Frequent users strain medical system
Mostly homeless group makes disproportionate use of 911, hospital emergency rooms
With an ambulance gurney cradling his defeated body, Raohl Hursh sought peace with his past inside the frenzied emergency room of the UC San Diego Medical Center in Hillcrest.
It was his 29th visit in four years, his 12th in a month, his second in four hours.
"I've already tried to kill myself,” the former serviceman with a history of mental illness said, vodka-addled and occupying a room where a beehive of doctors and nurses would soon hover over a heart attack patient. “I’ve killed others. ... So I’m being punished for all this. It hurts. It hurts.”
Hursh is a frequent emergency services user, or as some emergency workers cynically call them, a “frequent flier” — a group of mostly homeless patients who use the 911 system and hospital emergency rooms in great disproportion to their small numbers.
Hursh is part of the top 1 percent of health care users nationwide who account for 22 percent of health costs, according to a federal health agency report released in January, which included the elderly and those with chronic illnesses. Repeated calls to 911 from patients like Hursh are among the most frustrating entry points to the medical system, and a burden to local taxpayers.
In San Diego, according to the city medical director’s office, 1,136 frequent users are on course to use the EMS system at least six times this year, and to generate more than $20 million in ambulance and paramedic charges alone. They represent a minuscule eight-hundredths of a percent of the city’s population yet account for more than 17 percent of paramedic and ambulance calls in the city.
Nevertheless, they are viewed as emblems for rising health care costs that have strained American household budgets as they hamstring the economy as a whole.
“Homeless frequent users can be more noticeable than others in ERs, but they are trapped in the same upside-down health care system as the rest of the nation,” said John Lozier, executive director of the National Health Care for the Homeless Council, an advocacy organization in Nashville that seeks health reforms to better serve people without homes. “What they need, and we all need, is good, strong primary care that will prevent many emergencies from occurring in the first place.”
National health care spending reached $2.6 trillion in 2010, or $8,402 for each American, according to the federal Centers for Medicare and Medicaid Services. The public and private sector costs are 18 percent of the U.S. gross national product and could rise to 25 percent by 2025, according to the Congressional Budget Office. Such medical expenses, it warns, will threaten the safety net, leave businesses little surplus for job creation and force families to choose between medical care and solvency.
But drawing from a growing national movement to help frequent users, city medical director Dr. James Dunford wants to make San Diego a battleground to reduce their local price tag, and ease their anguish.
“The quality of our system should be assessed by how we care for the sickest people because they pose the greatest threat, not only to themselves, but to the entire economic underpinning of the health care system,” Dunford said.
“Imagine if in the process of saving money, you could actually help these people,” added Dunford, who regularly pulls ER shifts at Hillcrest to take the city’s frequent user pulse.
He wants to give frequent users a new entry point into the health care system: through coordinated health care and housing programs that can improve their lives at a fraction of the local public costs.
Dunford has already worked for years to compile real-time, electronic 911 records that he now wants to use to identify frequent users by name, need and location where they can likely be found. From there, he wants to work with other city stakeholders to enroll them in programs like the United Way of San Diego County’s fledging Project 25 program — which seeks to provide frequent users subsidized housing and public medical programs that emphasize much cheaper primary care over dialing 911.
The obstacle confronting Dunford and like-minded medical professionals is that frequent users are difficult to treat, as they cope with chronic ailments like diabetes and high blood pressure under the hard bark of mental illness and substance abuse.
It is also, Dunford says, that hospitals across the country rely on frequent users as a driver for billions in federal reimbursements. The government gives these medical centers more than $11 billion in funding annually to treat uninsured and low-income patients, including frequent users.
“The cost is borne by the taxpayers without ever taking a look at how that money could be better spent,” Dunford said. “There are no benchmarks or incentives to provide higher quality care. Only the idea that some hospitals take care of more people like this, and we are going to pay them to do it.”
Meanwhile, the doctor, his ER colleagues, firefighter-paramedics and police officers shoulder through the status quo as they listen to Hursh’s pleas in harried environments.
“Do you know which hospital you’re at?” Dunford asked, stealing a free moment to evaluate Hursh back at the Hillcrest ER.
“This is the VA, isn’t it?” Hursh replied, gazing up at Dunford with placid eyes from an exam bed. He was given a saline IV, observed until sober and released back to the streets — his usual turnstile of care.
The Department of Veterans Affairs later confirmed a five-month Marine enlistment in 1973, with no record that the man who is variously documented as ages 59 and 56 ever saw action.
Dunford and his supporters acknowledge that repairing the lives of such patients will be institutionally grueling.
“You have to convince the system to continue to prevent an increase in costs,” said Patricia Leslie, director of the Social Work Program at Point Loma Nazarene University.
According to a table comparing a dozen California-based frequent user programs published last year by The Corporation for Supportive Housing, long-term savings from such programs can be difficult to measure. Two-thirds of the frequent user programs were unable to determine the cost of providing coordinated care for their clients, let alone the dollar savings.
Still, an Annals of Emergency Medicine study found that programs providing frequent users a coordinated array of social and medical services had the potential to save millions in taxpayer dollars. An estimate by San Francisco General Hospital cited by the study showed that when the hospital provided case-managed, comprehensive care to those frequent users, it reaped a 30 percent savings.
“It makes no sense to continue doing business as we’ve historically done it. These programs work,” said Bill Hobson, executive director of Seattle’s Downtown Emergency Service Center, which in 1979 became one of the nation’s first agencies to offer an integrated array of clinical services and supportive housing.
Doing nothing is sustainable “only if your local government has bottomless revenue and can continue to afford for people to cycle constantly through their emergency departments,” said Hobson, who recently offered consultation on his approach in Anchorage, Alaska.
In San Diego, Dunford said, frequent use is not only threatening the city budget, but is slowing response times to other emergencies and wearing down EMS and ER crews.
It’s also become an accepted reality. Three decades of downtown gentrification have gone hand-in-hand with sirens and men and women staggering, sometimes dying, on the streets.
Over the next four days, U-T San Diego and the nonprofit California HealthCare Foundation Center for Health Reporting will publish a series of stories, photos and video, documenting San Diego’s push to address the seemingly intractable problem of frequent emergency services use.
Readers will share the frustrated idealism of Dunford, as he wades into the frequent user pool with a Hillcrest emergency room staff nearing its wits end.
They will climb into the rig of San Diego Fire Department Engine Co. 7, as paramedic Dave Stepp dutifully roams the epicenter of frequent use trying to treat each 911 call with urgency, though he has visited the addresses and people countless times before.
They will share the City Heights apartment of Joan Kloh and her boyfriend, Chip Bloemendaal, as they become a poster couple for Project 25, straddling their recent lives of homelessness and addiction while they try to repair broken family relationships and re-learn what it means to be whole.
And they will share the blacktop existence of frequent users themselves, some skirting death, but not without first ringing up the costs that Dunford seeks to reduce.
Hursh will reappear here, after visiting the ER at least 21 more times since September. In one incident, he was severely beaten by another homeless man, generating a six-figure intensive care unit bill.
Lives will intersect and program goals will be tested along the volatile path shared by frequent users and the people tasked to care for them.