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Notes -
Two case studies in government waste:
As you can likely imagine right now a lot of people in medicine are sharing tales and taking sides in the great DOGE debate. Two that popped up on my radar and stuck out to me:
Some problems: -As an emergency room most of their patients have no insurance or Medicare or Medicaid, meaning the facility often get paid less than cost. They only stay open at all because of their state grants.
-Many of the patients are drug addicts or malingering (because of homelessness for example). Every day you’ll hear something like “you’ve been here every day for the last three weeks” or “have you considered stopping using PCP? You always seem to fight with the police when you do” and “here’s your follow-up appointment, will you go? No? Fuck me? Okay thank you have a nice day.”
-Many of the patients who do actually have mental illness are in denial about it, or have some sort of limitation that prevents them from attending aftercare appointments.
-The “best” solution is probably to violate patient rights and involuntarily commit them to make someone else be on the hook for making sure they go to their aftercare.
-In the meantime, the hospital has hired several additional staff to manage some of the administrative complexities associated with this change (for example hammer calling the patients to remind them to come to the appointment). They have also hired night staff whose job is to sit in an office overnight purely to schedule appointments with an outpatient program (otherwise no patient could be discharged overnight because they wouldn’t have an appointment to go to…).
Anyway, he dutifully completed his requirements in a timely fashion (which were all pointless! Ex: what is the motto of the VA???). So, months later his rotation is starting soon. He begins the process of emailing the education team once every 2-4 business days. You have to email them multiple times before they respond. The conversation goes something like this over the course of multiple weeks, “I think I’ve completed my onboarding do I have to do anything else?” “no” “okay is my onboarding done” “no” “okay when can I pick up my ID card” “when your onboarding is done” “I thought my onboarding was done” “yes” “okay what I am waiting on” “nothing.” I have seen the emails; it really looks like this.
At this point his program tells him to CC the chief of medicine at the VA hospital, at which point the person responds with “okay we put in a ticket for this a month ago, your training is complete but your training is marked as incomplete.” A screenshot has been attached that shows the request and an automatic response that says something about high ticket volume and that they will get to it at some point. The chief of medicine replies “….does the trainee need to do anything?” (we are here).
The resident will be able to rotate but will not be able to do any work without computer access.
It’s worth noting that the VA is paying for this resident to be there, despite the fact he will in fact not be able to do anything. At his last VA rotation (yes they go through this for every resident every time) he was six weeks into an eight week rotation before he got access.
We have gotten to an odd place where people can nonchalantly talk about fighting police weekly and utilizing millions of dollars of public resources as "rights". This seems like yet another example of why the left and Democrats are so alienated from "the working class", as far as such a thing exists. Relaying a story like this to an Amazon delivery guy, a stay at home mom of 3+, a legal secretary, or a midlevel real estate agent and they'd very likely be seething with rage, thinking about how they just got a $3000 bill from a hospital because their kid had an asthma attack, which came just after finished paying off the bill for their other kid's birth.
Why didn't they just pretend to be homeless again? That is the question they ask. Why is the violent drug user getting better treatment from the state?
One of the other posters hit on this but basically in most states people have a right to be not forced into treatment (of any kind, not just psychiatric) as long as they are not actively suicidal or homicidal (gross oversimplification the laws around this are very state specific and complicated).
Drugs don't count for this. We can't force someone to take their diabetes medication. We can't force someone to go to a psychiatrist (again with above caveats).
This is generally good despite the edge cases.
Its not forcing anyone. The hospital has a clear need to have a minimum treatment program of 30 days. You can accept that program or not
If a patient comes into the emergency department the options are (loosely) you discharge or admit them.
People are allowed to go home even if doing so may result in death or bad outcomes. We typically calling this leaving AMA (against medical advice). Common reasons for this are illness disrupting decision making, denial, and needs (like drug use, or I have a flight to catch, or I gotta go to work).
If people in the hospital think a patients decision making is impaired (for instance: dementia, medical illness resulting in confusion so they can't make a decisions with full thought) they can do a capacity assessment. This usually involves calling psychiatry for help but you don't need to. If the patient understands the ramifications of their decision (oversimplification again) they get to go home and die or have their frostbitten fingers fall off or do too much heroin.
A sub category of this is psychiatric extremity.
If a patient comes to the ED and has a psychiatric history or has psychiatric symptoms then psychiatry needs to see them and say they are safe to go home. Some critical thought should be used to determine if psychiatry is actually needed but for various reasons (including the ED being overworked, midlevels, and liability concerns) no critical thought is used.
For instance "I'm sorry I said I wanted to die, but I had fallen off of a dump truck and could see all the bones in my legs going the wrong direction and it was very painful" "or I came here because I was looking for a therapist" now generate a need for an outpatient follow-up appointment. Also "I have no psychiatric problems but I was confused because I have early onset dementia" and "I came here because prison lore is that I don't have to go to jail if you guys say I have psychiatric problems" or "no I'm fine, that was some good heroin, let me out so I can go get more before they run out." None of these people necessarily need a psychiatrist, the ED psychiatrist's job is to determine if they do and if they are safe to go home.
Now they are required to see someone (supposedly, I don't know the legislative details), wasting everyone's time.
The other primary option is admission. If the patient is a threat to themselves, others, and in some states property (with a lot of at times hazy and at times specific clarification on what all of that means) then they can be involuntarily committed. You can also just ask the patient if they want to stay, which depending on resource availability may involve admitting someone who really doesn't need it. All kinds of complications fall out here, for instance some patient's say they want to be admitted but are admitted involuntarily any way.
In past times the U.S. was very free with involuntarily admitting people, very resistant to actually discharging people (from the ED and from the psychiatric hospital) and abused people in various ways, our current legal framework exists to protect against those abuses, some of which were very very serious (gang rape of patients at state hospital for example).
The downside of reforms was that homeless people who are too mentally ill to function or chronically treatment non-compliant are allowed to wander the street.
You may not care about those people, but we also used to accidentally catch people who really weren't mentally ill or were definitely safe to be at home. Not making this mistake is harder than you think because its very common for people with no mental illness, mild mental illness, and severe mental illness to all say the same things (especially when someone is taking the medication only because they are locked in a state hospital and will stop as soon as they leave and start murdering again).
Its not about caring/not caring about these people. Its about not elevating them above everyone and everything else
It's not that simple. It's not always clear who is who. Some frequent flyers are coming back because they don't want to go to the shelter. Some are coming back because the ED keeps not treating them because they think the problem is mental illness and they never did a basic work up...
It may be helpful to model this similarly to however you feel about the legal system, letting guilty go free and so on.
The legal system doesn't involve people coming into my house, stealing tens of thousands of dollars, and then the next time they are at the front door I am supposed to let them back in. In fact, most of the more sane jurisdictions allow for pretrial detention of something as serious as a burglary or theft by deception.
The problem is the state blatantly violating freedom of contract by forcing these victims to treat these menaces, and then trying to fudge away the actual cost of the insane policy by smuggling it through various re-distributive schemes as opposed to a budgetary line item.
$100 billion for ER visits from meth heads and heroin addicts is less defensible then "we can't have people dying in the streets (ignore this massive cost we've hidden with subterfuge)"
The problem isn't necessarily your idea (although I'm sure some would take issue with it), the issue is the implementation. How do you decide? Some people with chronic medical illness look like a mental health patient, some mental health patients try repeatedly to get medical care and get ignored... when the issue is "live or die" you have to get things absolutely right.
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