Emergency rooms are monopolies
vox.com
vox.com
[0] https://www.ftc.gov/system/files/documents/public_statements...
[0] https://www.beckershospitalreview.com/finance/the-12m-patien...
See premiums rising and all of a sudden, "We need to consider letting this person die a noble death."
It's like a paradigm shifting, without a clutch.
just like tax laws, medical laws and implementation are done to favor specific groups to the detriment of others unfortunately
This is like, the main way to make insurance affordable.
Edit: The media only publishes the most extreme examples so I wasn't left with many options.
That doesn't really have much of an effect these days, though, because if anything, we already have an excess of hospitals in most areas where this would come into effect.
That's why hospitals have been hemorrhaging money, and so many have either gone broke and closed up entirely or been consolidated into larger hospital systems. The independent hospital is a dying breed, and it's been dying for a very long time.
In other words, there just simply isn't really any appreciable desire to open hospitals in those regions. The Certificate of Need isn't the limiting factor; their ability to break even on their operating expenses is.
"More likely, CON has affected the intensity and speed with which hospitals pursue particular construction activities. For example, the absence of CON in Indianapolis is likely an important factor in its rapid build-up of new full-service hospitals and specialty facilities. In Seattle, where CON is present, multiple hospital organizations are seeking to build new facilities in population-growth areas, but they must await review and final approval. CON requirements in this community could explain why Seattle hospitals expressed greater interest in better management of their existing capacity in the face of growing demand, because they cannot move quickly to build more capacity."
Anecdotally, there has been a 10 year long fight near where I live over opening a hospital with CON laws being at the center of state supreme court litigation[1]
As someone who works in healthcare and understands the economics of the system your perception cannot be further from reality.
[0]https://www.healthaffairs.org/doi/full/10.1377/hlthaff.25.3.... [1] http://www.charlotteobserver.com/news/local/article126222794...
As someone who's also worked in healthcare and also has an actual degree in economics, I stand by my point. In general, the CoN requirement doesn't have much of an end impact on prices for patients.
However, I will not fall back on my credentials since I prefer evidence instead of grandstanding.
Here are a few links that I think could help change your mind.
https://www.mercatus.org/system/files/mercatus-mitchell-con-... http://www.econtalk.org/archives/2012/11/cochrane_on_hea.htm... http://www.econtalk.org/archives/2017/10/michael_munger_4.ht...
I've excerpted the following quote from the first link as I think it summarizes my viewpoint quite well.
"A review of 19 peer-reviewed academic studies finds that CON laws have worked largely as economic theory predicts and that they have failed to achieve their stated goal of cost reduction. The overwhelming weight of evidence suggests that CON laws are associated with both higher per unit costs and higher total expenditures. The evidence is mixed on whether CON laws have increased the efficiency of particular hospitals by channeling more patients through fewer facilities, and there is no evidence that CON decreased overall investment as its proponents had hoped. The weight of evidence suggests that CON regulations persist because they protect politically potent special interests from competition"
Just a few days ago: http://www.newsobserver.com/news/business/article188329569.h...
From physicians to pharma companies, everyone is focused on leverage and ensuring they control the supply in their vertical.
Everyone pretends like the next round of drugs will make us so much healthier/live longer/etc. But we could have 0 innovation in medical/pharma technology in the next 20 years and if we instead focused on innovating in efficiency, expanding supply of docs and healthcare workers, and building a sustainable system, we would all be better off for it.
The next new procedure or pharmaceutical can’t do jack shit when most people that need them can’t get them in a timely and affordable manner.
Raise the bars for what you contribute to, folks!
http://www.cbs46.com/story/34481437/local-hospital-says-its-...
And then economists wonder why the savings rate is so low.
However, in the mean time there are ways to help.
1. If you don't already have one, get a Primary Care Physician. Go for a wellness visit, get their practice to know you. Then if something like that happens at 1am, you can call the office, leave a message and get a callback from a nurse within 15-30m who can help you through your options and help with over-the-counter options to make it through the night until the office opens (or until urgent care opens). Or of course they can counsel you to go to the ED if they think there's a risk. But the point is, you can already weed out some unnecessary ED visits that way.
Note: not all providers have that service, so it's best to enquire when selecting a physician.
