The January 2021 issue of JAMA Neurology had an article that stated that the current U.S. spending on emergency room (ER) and inpatient costs for patients with functional neurological disorders is $1.2 billion and climbing. That doesn’t include, obviously, the costs of treating functional disorders in other specialties.
Now, $1.2 billion is a pittance when you compare it with, say, the total costs of Alzheimer’s disease ($277 billion/year), but it’s still a lot of money. Especially when you consider that, unlike Alzheimer’s disease, a lot of the spending associated with functional disorders is avoidable.
The problem is that getting good psychiatric care isn’t easy, and that’s what many of these people really need. A lot of psychiatrists, including the excellent one my son sees, don’t take insurance. We’re fortunate to be able to pay for the visits, but most people aren’t. So the psychiatrists and mental health professionals who do accept insurance get rapidly overwhelmed and burned out, end up seeing their own psychiatrists, and then drop insurance plans, too.
Not only that, but insurers are willing to pay for these patients to go to ER and get labs and pricey imaging. At the same time mental health benefits are often limited or nonexistent, even when considerably less costly than the ER visits and imaging.
I don’t fault the ER doctors or hospitalists for ordering expensive tests on these patients. They often don’t know the patient and have to take them at face value. I’ve been there, too, when I’ve taken inpatient call. Someone comes in with a group of symptoms. You may be 99.999% sure they’re functional, but at the same time it’s not worth risking your medical license or malpractice premiums to just say that. Defensive medicine will always win that argument.
The trouble is that ER, and the inpatient setting, are often the worst possible places to be managing functional disorders. This is really a case where a stitch in time saves nine. The cost of their getting appropriate care to prevent underlying issues from driving them to ER is going to be less than the inevitable visit when they don’t.
That’s not to say these people might have a legitimate medical issue that should be evaluated – sometimes urgently. But once that’s off the table repeated ER visits and testing quickly become an exercise in futility and diminishing returns.
Many health care system payers need to recognize that, so these people can be treated appropriately from the beginning, and not end up shuttling between ERs, looking for an answer and help they aren’t equipped to provide at a cost that’s not sustainable.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.