September 30, 2011
Stuck in Bed, at Hospital’s Expense
By JOHN LELAND


ON Jan. 4, 2010, Raymond Fok was changing trains on his way to kidney dialysis treatment when he collapsed on the Canal Street subway platform. Emergency medical technicians examined him and took him by ambulance to the nearest hospital, New York Downtown, near the foot of the Brooklyn Bridge. Workers in the emergency room recorded that Mr. Fok’s speech was slurred and that he was lurching from side to side when he walked.

“He was a very typical hemorrhagic stroke,” said Jeffrey Menkes, the hospital’s president. From the emergency room, the hospital admitted Mr. Fok to the intensive-care unit on the third floor, where workers tried to find out more about their patient — not just his medical history, but his insurance or Medicaid status, his address, his Social Security or taxpayer identification number, the location of family members.

Once his condition had stabilized, the hospital moved him to a regular room on the fifth floor, where staff members expected to treat him for 7 to 10 days before discharging him to a sub-acute-care center for rehabilitation, the usual regimen for stroke victims.

Nineteen months later, Mr. Fok, 58, greeted a reporter from his bed in Room 516, eager to have a visitor. In the previous year and a half, perhaps 100 or more patients had come and gone from the room’s other bed, but Mr. Fok had gone nowhere. “Yes, I remember you,” he said. “John, right?”

The price of his treatment: $1.4 million.

And who was paying for it?

“The government,” Mr. Fok guessed, though he was not sure. “The hospital is losing money.”

In a city with a large immigrant population, it is not rare for hospitals to have one or more patients who, for reasons unrelated to their medical condition, do not seem to leave. At Downtown, where a bed costs the hospital more than $2,000 a day, there are currently three long-term patients who no longer need acute care but cannot be discharged because they have nowhere to go. The hospital pays nearly all costs for these patients’ treatment. One man left recently after a stay of more than five years.

They are the forgotten people in the health care system — uninsured, usually undocumented, without resources and stuck in the system’s most expensive course of care. Some are abandoned by or estranged from relatives; some belong in rehabilitation centers, where care is much cheaper, but because of their immigration status they are not enrolled in Medicaid or Medicare, so the places will not take them. For hospitals, some of these patients, like Mr. Fok, come in as medical cases and then quickly become puzzles for detective work.

Mr. Fok released the hospital to discuss his treatment, which involved every department of the staff, from laundry and food services to psychiatric care, social work and community outreach.

“The first two or three months was a hard time,” Mr. Fok said from his hospital bed, the left side of his face still partially frozen from the stroke. He had a tattoo around one arm and two lumps on his bare leg where the dialysis needles removed and then returned his blood three times a week. He has spent 23 years in the United States, but his English remains rudimentary.

In the beginning, he said, “always I thought, how long before I go out? Because when you wake up in the same room every day it’s the same thing, ‘When I can get out?’ It’s always depressing. But day by day, day by day, you don’t need to worry about what will happen, because when you wake up it’s always the same room.”

RAYMOND FOK was born in Madagascar and grew up in Hong Kong, where he became a police officer. In 1988, he brought his wife and two young sons on what he told officials was a vacation in New York, and then never returned. Mr. Fok left some question about his reasons for overstaying the family’s tourist visas, repeating that he had feared Hong Kong’s approaching handover to the Chinese government, though at the time this was nine years away.

In New York he found a job at a vegetable market in Chinatown, earning $5 an hour to feed a family of four — and soon, with the birth of his daughter 18 years ago, five. A friend helped him rent an apartment in a heavily Chinese section of Bensonhurst, Brooklyn, and taught him to navigate the subways. But the friend refused to help him apply for permanent residence, Mr. Fok said.

Eventually he landed a job driving a truck for a Chinese-owned company in New Jersey, at $400 a week, off the books, with no insurance benefits, he said. He had a driver’s license and bought a car to commute.

“Make a life, pay rent, support a family,” he said. His wife worked in a laundry on Delancey Street. His sons went to school and later found jobs in bodegas or bagel shops. It was enough.

But driving was stressful, with no extra pay for overtime, and he lived on fatty foods consumed on the go. When his kidneys failed, an emergency-care provision in Medicaid paid for dialysis treatments, though he was otherwise ineligible for coverage.