2. Many insurers have a nurses hotline but few people know about it. Check your policy. In the same way, they can help triage your situation, though it's less ideal since they don't know your medical record so they will tend to play it safer (ie. higher likelihood to send you to the ED). But it's better than nothing.
3. If the issue is pain management, you can also try your neighborhood 24/7 pharmacist. They can't diagnose you but again they might have tips to help you through the night until you can get proper care.
Of course, this raises the question. Why isn't urgent care a billing code in small emergency departments?
Because it's still emergency physicians performing the work, for the same cost (both marginal and overhead).
The answer is to open up actual urgent care practices, which are cheaper to run, not to change the billing codes used in emergency room settings.
I mean, when I've been in the local ER it hasn't exactly been a hive of urgent activity, you chat with the intake nurse and then watch her sit there and do things other than interact with patients for half an hour.
Emergency medicine and primary care are completely different settings. "Adding primary car doctors to ERs" doesn't really make any sense. The structure of care delivery is completely different.
(and of course they don't because they aren't going to bill insurance companies any less than they can consistently get them to pay)
Yes, the actual structure of care that is delivered is entirely different. You can't just stick primary care inside an ER and expect it to work. The two aren't similar.
How often does this happen? If it's not life threatening, why can't it wait until dawn?
There was a period in time where there were very high losses in emergency rooms because there are legal obligations for conferring care in that setting. Many emergency rooms were getting closed down and that's also a big problem for communities. So it's in a way understandable (not necessarily excusable), because some of this I would infer is cost shifting to meet those obligations. Maybe it's shifted to too much profit now.
Both sides of the problem, IMHO come from completely disconnected cost/profit transaction loops in America's healthcare. It's one big reason why single payer systems cost so much less. There is a much more straightforward relation between costs, care, and budgets in those systems so you can actually manage the direct problems instead of managing multiple red-tape layers each trying to competitively maximize, minimize different areas.
Yup. In 2006, I was in a serious bicycle accident in San Francisco w/ some head trauma. SF General was the only hospital in the area with a (Level 1?) ER that treats head trauma. I also had two broken arms. Even though I was in shock, I remember very clearly asking everyone involved in getting me from the accident site to the ER if SF General accepts Blue Cross, my insurance carrier. I was more concerned with facing a giant bill than my own health. Eventually someone said they do take Blue Cross, and I stopped worrying.
Later I came to find out that SF General bills Blue Cross, but they do not have a contract with Blue Cross. 100% of my treatment was out of network. Then I got a bill for about 50,000 USD. Between that, trying to pay for physical therapy, and a disruption to ability to earn a living at the job that paid for my healthcare, I struggled for a long time after the accident.
My main point was that your basically screwed before you arrive, and you're just gonna have to cope with it after the fact. Expecting a patient going into an emergency room to understand, or have the capacity to, navigate "the fine print" stuff is not realistic, yet that's exactly what they expect that patient to do. It is quite lame.
If all management has to do is look the other way and collect benefit (and eventually blame paramedic), they will look the other way and punish employees who took longer to get you to hospital - cause you prefered cheaper one a bit further away.
I don't expect injured patient to protect himself perfectly. However, I think we would all benefit if we labeled what happened to you accurately - a kind of fraud - instead of pretending it is ok, because system works that way.
Many people do not use them correctly; I can't blame them sometimes, when that's the only option around, but there's a whole host of issues people drift into ERs for that ought to be solved by an aspirin and a night's sleep, or an urgent care clinic. In the past five years, there's been a huge explosion of Convenient MDs and the like springing up everywhere; honestly, if you just had a nurse practitioner or PA assigned or on-call at Rite-Aids or CVSs to write scripts for no-brainer prescription medications, you'd solve half the healthcare problems people deal with.
They pay extra to small hospitals that don't receive enough privately-insured patients to break even on standard Medicare reimbursement rates. For other hospitals, they pay rates that are below-cost, and hospitals charge private insurers extra to make up the difference.
It's true that most hospitals themselves are non-profits, but the service providers in the hospital range from moderate capitalists to very predatory ones. Donating to the hospital just means they charge less overhead, and the medical corporations operating within them keep more. Doctors are great and all, but I don't feel like they need my charity.
You can try to regulate these facility fees, or force them to be made public, but as it stands there's no reason for them to go anywhere but up, indefinitely.
