jersey.