For Mr. Menkes at New York Downtown, any day the emergency room door might let in the next Mr. Fok. Under federal law, hospitals are required to treat anyone who comes in, regardless of his or her immigration status or ability to pay. Half of the in-patients at Downtown are Asian immigrants, many of them undocumented, Mr. Menkes said. Forty-five percent of those on the staff speak at least one dialect of Chinese. When Mr. Fok arrived — with no Social Security number, no green card, no insurance, disoriented, no known family or address — the hospital was ready for him.

Downtown Hospital, which has an annual operating budget of $200 million, runs at a slim margin, Mr. Menkes said. Three-quarters of its patients receive either Medicaid or Medicare, which have cut reimbursement rates for doctors, even as expenses have risen. Many private doctors have stopped seeing Medicaid patients, but for the hospital, a private nonprofit institution, this is not an option. The hospital loses money on most babies it delivers, Mr. Menkes said, because reimbursement rates fall below the cost of delivery in New York.

Mr. Fok came in the door a sick man. He had kidney failure, hypertension and a weak heart, in addition to having suffered the stroke. He could not eat because of a swallowing disorder caused by the stroke. His left side was immobilized.

“While he was in I.C.U., he said he wanted to die,” said Norma Robinson, a case manager in the hospital’s continuum of care department, which coordinates a patient’s physical and emotional treatment. “Psych came in. A social worker evaluated him. He said he had a son but didn’t know the son’s name.”

So began a mission by the hospital staff to reconstruct the identity of Raymond Fok, with little cooperation and sometimes active interference from the patient. The family had no land telephone line, and Mr. Fok said he did not know anyone’s cellphone number. The detectives were starting from scratch and could not necessarily trust their prime source.

In the hospital’s favor, Mr. Fok had no one else to talk to. He had very few visitors, and his roommates changed every few days, before he could bond. “We were his visitors,” said Chui-Man Lai, an assistant vice president of patient services, community outreach and provider relations. “That’s why information comes up to the surface bit by bit. Mr. Fok didn’t want to expose his family, because the whole family is undocumented.” (His daughter is actually a United States citizen.)

Gradually, nuggets of information came to light. “He said, ‘I have two sons but I’m not associated with them,’ ” Ms. Robinson said. He said that his wife worked in a laundry but that he did not know the name or number. For nearly a year, according to staff members, Mr. Fok declined to provide any other information about his family. He sometimes refused physical therapy or spoke inappropriately to the therapists, said Sharon Fan, a social worker. Ms. Robinson instructed the nurses to watch out for family members visiting him.

When his health became stable, Mr. Fok no longer needed the acute-level care the hospital provided. The administrators tried to find a less costly home for him.

“No nursing home would take him because he had no Medicaid and no green card,” Ms. Robinson said. Early this year, after more than 12 months of treatment, employees had a brief glimmer of hope. An evening nurse spotted a woman who seemed to be Mr. Fok’s wife visiting the room. But hopes were short-lived. “She said she can’t take care of her husband,” Ms. Lai said. The staff redoubled its surveillance, but never saw her again. “It was just that one time,” Ms. Lai said.

Mr. Fok told the hospital that he lived in a five-story walkup, which made going home all but impossible. He needed regular transportation to dialysis, and even if he had Medicaid, the transportation providers carry patients up or down only two flights of steps, said Emma Turner, an administrative supervisor in the continuum of care department.

In fact, the Foks’ apartment is on the ground floor, just five steps up from street level.

“He didn’t belong here,” Mr. Menkes said. “But what’s the alternative?”

TO a stranger meeting Mr. Fok for the first time, he can seem eager for conversation, candid about his life. One former roommate described him as amiable and talkative. He loved soccer. He hated the hospital food. On an August 2011 morning at the hospital, he described the strained family situation in Bensonhurst.

“My sons hate me,” he said. “They say, ‘Why you bring me here? You don’t have idea. You bring me here; it was a mistake.’ I don’t think it was a mistake. When you come here you see a lot of the world. In Hong Kong you see just a little bit of sky, but here you can see a big sky, a lot of people, different people. It’s the capital of the world, New York. Different people, different cultures. But they don’t like it.”

He added: “I’m not worried about it, because I got to take care of myself, first. And second, when they grow up they will understand. One day they will have families and they will understand, too.”

His sons, who he said are 29 and 22, declined to be interviewed for this article. His daughter deferred to her brothers.

