During the latter stages of the debate over reform of the American health finance system, one of the key issues that seemed to fade amidst the rhetoric was the question of how the revamped health finance system will ration care (see also here). Inasmuch as it is still not clear to me how care will be rationed under Obamacare, this recent Happy Hospitalist post caught my eye:

I’m down in the ER the other day when I see a chief complaint fly by on the radar.  What is that chief complaint you ask? ìRefused by Detox.î

The patient was so drunk, even the community detox center refused them.  So how did this play out?  The patient was taken by ambulance from his home to a small town community ER for altered mental status.  There, he was  booked into the ER and seen by a small town community ER physician family practice resident or PA or NP.  Diagnosis you ask? ìAcute alcohol intoxication. Plan:  Discharge to community detox center.î

The patient was then transported to detox  by a cop where he was promptly refused by detox for being too drunk. Too drunk for detox.  How sad is that.  At this point another ambulance was called and the small town hospital refused to accept him back because he was "too drunk" for them to handle if he became comatose and critically ill.

So the ambulance drove him 75 miles to Happy’s hospital which has to accept him, where he was promptly booked into the emergency department in front of the 28 year old with heart burn, the 19 year old looking to get a pregnancy test and the 14 year old who’s mother brought her in because she just had her first period.  What happened with our drunk?  He was promptly placed in a room where stat lab confirmed what everyone else had suspected.  He was drunk.  The big city ER doctor billing $500 an hour proudly made his diagnosis and disposition plans known to the world: ìAcute alcohol intoxication. Plan: Discharge to community detox.î

By now, the patient’s alcohol level was down to 320 and he was awake, responsive and asking for a samich as the cops show up to take him away. Let’s conservatively add it up:

• Two ambulance rides $1,000
• Two ER visits $3,000
• Two ER physician visits $500

Almost $5,000 to take care of a drunk in which doing nothing would have given you the same result.  And you wonder why Medicaid is going bankrupt.

The Hospitalist goes on to point out how expenses such as the foregoing is eventually going to lead to failure of many inner-city hospitalists. But an equally troubling issue is whether anything will change in regard to future opportunities for misallocation of expenses under an increasingly subsidized health care system?

Frankly, I doubt it.