The Bottom of the Health Care Rationing Iceberg | NEJM – nejm.org

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A stink filled the room as my patient eased coal-black toes out of his shoes. After spending winter nights in a tattered sleeping bag behind a local grocery store, he had developed frostbite and then gangrene.

In the hospital, we gave him intravenous antibiotics and debrided the dead tissue from his toes. Soon he felt better. He was enjoying regular meals and the kind attention of his nurses. Each day, a new crayon portrait of his life on the street went up on the walls, scary scenes depicted in bright colors and childlike simplicity.

When the hospitalist said he was getting ready to discharge him, the patient’s nurse shook her head and crossed her arms. “How is he supposed to heal if he goes right back out to the streets?” she asked.

She wasn’t wrong. More than one in four discharged homeless patients is readmitted within 30 days, according to a recent study by a team from the Boston Health Care for the Homeless Program.1

The hospitalist noted that the patient would have been discharged much earlier if he hadn’t been homeless. “But is hospitalization really the cure for homelessness?”he asked, as he ran a finger down a list of emergency department patients waiting for a hospital bed. “Don’t we owe them something, too?”

There it is, I thought: the bottom of the health care rationing iceberg.

Since February, like ethicists around the world, I have spent most of my time thinking about the tip of the health care rationing iceberg. As Covid-19 cases exploded across epidemiologic maps, I scrambled to write new guidelines for my health network for the ethical allocation of mechanical ventilators, just in case we ran out.

Among the difficult questions that kept me up at night was how the system could help frontline clinicians make fair choices between two people who needed mechanical ventilation without perpetuating historical health inequities.

Despite that heady challenge and the urgency of the Covid-19 pandemic, I couldn’t shake the feeling that this effort was all a distraction. Here I was, trying to do a perfect job allocating a handful of mechanical ventilators for an unprecedented viral pandemic, while every day the entire health care system utterly fails to fairly allocate all kinds of health care to an enormous number of vulnerable people.

From hospital beds to primary care appointments and funding for expensive medications, health care resources are finite. We have to choose who gets what, and there is no question that wealth opens doors in health care that are closed by lack of insurance. Geography shapes health care destiny. Bias, we should admit, is not the exception but the rule.2

What really differentiates the fair, transparent, systematic, and formal Covid-19 rationing plans we have drafted is that on most days, health care rationing happens ad hoc, in the shadows, nonsystematically, and without formal guidance. We are making it up as we go, and the results aren’t great.

Drug overdoses, trauma, and weather exposure are not the only things that kill homeless people. Homeless people die when our generosity wears thin, such as when the intense financial pressures faced by hospitals lead them to show homeless people the door.

Many of us were stunned by a YouTube video that went viral in 2018, showing security staff from a Baltimore hospital ejecting a confused-looking woman in a thin hospital gown to a night on the streets.3 And then it happened again to dozens of patients in Los Angeles.4 Surely no well-thought-out resource-allocation plan set those events in motion.

It is not wrong to put limits on generosity. Resources are in fact finite. We do have a duty to allocate community resources wisely. The solution to homelessness isn’t to house homeless patients indefinitely in the hospital. Doing so begets other risks. It wastes community resources on low-value care. Hospital overcrowding — which is exacerbated by keeping stable patients in house — endangers the lives of emergency department patients awaiting a bed.5 Unnecessary hospitalization also exposes patients who are homeless to real risks, such as hospital-acquired infections and blood clots.

We argue at the bedside about when to discharge homeless patients because we don’t have the right options available.

Jim O’Connell is the founding physician at Boston Health Care for the Homeless, which recently showed that respite care for recently hospitalized homeless patients could cut rehospitalization rates in half.1 O’Connell calls frostbite like that which brought my patient to the hospital “the emblematic homeless condition.” He says, “It’s preventable. It’s disfiguring. Send people out to the streets too soon, and relapse rates are astonishingly high.”

I saw my patient in the hospital lobby the evening he was discharged to the street. His foot was cleanly bandaged and healing. He had a free bottle of antibiotics and an appointment at a local free clinic. Having declined subsidized housing, he planned to sleep in the same grocery store parking lot where frostbite first blackened his foot.

“How can you look me in the eye?” he said.

I did anyway, and I apologized. Then I watched him walk away.

As he grew less distinct, moving slowly out into the falling light, my pager went off. I turned away to see the next patient in line.

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