The New Health Dialogue

Imagine being sick enough or hurt enough to rush to an emergency room—and then leaving without getting the recommended tests or treatment because you can't afford it.

Doctors have a name for those discharges—"Against Medical Advice." It seems to be happening more often, both in the ER and in the rest of the hospital as health costs rise and insurance coverage falls.

MSNBC interviewed several doctors and patients about how the economy is affecting emergency care. A patient with acute appendicitis needing emergency surgery who waited for his mother to drive him to the hospital so he wouldn't have to pay for an ambulance. A patient with an infected kidney stone. People with chest pains who were not in the throes of a life-threatening heart attack that very minute but who couldn't or wouldn't follow up to find out what the pains signaled. A 31 year old knocked unconscious in a bike crash, who asked about the cost of the recommended follow up, only to be told by the ER doctor, that she was "a physician, not an accountant." Declining treatment, he still got a $600 bill.

"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."

In 2006, only about 1.3 percent of the nearly 120 million emergency room visits were categorized as discharges against medical advice. But that's still 1.5 million people. And that was before the recession. Doctors told MSNBC that they believe the numbers are under-reported, and growing.

This of course doesn't mean that every patient who ends up in the ER has a life-threatening condition; we've often written that ER crowding reflects the gaps in our primary care system. Nor does it mean that ER physicians should automatically order boatloads of tests without considering how much they cost, or whether all the tests are really needed or even advisable. "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."

But not getting tests and treatments that are necessary in an emergency isn't exactly smart either. Particularly if you are at risk—as some of these patients are—of ending up back in the hospital, even sicker, facing even bigger bills.

One of the myths you hear from foes of health reform is that anyone can show up in an emergency room and get care. he law, in fact, states that ERs must screen and stabilize patients. It doesn't mean that the care is free. Or affordable. Or that they get the follow up care that they need to get well or stay well. And you also hear that patients (or "health care consumers") will make smarter decisions if their own money is at stake. Not true. Not if they don't have money.