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Post Magazine: Health Care's 'Frequent Fliers'

Kenny Farnsworth called 911 hundreds of times -- sometimes daily. Was he part of the health-care problem, or a result of it?

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Dave Jamieson
Monday, November 30, 2009; 12:00 PM

Kenny Farnsworth, a homeless man, called 911 hundreds of times -- almost daily. In fire departments and emergency rooms, such patients are known as "frequent fliers" -- people of modest means and poor health or patients who rely on emergency room care. Are they part of the health care problem, or a result of it?

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Writer Dave Jamieson wrote about frequent fliers in The Treatment of Kenny Farnsworth, a cover story for The Washington Post Magazine. Jamieson took questions and comments about the story on Nov. 30, 2009. The transcript is below.

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Dave Jamieson: Hello all--

Happy to be here today. First, I want to say thanks to everyone who took the trouble to read the story over the busy Thanksgiving weekend. Long features and tryptophan don't always go well together. I've seen some passionate responses to the story so far, which hasn't exactly surprised me--Kenny tends to provoke strong feelings in people. More on that later. Let's get started, and I'll try to answer your questions as best I can.

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Broodland, DC: While I'm not familiar with "frequent flyers," I can tell you there's a real need for walk-in clinics to treat less seriously-ill patients. I volunteered at the Information Desk at Children's Hospital for many years, and there was always a steady stream of parents whose children seemed to have minor problems ("he has a fever/tummy ache/earache/sore throat") who wanted to see a doctor. We had no choice but to refer them to the ER, where they would likely have to wait hours while more seriously ill patients were treated. Establishing free or low cost neighborhood clincs would seem to be a no-brainer, but somehow this doesn't get done.

Dave Jamieson: Thanks for bringing this up, Brookland. One thing I heard from firefighters and medics during my reporting was that they'd like to see more easily accessible health clinics for the repeat callers they handle. Anyone who's been to one of our city hospitals on a busy weekend night can see how crowded it gets, and often there are people in there with what we'd call non-urgent issues. Getting these folks into primary care facilities rather than emergency care facilities would be a lot cheaper and, in the long run, more effective.

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Cambridge, MA: Great article. I worked as a 9-1-1 operator and police/fire dispatcher for six years, and there were a handful of citizens whose voices I could recognize. None of these people were gaming the system for the fun of it. They had problems. They just had no good way to find solutions. In some cases, this was due to mental health or substance abuse issues, but that didn't make their problems less valid. Our frequent fliers were often among the city's most vulnerable residents.

I remember taking a phone call from a notorious alcoholic, one who called two or three times a night to give us confidential tips (often along the lines of calling when the bars closed and informing us there were people who had been drinking alcohol driving away. Um, thanks.) On this occasion, he was so intoxicated he was difficult to make out, but he said someone had knocked his door in and had fallen asleep on his couch. An officer responded, and found the door intact and the caller blind drunk. When the cop left, he called again, and again, and again. By the fourth trip to the house, the officer was ready to haul him in for abusing emergency services and making a false police report. But this time, the caller managed to motion him to the back door . . . which had been broken in. There was indeed a stranger asleep on the couch.

Just because someone calls constantly doesn't mean they aren't telling the truth when they call. I am glad Dave Cole was able to help Kenny Farnsworth get the health care he needed.

Cops and firefighters are sometimes de facto social workers. They can do well or poorly in that role. But what we needed, and what many municipalities need, is more social workers to step up and help find long-term solutions to these chronic problems. Too often we hear about the five ambulance rides a day and just dismiss it as some wastrel or crank. But Mr. Farnsworth has only one life, and fearing death by choking daily for years is a terrible way to spend it.

Dave Jamieson: Thanks for writing in, Cambridge--it's great to get the perspective of a former dispatcher. Indeed, there are people who call so frequently that their voices can be recognized, and a lot of these folks don't feel they have other places to turn. An interesting anecdote: In D.C., one man called 911 repeatedly for help. It turned out he was an extremely obese man, bedridden and unable to do much of anything for himself, so he turned to paramedics for help. City paramedics and social workers intervened through the city's new Street Calls program, and that man is much better off for it. As you say, the work is often closer to social work, so why not approach it that way, at least to a certain degree?

