Image: Jesse Ashlock
Courtesy of Jesse Ashlock
Jesse Ashlock of Brooklyn, N.Y., was knocked unconscious in a bicycle accident last July that also left him scraped and bruised.
By JoNel Aleccia Health writer
msnbc.com
updated 5/11/2009 9:12:42 AM ET 2009-05-11T13:12:42

In hindsight, maybe Jesse Ashlock shouldn’t have walked out of the New York emergency room last summer, only a couple hours after being knocked unconscious in a Brooklyn bicycle crash.

Medical crews told him he needed a blood test, chest X-rays and probably a CT scan to check for head injuries. And he certainly should have had treatment for major road rash, including raw scrapes on his face, neck and hands.

But the 31-year-old editor for a design magazine was between jobs, briefly without health insurance and afraid of being stuck with a sky-high hospital bill. The doctor on duty dismissed Ashlock’s questions about cost, telling him she was “a physician, not an accountant,” he said.

So Ashlock stalked out of Woodhull Hospital without treatment, becoming part of a small but growing number of patients turning down emergency care because they fear they can’t afford it.

“I’ve heard all kinds of horror stories … I could easily imagine it being $5,000,” said Ashlock. “I was worried about having a concussion and worried about going to sleep, but I was fine.”

Even as rising unemployment strips people of health insurance, sending many to emergency departments for care, doctors on the front lines say the lingering recession is also prompting an unexpected outcome.

More patients, they say, are refusing potentially costly procedures ranging from tests to confirm heart attacks to overnight stays to monitor dangerous infections.

“I have definitely seen an increase in this problem,” said Dr. Sara L. Laskey, who works in the emergency department of MetroHealth Medical Center in Cleveland, Ohio. “They’re really making conscious decisions about what they do and don’t want done.”

Just last month, Laskey saw a woman with bronchitis and pneumonia with life-threatening oxygen levels who refused hospital admission because she had no insurance. Even when Laskey arranged for her to have an oxygen kit to take home, the woman turned it down because of the cost.

“She refused, saying she would share her husband’s oxygen,” Laskey said. “Ultimately she left without the oxygen or an admission.”

Discharged ‘against medical advice’
Increasingly, such cases are raising ethical dilemmas for doctors, forcing them either to persuade patients to agree to treatment or else to discharge them “against medical advice.” That’s a formal designation that signifies a patient is knowingly disregarding a doctor’s guidelines.

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About 119.2 million visits were logged in U.S. emergency departments in 2006, according to a report last year by the federal Centers for Disease Control and Prevention. Of those, about 1.5 million, or 1.3 percent, ended with discharges against medical advice, or AMA. Doctors believe those numbers are both underreported and growing.

“Even without the recession it goes on all the time, but it probably goes on more now,” Dr. Neal K. Chawla, who works at a stand-alone emergency clinic run by Inova Fairfax Hospital in Falls Church, Va.

“It’s like, ‘OK, I’m not dying of a heart attack, let me go home,’ ” he said. “I have similar conversations two or three times a day.”

Just this month, Chawla, a spokesperson for the American College of Emergency Physicians, said he argued with a man who refused hospitalization to drain a large abscess on his buttocks; another man who declined admission for an infected kidney stone; a woman with low-risk chest pain who didn’t want to pay for further cardiac exams; and a patient with acute appendicitis who needed emergency surgery but didn’t want to pay for an ambulance.

“He called his mother to drive him over,” Chawla said.

Some patients can be convinced to submit to care, but others can’t, said Dr. David J. Alfandre, a researcher with the National Center for Ethics in Health Care run by the U.S. Department of Veterans Affairs.

“Everyone has a right to decide what’s done with their body,” said Alfandre, who reviewed studies of discharges against medical advice in a report for the Mayo Clinic Proceedings in March. “The hard part is ensuring that the patient understands the risks and benefits.”

Rates of hospital discharges against medical advice are about the same as for emergency rooms: between 1 percent and 2 percent, Alfandre found. Of some 39.4 million hospital discharges in 2006, about 390,000 were classified as AMA, according to statistics from the federal Agency for Healthcare Research and Quality.

Overall discharges grew by 14 percent between 1997 and 2006, but AMA discharges, the smallest category, jumped by 48 percent in that period.

“Early leavers,” as they’re sometimes known, are most often men on state-sponsored Medicaid or with no health insurance who have serious social and financial concerns, research shows. About 21 percent of people discharged against advice had no insurance, compared to about 7 percent of routine discharges, according to AHRQ.

‘If they leave the ER now, they’re likely to go back’
People who leave against advice are at higher risk for ending up back in the hospital, or for becoming seriously ill or dying, Alfandre said. Asthma patients who leave AMA are about four times more likely to be readmitted, his review showed. General medical patients are about seven times more likely to wind up again in the hospital.

“Patients should be told, ‘If they leave the ER now, they’re likely to go back,’ ” Alfandre said.

Several emergency department doctors said they see many more reluctant patients than they ever sign out against medical advice.

“If it’s a really dumb decision, I’ll sign them out AMA,” Chawla said. “Cardiac is one of the big ones. We’re very cautious about the heart.”

Other doctors said even when they don’t sign patients out against advice, they do have detailed conversations about the value of certain tests and procedures.

“In my mind, that’s not necessarily a bad thing. Testing is out of control,” said Dr. Jeffrey Sankoff, who works in the emergency department at the Denver Health Medical Center in Colorado. “I think it’s good we’re having those conversations about risks and benefits."

Those talks can help direct patients to solutions less dire than refusing treatment. Most hospitals provide charity care, though the amounts and conditions vary widely. Many also offer help connecting patients with services such as Medicaid. And most hospitals will set up payment plans, if nothing else, to allow patients to manage the bills.

No care, but billed anyway?
Not every doctor is so proactive, however. In Jesse Ashlock’s case, no one stopped him as he stripped off an X-ray vest, put on his shirt and strode out of the emergency room, still bleeding from the scrapes on his face and hands.

“I think the frustration is that they didn’t want to discuss the cost,” he said of his decision to leave.

Adding what he regards as insult to injury, Ashlock later received a bill for $618.67, which he still hasn’t paid. He called Woodhull Hospital officials to ask why he was being charged for services he didn’t receive, but the bill still stands.

It covered the cost of his evaluation, according to a spokeswoman for the New York City Health and Hospitals Corp., which operates the hospital. After being contacted by msnbc.com, hospital officials contacted Ashlock to resolve his bill, said Pamela McDonnell, HHC's director of media relations.

In the end, Ashlock said he’ll probably pay the bill in installments so it won’t damage his credit. And he’s grateful overall that his injuries from the bicycle accident have healed, leaving only small scars.

“You just have to look on the bright side. I’m walking around and talking to you,” he said. “Still, $600 is a lot of money.”

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