It says:
"Trouble breathing? Nausea and fever? Stomach pain? Our ER can help."
"What's your body telling you? Any one of these symptoms could be a warning sign of something serious. Our emergency room offers fast, expert care 24/7 to keep you healthy."
I had never really thought of hospitals, especially ERs, as a business before I saw that. I guess that was naive.
The chance of that bill ever going anywhere is effectively zero.
California has a larger economy than all but five nations in the world, so that doesn't seem like a major problem.
What exactly that has to do with someone being haunted for debt? Or is he suggesting you should fraud ER and you are suckers if you don't?
If your kid has a possible ear infection or broken arm, and you have insurance, you go to an urgent care clinic. If you don't have insurance, you go to a hospital. In all other respects, the care is the same.
The kid with the simple ear infection will wait longer in the ER. (Note that I added simple: if the ear infection is complex the ER may see the kid sooner, but those are cases where when Urgent care finally gets to the kid they transfer to the nearest ER)
Most "decent" urgent care facilities will triage. That's one of the reason why you're asked why you're there on check-in (and also to ensure you're not complaining of something acutely emergent).
Waiting time is a matter of how the facility is managed. If an ER is handling a lot of noncritical cases, they can set up a facility for handling those cases, which would look just like an urgent care clinic. In fact, I once had a minor injury and went to the ER, and was transferred to an urgent care clinic in the same building. I had insurance.
No, but if you can't pay, and you won't drop dead in the next eight hours, they will try their best to toss your ass out onto the street after prescribing you a $900 bottle of aspirin.
Wen you're that far out of alignment, something is seriously wrong.
The US could scrap Medicare and use the savings to fund European style healthcare for everyone. You still get the option to top up with private health care, which can be pricey - $150 a month for a family, but there's always a base line to fall back to.
So if a big drug company sells a drug very cheap in some poor third world country, they have to sell it for the same price in the US?
Wouldn't the most likely outcome of that be that they stop selling their drugs in poor countries?
And the poor countries would just make knock-offs, and sell them to other poor countries. The US as a whole would lose out because much of the US economy is based on the dubious concept of 'intellectual property'
A way less intrusive way to ensure the same end result is to allow reimporting of prescription drugs.
There was a bill to do this last year, but unfortunately it was killed in the Senate.
Many ERs are also severely overburdened, understaffed, and overcrowded often with very high ratios of non-emergency patients to emergency patients. This creates huge wait times for patients and puts significant stress on medical staff.
Talk to your friends, family, coworkers, almost everyone has a bad story to share, whether about absurd wait times, wild costs, billing screw-ups, insurance debacles...
And talk to your doctors and nurses too, they are just as frustrated.
There's only one way forward which will work, although there are lots of different ways to do it: universal healthcare.
It’s not that hard to understand; you try to control market forces when you’re talking about inelastic demand because that kind of demand is an opportunity for serious abuse. Isn’t that the reason the US has its war on drugs? Yet it can’t see this more expensive and deadlier problem?
as a kid growing up in the UK I remember watching (and not understanding at all) the episode of the Simpsons where Homer went to A&E, was told he needed a triple bypass urgently, couldn't afford it, and his condition got worse and worse
in my mind you went to the doctor/hospital when you were sick, and you came out well (or not at all), money didn't enter into it
I re-watched it again as an adult a few weeks ago, now with an understanding of HMOs, deductibles and previous condition waivers among other things, and found the episode to be really quite sad
Imagine what the gasoline market would look like if from time to time a person had to buy 100,000 gallons of gasoline or they would die.
Medicare care in general does not have any of those characteristics (except for maybe annual checkups - but that's not where the bulk of medical costs are in our system). That has to do with the nature of the product and how it must be delivered, not necessarily with any monopoly effect. Even with a checkup, if you go to a different doctor every time that would reduce the effectiveness of the care.
In many European countries, gasoline taxes are quite high. Wikipedia's "Fuel tax" page says that in 2014 Germans paid US$6.14 per US gallon of gasoline.
Yet there is also an abundance of suppliers in Germany.
The hospitals in many European countries are publicly owned and operated. Quoting Wikipedia's "Healthcare in Denmark" page, "The central government plays a relatively limited role in health care in Denmark ... Hospital care is mainly provided by hospitals owned and run by the regions."