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Washington, D.C.: How'd you find Kenny and this story?

Dave Jamieson: Thanks for asking. I used to cover police and fire as something of a beat reporter in town. After a few ridealongs with firefighters, I was fascinated with frequent flyers--the fact that emergency responders were often picking up the same people, over and over. I started asking around about regulars, and Kenny's name often popped up, usually with a smile and a shake of the head. When I tracked him down, he was very kind and open with me about his life and his struggles.

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Bethesda, MD: Mr. Farnsworth must have an amazing personality. On the surface, he comes across as a bad apple, bad attitude, difficult personality, gouging at the public trough -- but a number of people aoparently find him endearing enough not only to welcome his company but even sort of coddle him. I'm happy for him, I guess, but I did find this sort of strange. My sister is an EMT in Anne Arundel Co., and she says if she had to pick up the same non-patient day after day, she's not sure how long she could take it.

Dave Jamieson: Kenny certainly does have an interesting personality. As I mentioned above, he provokes a lot of passion in people, especially the ones who handled him for many years. I think a lot of medics and ER workers simply got fed up with seeing him so often, and I can certainly understand that. It's a rare person like Dave Cole, the paramedic, who takes an interest in him and tries to help him manage his health problems and his life in general.

I think Cole took a shine to him partly because Kenny is such a colorful guy--he's lived a long and often difficult life, and he's pulled together his share of stories. I think that's why some medics and ER workers sympathize with him, while plenty of their co-workers just can't.

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Arlington, Va.: Since it seems unlikely that Farnsworth will ever be able to pay his bills ... what happens to them?

Dave Jamieson: Great question. Kenny is considering declaring bankruptcy, which he did once about a decade ago. I'm no expert, but I think that would basically clear out his debts. The bills would simply go unpaid. Of course, when a hospital doesn't get paid, those costs are passed on elsewhere, at least partly into rising health care premiums.

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Maryland: This fellow seems like he'd have benefited from managed care. He seemed to have Medicare although he wasn't retirement age. Would he have benefited from one of these Medicare Managed plans we keep hearing about?

The waste from lack of coordination must have been significant. I can see how someone who is homeless might have trouble always landing at the same provider, but wouldn't that have made resolution of his swallowing problem quicker?

Dave Jamieson: Good thoughts. Kenny qualifies for Medicare because he's disabled (which also gets him his only income). He certainly would benefit from managed care. As far as the lack of coordination comment goes, you're absolutely right. When you've seen a dozen different ER doctors in the last few months, they can't possibly be on the same page. I think that's partly why it's so important--and certainly cheaper--to get folks into more of a primary care setting once they've come to rely on the ER.

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Silver Spring, Md. : Why did it take so long for Kenny to get the surgery that ultimately helped him? Was it his own fears, money, or discouragement from doctors?

Dave Jamieson: I do wish I could've answered this question more fully in the story. Unfortunately, privacy laws tend to make doctors and other health care workers a bit cagey when it comes to discussing patients in print. So I mostly had Kenny's version to go on. I think it was a combination of his fears and perhaps some differing opinions on whether the surgery was the right move or not. He did go to see several specialists--as far as Boston, even--but Kenny says it was a complicated situation. Ultimately, after plenty of deliberating, Kenny and his ENT decided this particular procedure was the right move. And apparently it was.

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RE: disabled: How is Mr. Farnsworth disabled? Granted, in this terrible economy, no one can find a job. But are there certain types of jobs he CAN do? Would he be able to hold a regular job now that his choking problem is under control?

Dave Jamieson: I don't know the government's definition of disabled, but he certainly satisfies mine. Kenny has a lot of trouble getting around, even walking just a few blocks; his hands don't work all that well; and he experiences a lot of chronic pain, for which he takes meds. He would like to work as a dispatcher, but he doesn't seem to think he could perform much else that requires physical activity.

