SOUTHERN COLORADO — A shortage of doctors that can perform autopsies, combined with the rise in drug overdose deaths, has left some small county coroners in a financial bind.
According to the El Paso County Coroner, a medical examiner is a physician who has trained in pathology and completed a fellowship in forensic pathology. It takes around 13 years of education to become a medical examiner. Forensic pathology is the field of medicine that a medical examiner practices. Medical examiner is the technical job title, and a forensic pathologist refers to the type of doctor they are.
It's important to understand the role of a medical examiner, because Colorado requires an autopsy to be performed by a medical examiner. In El Paso County, there are currently four medical examiners in the Coroner's Office, which is the largest number in any Colorado office, according to the coroner.
El Paso County alone deals with thousands of deaths every year, and about a quarter of those require autopsies. Plus, smaller communities send any sudden or unexpected deaths that need an autopsy to the El Paso County Coroner's Office, and that caseload is not expected to slow down any time soon. "We perform autopsies for about 21 other counties around Colorado," said Dr. Leon Kelly, the coroner and chief medical examiner for the El Paso County Coroner's Office.
Dr. Kelly said there are only a handful of Colorado counties with a coroner that's also a board certified forensic pathologist, like he is. In Colorado, to become a coroner "does not require you to be a physician. The overwhelming majority of coroners in Colorado are non-physicians," said Dr. Kelly.
The National Association of Medical Examiners, or NAME, gives accreditations to coroner's offices. The El Paso County Coroner's Office is accredited by NAME. NAME stipulates that medical examiners only perform 250 autopsies a year, for quality assurance. However, each medical examiner in El Paso County averaged 305 in 2018. So, Dr. Kelly said they have approved and funded a new position for another medical examiner, who should be starting next year. At that point, Dr. Kelly said they would be fully staffed and in compliance with their numbers, a rarity with the current shortage of appropriate doctors. "There's only about 400-500 forensic pathologists in the country... The vast majority of communities, particularly in Colorado, don't have a forensic pathologist," said Dr. Kelly.
Dr. Kelly said that's why smaller counties have to pay to send their sudden or unexpected deaths to be autopsied in El Paso County. El Paso County charges around $1,500 per autopsy, and Dr. Kelly said the money goes into the El Paso County general fund. However, that money does place a financial burden on smaller county coroners and their budgets. "The more drug deaths we see, the more homicides we see, the more people on the road that we have and the more car crashes, are going to put a strain on those smaller counties," said Dr. Kelly.
The Otero County Coroner, Robert Fowler, has held his position for the past four decades. Fowler said his office typically averages 150 deaths a year, but in 2018 it jumped to over 200 deaths. Fowler also said for 2019, the numbers will be even higher, maybe more than 250 deaths. "We are having more drug deaths every single year... And part of the consequence of that is I have a budget that's from Otero County, and now the last few years I've gone over budget every year," said Fowler.
Fowler said it has not always been that way. For instance, Fowler said they actually were under budget in 2007. But Fowler said that began to change in 2012, when they were around $3,000 over budget. Fowler said in 2015, his office was over budget for autopsies by more than $7,000. The office also was over their autopsy budget in 2018, when they budgeted $28,000 and spent $36,000. These figures are just the money spent on autopsies, not their full budget. "The smaller counties are having to pay for it, there is no money from the state to fund this," said Fowler.
Here's a list of autopsy budget figures from the Otero County Coroner:
- 2012 - budgeted $20,000, spent $23,000
- 2013 - budgeted $21,000, spent $25,500
- 2014 - budgeted $21,000, spent $20,600
- 2015 - budgeted $21,000, spent $28,100
- 2016 - budgeted $21,000, spent $21,600
- 2017 - budgeted $21,000, spent $23,365
- 2018 - budgeted $28,000, spent $36,000
- 2019 - budgeted $28,000, through Sep. 1 have spent $35,440 (expected to go over $40,000 this year)
Fowler estimated an autopsy costs around $2,000 total, when considering the additional costs of supplies, equipment, and transportation. Fowler said he expects to autopsy 30 bodies this year, meaning they could spend $45,000 on autopsies. The budget for autopsies in 2019 was $28,000. "People have to understand the coroner has sort of a tough job any time period. And now with this increase in the drug deaths that changes our burden, and the increase in the drugs and the amount of people using those has changed significantly, and we're going to see that change in the future," said Fowler.
Fowler said trying to keep up with the increase in drug related deaths is difficult. So, in cases where the person was transferred out of county and has a lot of documents from the hospital at the time of their death, including a toxicology report, Fowler may not do an autopsy to try and cut down on costs.
However, Dr. Kelly said some coroners have resorted to questionable methods. "Should [they] do what [they] think is the right thing to do, which is the standard of care, or do [they] not have enough money in the budget? And so, [they] don't autopsy someone who really needs to be autopsied... Tried the route of drawing samples at the scene of death and sending those only for toxicology if they suspect a drug overdose," said Dr. Kelly.
Dr. Kelly said it's a problematic shortcut for two reasons. First, not all deaths that look like drug overdoses are. Second, cases where drugs are present do not necessarily mean it was an overdose that killed someone. "You now have no idea why this person has died... hoping to get an answer in the most efficient and cost-effective way, and sometimes that will work, and there's some communities across the country that honestly don't have a choice," said Dr. Kelly.
Both coroners said it's a choice critical to learning more about public health, which is why the funding for coroner's offices is so important, because how someone died could help someone still alive.
The El Paso County Coroner said opioid deaths were increasing, but around two or three years ago, they started decreasing. He said better education, awareness, and things like Narcan could have impacted those numbers.
To read through the El Paso County Coroner's 2018 Annual Report, click here.