Do you want to see my Medicaid card?
It’s three o’clock in the morning. I am already on my fifth call for this shift, and I do not get off until 6:30 am. Let’s just say I am not in a good mood. We pull up to the address and guess what, our so-called patient is standing on the sidewalk waving at us. As we pull along side this person who urgently needs an ambulance, my partner rolls her window down and as politely as she can, utters the question, “did you call 911?” He answers yes with a head bob. After this, I think to myself, this guy must really need my skills as an advanced life support technician; he cannot even speak.
“Get in the back,” my partner instructs him. We exit the vehicle to help him. As we pile single-file into our over abused taxi, my partner initiates patient care with the standard interview. In my 13 years as a paramedic, this part always seems to excite me in an evil sort of way. I have grown accustomed to the thought, what will these people think of next? Unfortunately for me, nothing new this time, just the same old boring crap. This gentleman (I say that in the loosest definition of the word) proceeds to explain just exactly how his foot hurts. He describes the pain and how it has been hurting for weeks. He went to the doctor “again” today for the pain, and the doctor gave him a prescription for some pain medicine. However, he just did not have time to go and get his prescription filled, and now he wants us to take him to the emergency room. Yes, you heard me, he wants to go to the emergency room for a two week old injury that he has already been seen for by a doctor at least twice because he did not get his prescription filled and now that it is three o’clock in the morning he has decided it hurts bad enough to warrant an emergency.
Our government has mandated that I am not allowed to refuse care to this individual, as I am not qualified and goes against every thing that the Hippocratic Oath stands for; even when I know he is being ridiculous. Furthermore, I would loose my job if I told this individual exactly what I think of him. So, off to the emergency room we go. En route I ask the infamous question, by which the very fabric of the ambulance business survives (if we don’t get this information the company does not get paid), “Do you have any insurance?”
“Yes,” he replies. “Do you want to see my Medicaid card?”
You would think a response like that would elicit some sort of emotion in me, but no. I probably hear that same statement at least two times a night. I have grown accustomed to the uneducated and realize that they and they alone have mastered the system. I am merely a pawn in this game of chess. There are certain people who view Medicaid as health insurance even though Medicaid is not health insurance at all; it is a government assistance program that pays for healthcare for a certain demographic of people (usually poor or the elderly) who may not be able to obtain health insurance on their own.
By regulations of my supervisors, I must call the hospital and tell them what type of patient I am bringing to them. The nurse is unsurprised by my report and she tells me to take him to triage, where they sort patients by injury or illness and assign them a level of priority. The patient overhears the conversation and keys in on the word triage. He immediately begins to protest because he obviously has enough knowledge to know how the system works. He immediately begins an informal dramatization. The way he carried on you would think that he has just stepped on a land mine and now his foot seems to be hanging to his leg by a mere thread. There are absolutely no signs of trauma and/or loss of use, but he tried to convince me that if he could not be seen immediately he might loose his entire leg. His protestations gain no ground with me, for I too have been long associated with this game. Everyone involved in hospital care knows that triage equals a long wait, and everyone sicker than you (in this man’s case that will probably be everyone) will be seen before you.
Upon arrival at the emergency room, I open the door so the patient can exit. After another round of trying to convince me he was dying, he exits and we casually make our way to triage (better known as the waiting room). He is walking just fine and I am actually struggling to keep up. He seems to know the way and he appears to be in a hurry to get there. I give my report to the nurse and return to my truck. I am always rushed, and I have to hurry and finish so I can be ready to perform another life saving task.
Shortly after I get back to the truck, about three minutes had passed since I last saw my patient, I look toward the main entrance to the emergency room and to no surprise my patient walks outside. He pauses in front of a man, and I watch as the individual with whom he is now conversing gives my patient a cigarette. I continue to watch as my patient turns and begins to walk down the sidewalk; he left the hospital so I guess he did not really need a doctor after all, maybe he just needed a ride downtown. My patient fades out of sight as I finish the necessary paperwork so that Medicaid will pay the ambulance company for this trip.