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Washington, D.C.: How widespread is the problem of "frequent fliers"?

Dave Jamieson: Great question. I tend to think it's a problem just about everywhere. Of course, it's probably a greater problem in our cities, where there tends to be a lot of homelessness and poverty. (Not to say those things don't exist in rural areas.)

But here's something to consider: According to recent research by the New England Healthcare Institute, we *all* tend to overuse the emergency room, for chronic and non-urgent health problems, regardless of our income or our insurance status. So this is a problem not just among the poor or the uninsured. And I think that's partly because the ER is the one place where we all know we can show up and be seen at any hour, regardless of our ability to pay.

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Fredericksburg, VA: While I have no doubt that Mr. Farnsworth possibly does suffer from a series of ailments, why didn't you as the reporter also acknowledge that a series of bad life choices led him down this path (no steady job, not finishing higher education or following through)? The abuse and high costs to the health care system, already strained, is alarming and frustrating for me to read about.

Dave Jamieson: Thanks, Fredericksburg. To a certain degree I did acknowledge those life choices, simply be reporting them in the story. And I did rib him a bit for his pickiness--he refuses to live in places like transitional group homes, while a lot of us would think he should lower his standards just to get a roof over his head. I think his pride and his high standards are partly why he has trouble improving his situation.

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Indianapolis, IN: Articles like this one should be required reading for anyone who doesn't understand why healthcare reform is crucial.I'm afraid journalists like Mr. Jamieson are still preaching to the "choir" of readers who don't buy into the scare tactics broadcast by special interests that stand to lose their bloated profit margins.

Dave Jamieson: Thanks for the kind words, Indy. This is a point I did want to address. We were pretty careful to steer clear of the health care debate in this story. Some of the commenters here and elsewhere have suggested this was a pro-reform story. I don't think it is. I think it's rather apolitical: Frequent flyers and costly ER care are serious problems, and we need to find ways to address them (and I explored some of those ways in the story). But I did want to make the point that a lot of emergency care *already is* subsidized by taxpayers--through that huge stack of unpaid ER bills-- we just don't always acknowledge it.

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Washington, DC: As the wife of a DC paramedic, I have heard more stories about "frequent fliers" than I care to admit. This problem is city-wide. My husband and his partner know the addresses by heart and the patients know them. They even request which hospitals they want to go to by the DCFEMS number assigned to the hospital. When asked what makes the headache different today than 3 days ago when it started, for the assessment, they are cursed at and threatened. However, he loves his job and his patients and he and all the EMS providers in the District have earned my respect.

Dave Jamieson: Thanks for writing in--good to get your perspective. The volume of frequent flyers certainly can take a toll on paramedics and ER workers. In fact, I heard the story of a good paramedic who simply quit upon handling his fourth regular of the day. Just walked off the job. And I think that's why it's important--and not just from a cost-saving perspective--to approach frequent flyers outside of the ambulance and the ER to address their problems. And I think other cities would do well to follow D.C. and San Fran and others in taking more of a social work approach to the patients who need it.

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Overuse of the ER: We all overuse the ER, I think in part due to liability. I work in the health care industry, and every provider's VM message states that you need to go to the ER if you feel you are in danger. They do it to protect themselves from lawsuits, and danger can mean just about anything.

When you can't get a doctor or nurse on the phone, or even if you are on the phone & their answers don't satisfy you, the only option is the ER. A facility or clinic targeted at lower levels of care would be great. In rural areas, a return of the country doctor who makes house calls would be well worth whatever price you pay to get that doctor to live out in the boonies.

Dave Jamieson: I think you're exactly right--a lot of people overuse the ER simply because there's an incentive to. Even if a health problem isn't an "emergency," that doesn't mean it can wait a week or two to be treated.

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Dave Jamieson: Well, that's about all the time we've got. I want to thank everyone for sending in their thoughtful questions, and sorry to those who I wasn't able to get to. Thanks again for reading. Best,

dave

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