Anna Brown's Death

Anna Brown was 29 years old when she died suddenly last September.

She left two small children. 

Sometimes, the tragic and untimely death of a young mother commands our attention.  Anna’s death in Missouri drew a little national interest just last week. 

She died alone on a concrete jail cell floor.  It happened just a few minutes after she was arrested for trespassing.  She refused to leave a hospital emergency room while she was in agonizing pain.   

Anna Brown was homeless, had mental illness, and was on Medicaid.  Hospital officials thought she was a drug-seeker.  They were wrong. 

According to news reports, a morning fog blanketed St. Louis on September 20, 2011 – the day Anna died.  She spent much of her final day going from emergency room to emergency room begging for care.  She started at St. Louis University Hospital complaining of pain in her leg.  She was evaluated and released with a prescription for painkilling medication. 

Unsatisfied with her care, she went next door to Cardinal Glennon Children’s Medical Center.  There clinicians found tenderness in her leg, but explained that they could not treat her because she was not a child. 

Her pain was so bad that she could not walk.  So she was transported by ambulance to a third hospital, St. Mary’s, where she was diagnosed with a sprained ankle. 

But Anna Brown was afraid something more serious was wrong with her.  So when St. Mary’s said she could go, Anna Brown refused.

That’s when St. Mary’s had her arrested for trespassing.  

A police officer later reported that “they thought that she was a drug seeker.”  The police wheeled her out of the hospital in handcuffs.

When she arrived at the jail, she was having trouble breathing.  Officers placed her on the floor of her cell and left her alone.  She died within fifteen minutes of undiagnosed blood clots in her leg that traveled to her lungs.

What a tragedy.

It was compounded by others in Anna Brown’s life.   

She had lost her house a couple of years earlier to a tornado.  She lost her job shortly thereafter.  When she could no longer afford to pay her heating bills, her service was discontinued and she took to building fires in her apartment to keep her children warm.

Child protective services found out, and the state removed her children from her care.

Her mother took in the children, and reported that the family court gave her a choice – she could care for Anna’s children or Anna, but not both.  She was forced to choose her grandchildren over her daughter.

So Anna became homeless.  At the time of her death, she was using city shelters and frequenting a drop-in center for people with mental illness.  Contrary to the assumptions of the clinicians who examined her on her last day of life, she was not using drugs.

Too much of Anna’s story isn’t uncommon. 

We have all read reports about patients with mental illness “flooding” hospital emergency rooms because of state cutbacks to mental health services.

These usually suggest that patients choose emergency rooms for non-emergency health reasons because they have no place else to go. 

In defending its actions just last week – a full six months after Anna Brown’s death – St. Mary’s Hospital sounded this theme.  It issued a statementthat read in part “the sad reality is that emergency departments across the country are often a place of last resort for many people in our society who suffer from complex social problems that become medical issues when they are not addressed.”

That statement may be true.  But Anna Brown wasn’t suffering from “complex social problems” when she showed up at St. Mary’s. 

She was suffering from neglect of her medical condition.  That neglect didn’t begin at St. Mary’s; it just ended there.

And we are mistaken if we think this doesn’t happen every day in every state in the nation.

Medicaid emergency room co-pays, cuts to mental health and substance abuse treatment, inadequate funding to combat homelessness, and anti-loitering laws are all just symptoms of this neglect.

Anna Brown died from blood clots, but she also died because too many people looked past her suffering and saw a caricature of a homeless, mentally ill patient, and jumped to a conclusion about what they think such a patient represents.

Anna Brown may have visited far too many emergency rooms on the day she died, but the fault wasn’t hers.  And she and her loved ones paid the price.   

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Are Healthy Infants Really Clogging our Emergency Rooms?

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A growing number of highway billboards encourage people to use hospital emergency rooms.  The ones in my area advertise pre-registration to avoid lines or shorter waiting times.

These billboards clearly aren’t targeted to people riding in the backs of ambulances, who generally aren’t ER comparison-shopping.  They’re for potential ER users who are in a position to make a choice.  That’s the “non-urgent” crowd.

The irony is that these billboards are proliferating just as state policymakers impose new charges to discourage non-urgent ER use.