With Mr. Fok unable to work, the others had to pay the $1,200 monthly rent without him. He said his sons paid only the electric bill, so they could run the computer and air-conditioner; for the rest, his wife worked 13 hours a day, seven days a week at $5 an hour. She had little time to visit him in the hospital — and no time to take care of him should the hospital discharge him.

New York’s Department of Social Services allows Medicaid and other welfare benefits to illegal immigrants who can demonstrate that the government does not intend to deport them, or who have an immediate relative who is a citizen and files an application on their behalf. Getting the first kind of documentation can take a year or more, Mr. Menkes said. But for Mr. Fok, the second, quicker, option was also possible. His daughter, who was born in New York, was about to turn 18, and could apply for him to receive benefits as what is known as a person permanently residing under color of law, or Prucol. There was only one problem: no one knew how to reach her.

“We continued to feed him, do his laundry, provide nurses and doctors,” Mr. Menkes said. “But he doesn’t belong in an acute-care hospital.” By early 2011, his bill had risen past $1 million, of which the hospital was receiving reimbursement only for his dialysis treatments, which were less than one-tenth of the total costs.

Finally, in March, there was a breakthrough. Mr. Fok was making progress in physical therapy, and staff members told him he could walk if he had a lightweight device called a hemi cane or hemi walker — basically a cross between a cane and a walker, designed for people with use of only one arm.

“I’m good with faces,” Ms. Robinson said. “I come out of the elevator and I see a girl who looks just like him, carrying a hemi walker. I said, ‘Who are you?’ She said, ‘I’m Mr. Fok’s daughter.’ ”

ON Aug. 17, after one year, seven months and 13 days, Mr. Fok returned to his apartment in Bensonhurst, carrying 21 filled prescriptions and his hemi walker. For the $1.4 million in services that Downtown had provided, total reimbursement to the hospital from Medicaid was $114,000, Mr. Menkes said.

Mr. Fok’s immigration status never kept him from receiving treatment, but it helped make sure that his care would be delivered in the most expensive setting possible and in a place no one wants to spend more time than necessary. He was cut off from his family. On several occasions he showed signs of depression or expressed suicidal thoughts.

If he had been insured or immediately eligible for Medicaid or Medicare, he might have gone to a nursing home after a week or two, where the average daily cost in New York is about $350 — and where he might have had steady companionship. Or he might have received a home health aide in his apartment, which could have cost even less, depending on the required hours.

For hospitals like Downtown that treat many illegal immigrants, the health care plan enacted last year does nothing to solve this liability, Mr. Menkes said. During debates about reform, lawmakers insisted that the plan’s benefits not extend to the nation’s 11 million illegal immigrants.

Lawmakers now are proposing cuts to Medicare and Medicaid to reduce the deficit, which may put even more pressure on hospitals like Downtown. Nor is this likely to change. Few politicians who want to be re-elected will advocate broadening public services to illegal immigrants or increasing the taxpayer cost of health care.

For Mr. Fok and his family, the return home has been difficult. After his discharge, he did not immediately get a home health aide. In a family already stressed financially and with difficult relationships, having a patriarch who needs full-time care has raised the tension levels. No one had time before; how could they now?

In late August, Mr. Fok’s older son called the hospital, irate.

“He said, ‘It’s an unsafe discharge; I’m going to report you to the attorney general,’ ” Ms. Robinson said. “ ‘Take him back.’ I said, ‘No, we’re not going to take him back.’ He said: ‘I work and I take care of the apartment. Take him back. I want to finish college, and I have a year and a half to go.’ ”

On a mid-September afternoon, nearly one month after his discharge, Mr. Fok sat in a wheelchair in the crowded waiting room at Chinatown Dialysis Center, a long ambulette ride from Bensonhurst. His hair and beard were neatly trimmed, and he wore a spotless T-shirt.

He was glad to be home, he said. “Yeah, of course.”

But as the conversation continued, he reversed this statement. He spoke in tired monosyllables and did not make eye contact, as he had in the hospital.

Since he came home, his sons have been angry at him, he said: “Because I give them a hard time now. They got to take care of me.”

He cannot prepare food for himself or walk to the door to open it. He needs help getting to the bathroom. He said he had not walked since leaving the hospital, even with the hemi walker. Asked if he would rather be back in the hospital, he said yes.

“I’d like to go back but cannot,” he said. “What reason to go back?”




Artwork:  Kyle T. Webster



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