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How ERs Fail Patients With Addiction: One Patient’s Tragic Death

Jameson Rybak tried to quit using opioids nearly a dozen times within five years. Each time, he’d wait out the vomiting, sweating and chills from withdrawal in his bedroom.

doubled their chances of being in treatment a month later, compared with those who were given only referrals to addiction treatment.

Yet providing that medication is still not standard practice. A 2017 survey found just 5% of emergency medicine physicians said their department provided medications for opioid use disorder. Instead, many ERs continue to discharge these patients, often with a list of phone numbers for addiction clinics.

Jameson didn’t even get that, Suzanne said. At McLeod Regional, he was not seen by a psychiatrist or addiction specialist and did not get a prescription for Suboxone or even a referral, she said.

After Jameson’s death, Suzanne wrote to the hospital: “Can you explain to me, especially with the drug crisis in this country, how the ER was not equipped with personnel and/or any follow-up for treatment?”

Hospital administrator Will McLeod responded to Suzanne, in a letter she shared with KHN, that per Jameson’s medical record he’d been evaluated appropriately and that his withdrawal symptoms had been treated. Jameson declined to be admitted to the hospital, the letter said, and could not be involuntarily committed, as he “was not an imminent danger to himself or others.”

“Had he been admitted to our hospital that day, he would have been assigned to social workers and case managers who could have assisted with referrals, support, and follow-up treatment,” McLeod wrote.

When Jameson Rybak slipped in and out of consciousness from opioid withdrawal, his mother, Suzanne, took him to McLeod Regional Medical Center. He was given fluids to rehydrate and medication to decrease his nausea, but he declined to be admitted for monitoring his withdrawal. “He kept saying, ‘I can’t afford this,’” Suzanne recalls. (Gavin McIntyre for KHN)

Nationwide, hospitals are working to ramp up the availability of addiction services in the ER. In South Carolina, a state-funded program through the Medical University of South Carolina and the consulting firm Mosaic Group aims to help hospitals create a standardized system to screen patients for addiction, employ individuals who are in recovery to work with those patients and offer medication for opioid use disorder in the ER.

The initiative had worked with seven ERs as of June. It was in discussions to work with McLeod Regional hospital too, program staffers said. However, the hospital backed out.

The hospital declined to comment on its decision.

ER staffs around the country often lack the personnel to launch initiatives or learn about initiating addiction treatment. Sometimes affordable referral options are limited in the area. Even when the initial prescribing does occur, cost can be a problem, since Suboxone and its generic equivalent range in price from $50 to over $500 per prescription, without insurance.

In South Carolina, which has not expanded Medicaid, nearly 11% of the population is uninsured. Among patients in the state’s program who have been started on medications for opioid use disorder in ERs, about 75% are uninsured, said Dr. Lindsey Jennings, an emergency medicine physician at MUSC who works on the statewide initiative.

Other parts of the country face similar concerns, said Dr. Alister Martin, an emergency medicine physician who heads a national campaign to encourage the use of these medications in the ER. In Texas, for example, hundreds of doctors have gotten certified to provide the medications, he said, but many patients are uninsured and can’t pay for their prescriptions.

“You can’t make it effective if people can’t afford it,” Martin said.

Too Late for Charity Care

Throughout the night at McLeod Regional hospital’s ER, Jameson worried about cost, Suzanne said.

She wanted to help, but Jameson’s father and younger brother had recently lost their jobs, and the household was running on her salary as a public school librarian.

Suzanne didn’t know that nonprofit hospitals, like McLeod, are required by the federal government to have financial assistance policies, which lower or eliminate bills for people without the resources to pay. Often called charity care, this assistance is a condition for nonprofit hospitals to maintain their tax-exempt status.

But “nonprofits are actually doing less charity care than for-profits,” said Ge Bai, an associate professor at Johns Hopkins University who published a study this year on the level of charity care provided by different hospitals.

That’s in part because they have wide leeway to determine who qualifies and often don’t tell patients they may be eligible, despite federal requirements that nonprofit hospitals “widely publicize” their financial assistance policies, including on billing statements and in “conspicuous public displays” in the hospital. One study found that only 50% of hospitals regularly notified patients about eligibility for charity care before initiating debt collection.

McLeod Regional’s most recent publicly available tax return states that “uninsured patients are screened at the time of registration” and if they’re unable to pay and ineligible for governmental insurance, they’re given an application.

Suzanne said she doesn’t remember Jameson or herself receiving an application. The hospital declined to comment on the Rybaks’ case and whether it provides “conspicuous public displays” of financial assistance.

“Not once did anybody tell us, ‘Let’s get a financial person down here,’ or ‘There are grant programs,’” Suzanne said.

Mark Rukavina, with the nonprofit health advocacy group Community Catalyst, said most hospitals comply with the letter of the law in publicizing their assistance policy. But “how effective some of that messaging is may be a question,” he said. Some hospitals may bury the policy in a dense packet of other information or use signs with vague language.

A KHN investigation in 2019 found that, nationwide, 45% of nonprofit hospital organizations were routinely sending medical bills to patients whose incomes were low enough to qualify for charity care. McLeod Regional hospital reported $1.77 million of debt from sending bills to such patients, which ended up going unpaid, for the fiscal year ending in 2019.

Believing they couldn’t afford in-patient admission, the Rybaks left the hospital that night.

Throughout the night at McLeod Regional hospital’s ER, Jameson worried about cost, Suzanne said. She wanted to help, but Jameson’s father and younger brother had recently lost their jobs, and the household was running on her salary as a public school librarian.(Gavin McIntyre for KHN)

After the ER

Afterward, Jameson’s withdrawal symptoms passed, Suzanne said. He spent time golfing with his younger brother. Although his application for unemployment benefits was denied, he managed to defer payments on his car and school loans, she said.

But, inside, he must have been struggling, Suzanne now realizes.

Throughout the pandemic, many people with substance use disorder reported feeling isolated and relapsing. Overdose deaths rose nationwide.

On the morning of June 9, 2020, Suzanne opened the door to Jameson’s room and found him on the floor. The coroner determined he had died of an overdose. The family later scattered his ashes on Myrtle Beach — Jameson’s favorite place, Suzanne said.

In the months following Jameson’s death, hospital bills for his night in the ER arrived at the house. He owed $4,928, they said. Suzanne wrote to the hospital that her son was dead but received yet another bill addressed to him after that.

She shredded it and mailed the pieces to the hospital, along with a copy of Jameson’s death certificate.

Twelve days later, the health system wrote to her that the bill had been resolved under its charity care program.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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