Two examples from recent weeks:  Florida’s Legislature voted to impose a $100 charge on non-urgent emergency room visits by the Medicaid population.  Connecticut decided to impose a new $35 charge on state employees doing the same.

It’s important to recognize that these fees aren’t that high compared to the $500+ co-pays and deductibles in many private insurance plans.

But it’s wishful thinking that they will reduce program costs without consequence.

To justify its decision, Connecticut used the example of an unnamed state employee who had 150 ER visits in a single year.  There are a handful of such people in every state.  They’re often called ER “frequent flyers,” and health care providers generally know who they are.  Though it’s not clear how many should be admitted as inpatients instead, there’s no question that we should want to keep them from overusing the ER.

However, ER charges target too many innocent parties, and when you decide to impose them can make a huge difference in whether they discourage use, or just penalize people for guessing wrong about their emergencies.

According to the Centers for Disease Control and Prevention, we all collectively accounted for nearly 124 million emergency room visits in 2008.

At the time of triage, only 8% of all visits were considered to be non-urgent – a pretty small percentage.  The percentage wasn’t too different among payer groups.  The two groups targeted by Florida and Connecticut – Medicaid recipients and state employees with private insurance – had 9.5% and 6.3% non-urgent visits, respectively.

On the other hand, if you look at the same patients after the visit, the percentage of non-urgent visits is closer to half.

This is because apparent emergencies often turn out to be minor maladies.

Aside from injuries, people go to ERs for mostly common complaints.  Almost 4 million (or 17%) of all ER visits by children were because of fever.  Children also had 1.5 million visits related to coughs, and 1.1 million visits because of vomiting.

Non-elderly adults had 7 million visits (or over 8% of all visits) for stomach pain.  Chest pain accounted for 4.8 million visits. Back pain accounted for 2.8 million visits.

Chest pain and shortness of breath were the two most common reasons for ER visits by elders.  Each accounted for over 1.4 million visits.

When the underlying causes of these complaints were diagnosed, the most common non-injury diagnosis was respiratory disease.  13 million people of all ages, or 10.7 percent, had this.  Over 7 million had diseases of the digestive or muscular-skeletal systems, and over 6.5 million had diseases of the nervous system. 

Though not commonly given as the reason we went to an ER in the first place, diagnoses of mental disorder accounted for just over 4 million visits – the 8^th most common diagnosis after injury.

The main culprits using ERs for non-urgent reasons are not adults, but infant children.  They don’t read billboards, but they are the only group whose non-urgent visit percentage was greater than 10% of all visits at the time of triage.

Around 381,000 U.S. ER visits by infants were non-urgent in 2008.  If it is normal for 8% of ER visits at triage to be non-urgent, then the number of excess non-urgent visits by infants was 85,100.  Florida’s share of these was around 5,000, and Connecticut’s was around 1,000.  The Florida Medicaid share and the Connecticut state employee health insurance share were even lower.

Keeping a small number of infants out of our ERs may not be good public policy.

The infant mortality rate in Connecticut is around 6 per thousand, and the infant mortality rate in Florida is around 7.  The best-in-the-world standard is around 2 per thousand.  That means that in 2008 there were statistically as many as 25 preventable deaths among Florida infants who visited ERs for non-urgent reasons, and 4 among the Connecticut infants.

Accepting 6,000 excess infant ER visits in Florida and Connecticut to try to prevent almost 30 excess infant deaths seems like a good trade-off to me.

No one questions the goal of getting frequent flyers out of ERs.  The way to do this is to require them to participate in disease management programs. 

If co-pays work to discourage everyone else from using the ER, we’re going to lose lives.

Column update: In a past column entitled A Long Term Care Win for Everyone I wrote about Florida Governor Rick Scott's decision to accept a $35.7 million federal grant for the "Money Follows the Person" program, which would have enabled people (especially young people) with disabilities to move from institutions back into their own homes.  However, it was reported recently that the Florida Legislature declined to allow the State Medicaid agency to draw down the money.  If this decision stands, it means that FL residents with disabilities will lose access to these $35.7 million, and will have to remain in more costly institution-based settings. 

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