I.

Two California hospitals are fined $1.6 million for dumping indigent psychiatric patients.

City officials allege that over two years, as many as 150 patients from the two hospitals were dumped on Skid Row, an area on the east side of downtown where thousands of homeless people live.

"We will not stand idly by while society's most vulnerable are dumped in the gutters of Skid Row," Delgadillo said in a statement.

Actually, that's exactly what you're going to do.

For the uninitiated: indigent patients frequently come to psychiatric hospitals with quasi-legitimate complaints, looking for somewhere to stay.  There's no insurance, so the hospital eats the cost.

$1.6M for 150 patients is $10666 per patient.  Medicaid pays, what, $700 per day? That's 15 days. 

These patients are likely to have used far more than 15 days each over two years, right?  Not to mention any consults (medicine, surgery, etc) for other ailments, labs, meds.  And potential liability issues, potential violence...  in other words, they would have cost the hospital way more than $1.6M.

So dump the indigent patients and pay the government their look-the-other-way money, you make it all back in two weeks.   Faster if you get a private insurance patient in that bed.  Solid.

Sounds like the government and College Hospitals have reached a mutually beneficial agreement.

II.

College Hospitals attorney Glenn Solomon denied any wrongdoing by the hospitals.

Well, there's the rub.   It's not like these hospitals threw a black hood over their heads and Guantanamoed them to a waterboarding park.  I wasn't there, but I'm guessing it went something like this: "sorry, we can't admit you.  We can get you transportation to a homeless shelter, if you want.  Hang out here, the van will come get you in about, oh, two and a half hours.  Want some juice and crackers?"

To the layman, it seems like hospitals are incentivized not to admit indigent patients; while that is only partly true in medicine, it is rarely true in psychiatry, especially psychiatric floors in multispecialty hospitals where they are accepted to be loss leaders.  It is extremely rare that people who need admission get turned away; far more common is that people who don't need admission get admitted anyway; for their convenience, for the doctor's convenience, to avoid litigation or violence, etc.

If the city really thought the hospitals did something wrong, if they really wanted things to change, they would probably have come up with something more powerful than this:

College Hospitals will be required to develop protocols for discharging psychiatric patients to "ensure homeless psychiatric patients will have the dignity and the continuum of care that everyone leaving a hospital deserves."

Now that's Change We Can Rely On.

What it comes down to is that no one knows what to do with these people, and no one wants  the responsibility-- but they don't want to lose all of the access (because there's money there.)  Hence a passive-aggressive shifting of responsibility, back and forth.  If the city really pushed the hospitals, the hospitals would push back-- "hey, you want us to handle it, reimburse us better."  Meanwhile, hospitals don't want to offload all of the responsibility because they need what little revenue is derived from indigent patients.

It's like a married couple, both have secretly cheated, both suspect the other knows, so neither ever brings it up.  And so it hangs like a fart over the relationship, toxic.  But the only way the relationship can survive is by never having a frank discussion about what to do.

If the hospital pretends to accept that the fine has any legitimacy-- i.e. they are partly responsible for the homeless people even when they are not in medical crisis, then they can get away with a small fine.   The city, meanwhile, gets to pretend that the homeless problem is a psychiatric problem-- and appear active on the homeless issue by asking for the hpspitals to change. 

What's the outcome?  Don't ask what benefits the homeless.  Ask what benefits the city and the hospitals: a new billing code and reimbursement for the additional service of "coordinated post-hospital care."  And the return of state hospitals.

Before you judge these outcomes either way, go back and find out what happened the last time we did that.

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