Bigger fix needed than penalizing hospitals

As a resident doctor at Grady Memorial Hospital, a large public hospital that serves Atlanta’s indigent, I have at times felt frustrated, and that my efforts were in vain.

I once treated a gentleman with very limited resources for his poorly controlled diabetes. After aggressively treating his diabetes and getting it under better control, he was discharged.

Prior to discharge, he received a free, seven-day supply of his medications, discharge instructions, diabetes education, a follow-up appointment and a bag of groceries. My team contributed to the grocery purchase to ensure he would have nutritious food at home; he had complained he had run out of food stamps and was eating any food he could find.

Within a week of his discharge, he was re-admitted with the exact same issue of poorly controlled diabetes.

Should Grady and the health care providers be penalized for his care? Unfortunately, because of his frequent re-admissions, Grady — like many other hospitals in Georgia — are penalized. The AJC recently reported that many hospitals were being fined because part of the Affordable Care Act reduces Medicare repayment for hospitals with excessive readmissions within a month.

Patients are autonomous. We are health care providers. Some things truly are out of our control. We do our best working with individuals who have limited social support, resources, education and job opportunities. Many of my patients struggle to do their best managing their health.

Nonetheless, when one lacks such basic necessities as food, shelter and clothing, how can a patient like the one cited above focus on managing his diabetes?

Greater emphasis should be placed on improving the social circumstances that impact people’s ability to comply with their recommended health care treatment.

We in the United States need to address the intersection of health care, environment and social conditions, such as access to opportunity, rather than attempt to fix just one of these areas.

In urban areas, there is a great disparity in living conditions. Often, I see patients living in communities plagued by violence, drugs, poor access to nutritious food, and housing that is barely livable. Many of these people are afflicted with significant mental health issues ranging from depression to post traumatic stress disorder. An overwhelming feeling of hopelessness is palpable and the most concerning.

An individual born into these conditions is at a disadvantage from the very beginning. He does poorer in school within a sub-par educational system. This makes finding higher-paying jobs inaccessible. He then struggles to make ends meet, barely living from paycheck to paycheck. Money goes to the expenses of everyday life, and one’s health care becomes secondary.

There are many confounding factors contributing to a person being unable to adequately manage his health care. These challenges need to be addressed in a comprehensive manner of evaluating and targeting the societal, economic, cultural and educational circumstances that impact one’s health care. These are beyond the scope of what one hospital can do to reduce re-admission rates.

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Dr. Erika Heard is a resident in internal medicine and psychiatry at Emory University School of Medicine.

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