The Expense of Saving Money


Our state government, just like every state government, is trying to save money.

One of the largest targets for this attempt at savings is the health care system, since health care is one of the largest expenses in any state budget.

In order to save money, the state government has several options: It can raise revenues, cut services, or cut payments. But unless these options are well-thought out, the attempt at saving money may have the opposite effect. Which brings me to the topic of this post.

In the emergency department, there are certain patients who we see on a regular basis. Some are present so frequently that they should literally have their mail forwarded to the hospital. Others, upon investigation, rotate from hospital to hospital and doctor to doctor for some type of secondary gain. And some are attempting to survive in a system that can be stacked against them.

It was one such patient’s fourth visit to the emergency department in two weeks. Each time she had difficulty breathing. She had a long history of asthma and has been hospitalized several times for asthma in the past. During one of those hospitalizations, she had been on a continuous albuterol nebulizer for an hour. She developed supraventricular tachycardia (a fast heart rate) which was presumed to be from too much albuterol and one doctor emphatically told her that she was thereafter “allergic” to albuterol and that the next time she ever used albuterol she would most certainly die.

Therein lies problem #1. A fast heart rate is not an “allergy” to albuterol any more than diarrhea is an “allergy” to antibiotics. A fast heart rate is a documented side effect of using albuterol. But the seed had been planted in the patient’s head.From that point forward, the patient was only able to use Xopenex.

Xopenex is structurally very similar to albuterol. In theory, Xopenex has fewer cardiac side effects than albuterol, but from a practical standpoint, there isn’t much difference in side effects between the two. Rapid heart rate is also listed as a documented side effect of Xopenex.

For a long time, the patient received her prescriptions for Xopenex for free from the state. Then the state decided to save money. It stopped paying for Xopenex for people on public aid. Albuterol was now the only approved rescue medication for patients with asthma.

But since the patient was “allergic” to albuterol, there was no way for her to pay for the “only” medication that she could take. And her doctor left the state because of increasing taxes and decreasing reimbursement for seeing Medicaid patients.

So when she had an asthma attack, the patient simply came to the emergency department. She informed the staff that she was allergic to albuterol and so the respiratory department had to find some Xopenex to use in the emergency department. She felt better after a couple of treatments and was discharged with a prescription for steriods and a Xopenex inhaler, but she never filled the Xopenex because she could not afford it. She was also referred to the county hospital for specialty care, but the trip was long and the waiting list for appointments was longer, so she never made an appointment.

So during the spring months, we sometimes see Joanne Doroshow several times per week. She fills her prednisone prescriptions and sporadically fills other prescriptions for maintenance medications, but she still ends up in the emergency department every time that she feels “tight.”

The amount of money that the state saves in withholding Xopenex from Joanne is more than surpassed by all of the money that the state must pay for her emergency department visits. In its attempts to save money, the state ends up owing more money.

The same scenario applies to patients with dental pain and to patients with other chronic medical conditions. When infrastructure and primary care are cut in cost saving attempts, the patients will still need medical care, and they go to whatever providers are available to provide that care.

The emergency department “safety net” will be there — until payment cuts cause the hospitals to close — but the care isn’t cheap.


  1. Jordan Schooler, MD, PhD on

    I think that’s really a story about the cost of documenting ridiculous “allergies” and giving in to unreasonable patient demands. I’m very glad the state won’t pay for Xopenex, and private insurance shouldn’t either. It’s a scam and has been shown to have no benefit over racemic albuterol.

  2. Even albuterol has got more expensive since the EPA has decided that the ozone layer is being destroyed by asthmatics and changed the propellant in the inhalers to a much more expensive one.

    • “The nine most terrifying words in the English language are: ‘I’m from the Government and I’m here to help.'” Ronald Wilson Reagan

  3. Maybe you and partners could send off a letter documenting these situations to the agency that makes these decisions …or get your post in some editorial pages. ?

    If the Supreme Court knocks down Obama Health plan, the health care system still has to be revamped. Ever consider becoming a much needed voice educating about the needs and cost effectiveness in our health care system? I don’t know if physicians already have input into it and/or have all along …but if so …it doesn’t seem that they are the docs in the trenches who know first hand what affects/challenges their patients, their practice and the ED’s/medical facilities. is there some political/job security reason that more physicians don’t rally together to speak out against the erroneous and unfair decisions …-the things that actually put more of a burden on practicing medicine and quality of care?

  4. Is the name “Joanne Doroshow” some kind of irony or inside joke that I don’t get? What does it mean? as I can’t see that you would **ever** put a patient’s real name in your column.

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