According to the Georgia Department of Community Health’s website, ambulance services are covered by Medicaid (GDCH). The government has an elaborate algorithm for determining how much they will pay an ambulance provider. In the metro Atlanta area Medicaid and/or Medicare will pay a base rate of $201.56 for a Basic Life Support Transport. They will also pay an additional $6.05 per mile after the first 10 miles (CMMS). However, these figures are nowhere near what the ambulance service charges. According to Dan West, the Chief of EMS Operations for Cherokee County, the charges for a BLS Transport are a base rate of $397.00, and mileage of $9.50 per mile while the patient is being transported (West). The charges go up from there depending on the level of care and treatments that are administered.
This kind situation –in which a patient abuses an emergency service– is a daily occurrence in Atlanta. It has been my experience that numerous citizens of Atlanta view hospitals and emergency room doctors as their primary care physicians, or in the case of the last guy a free ride somewhere. Along with this, the government—in the form of Medicaid and Medicare—now pays the exorbitant bills that are racked up by the hospitals. The Website State Health Facts claims that for the 2006 fiscal year Medicaid alone paid “almost 7 billion dollars” in the state of Georgia. This is only a portion of the amount that was spent that year in the United States totaling more than $300 billion (statehealthfacts). These numbers indicate that this phenomenon – that I like to call hospital abuse– is a nation wide problem.
I understand the need for public assistance. However, I feel like a recipient of such a valuable resource should take some ownership in these programs and not abuse them. On one side of the coin, certain people may view incidents like these with a viewpoint such as, “I paid $200 for an idiot to go bum a cigarette. After all, it is my tax money that pays for it.” It is hard to deny the fact that a statement like this has some degree of merit. In fairness, we must look at this from another point of view that might be summarized as, “We cannot let a few bad apples spoil the entire cart. Many people need this kind of assistance, and the good far outweighs the bad.”
Grady Memorial Hospital, the largest single recipient of Medicaid in the state of Georgia (totaling 269 Million dollars) is at the crossroads. Fifty-four percent of the patients at Grady are on Medicaid, while another 14 % are uninsured (GHA). Another source, Helena Cavendish de Moura, in an article cites that 75% of Grady’s patients are on Medicaid while the remainder is uninsured (Cavendish). You can see the broad spectrum and the differences in the numbers only compound the problem. The problem is so overwhelming that accountability and factual information is virtually impossible to obtain. These numbers are attempting to account for Georgia Medicaid payments; they are not inclusive of the federal monies that Grady receives. This type of inconsistency could leave a person with the thought that the problem is so enormous that we cannot even define it.
No matter how you want to look at it, there is a serious problem afoot. On my level I have taken the stance that while I am at work I just smile and take the patient to the hospital, no matter how insignificant his perceived ailment may be to me. I do this because I have a family to care for and I need this job and sometimes people really need emergency services. I ponder the situation at times, but I find myself running many too many calls to form a hardened opinion.
Works Cited
Cavendish de Moura, Helena. “Financial Crisis at Grady Hospital.” Tagged in 2007.
Georgia Public Broadcasting: www.gpb.org. February 17, 2008.
http://www.gpb.org/healthdesk/financial-crisis-at-atlantas-grady-hospital
Centers for Medicare & Medicaid Services. November 21, 2007.
U.S. Department of Health & Human Services. February 17, 2008.
http://www.cms.hhs.gov/AmbulanceFeeSchedule/
Georgia Department of Community Health. March 16, 2006.
State of Georgia website. February 17, 2008.
http://dch.georgia.gov/00/channel_title/0,2094,31446711_31946021,00.html
Georgia Healthcare Analysis. May 2006.
Georgia Budget & Policy Institute. February 17, 2008.
http://www.gbpi.org/pubs/healthcare/20060515.pdf
Statehealthfacts.org. September 9, 2007. The Henry J. Kaiser Family Foundation.
February 17, 2008.
http://www.statehealthfacts.org/mfs.jsp?rgn=12&rgn=1
West, Dan. Personal Interview. February 1, 2008.
678-493-4127 or by email at dwest@cherokeega.com