There are five such regions. Aren't there, using your argument, also five local monopolies in Denmark? But the situation in Denmark is nothing like the US.
The OP argued inelastic demand drives price gouging which isn't true in the case of gasoline. Price gouging in medicine isn't driven by inelasticity, its driven by a dearth of suppliers.
In Denmark, you have few suppliers but the suppliers you do have are owned and regulated by the government. It's not a relevant comparison. They are not a market-based supplier.
When there are so many forces pushing against the creation of a free market and a healthy balance between supply and demand, there is only one thing that the government can do: either socialize it (that's what happens with roads, for example), or regulate it like there's no tomorrow (that's what happens with utilities). However, in the US it is blasphemy to even suggest doing either thing to healthcare.
1 and 2 are absolutely valid points and share responsibility for healthcare costs.
> However, in the US it is blasphemy to even suggest doing either thing to healthcare.
I wholeheartedly disagree with this. Healthcare is the most regulated industry in America.
I now understand your point, thank you.
There’s no alternative sacrifices you can make to solve your cancer problem, though; you need a doctor and the right treatment.
Gasoline is also a very bad example. They get loads of tax breaks from local, state and federal governments because they are too big to fail in terms of jobs, revenue and utility. They also get a lot of help when they have to clean up tgeir mess. That’s what I would call subsidy.
With hospitals, you have one local monopoly to choose from. Therefore you get monopoly pricing.
Yes, if you're shot, you're not going to be too choosy about where the ambulance takes you. But most medical emergencies have some lead up to diagnosis and some wait time for the actual operation.
Even cancer is not treated immediately. You schedule an appointment to have it treated over a long period of time.
Now with all this time, you theoretically have the ability to compare suppliers. But in our world, there is one regional monopoly providing care.
THAT ISN'T THE ONLY REASON CARE IS EXPENSIVE. But it is a factor worth talking about and considering.
Even when there is more than source of care and when there is plenty of time and the person is interesting in comparison shopping, in practice that is still difficult to do in the US.
Last year there was a piece by Johnny Harris at Vox titled "I tried to find out how much my son's birth would cost. No one would tell me." https://www.vox.com/2016/5/5/11591592/birth-cost-hospital-bi...
Childbirth is the #1 reason why people go to the hospital. If the price estimate isn't available for an average/low-risk birth, then it's not going to be available for other procedures.
And again, this includes areas where there are multiple hospitals which provide maternity services, so your explanation of "local monopoly" isn't enough. (Quoting https://www.womenshealthmag.com/mom/costs-of-giving-birth : "this charging system often results in "wildly inflated" costs, and they can vary from hospital to hospital—even if you're just looking at ones in the same neighborhood.")
Your "basic econ 101" quip doesn't go very far to explain why it is that the governmental organizations which regulate these hospitals aren't, you know, regulating them to prevent such "basic econ 101" problems.
What's the point of giving them a local monopoly if they are going to abuse it?
Exactly. We need to be rid of it.
> Your "basic econ 101" quip doesn't go very far to explain why it is that the governmental organizations which regulate these hospitals aren't, you know, regulating them to prevent such "basic econ 101" problems.
My quip was directed at gas prices exclusively.
I don't have an explanation as to why the government does what is does. It seems to me it does everything in its power to make things worse. That's why I'd like to see less government in this industry.
> Even when there is more than source of care and when there is plenty of time and the person is interesting in comparison shopping, in practice that is still difficult to do in the US.
This is true for some cases and false for others.
In the cases its true, I believe its at least partially due to the fact that these hospitals have huge amounts of market power. Whether thats monopolistic or oligopolistic market power I leave to your judgement. But it undoubtedly plays a part. https://www.ftc.gov/system/files/documents/public_statements...
In the cases its false: wellness, vision, dental, ENT. Practices are very upfront about their costs. Even though these might entail shooting lasers into a person's eyes or putting a person under general anesthesia.
Why is it that I can call any dental office in America and immediately get a quote on a procedure but I can't call one of the two hospitals in my area and get a single price on anything at all?
I ask that genuinely. Why the difference? There are areas of the healthcare industry where its trivial and areas where its impossible to know.
During the golf war (first) I used to laugh at gas stations advertising that they sell gas made in the US. The refinery is in the US, but all the crude came from Canada. (This of course only applies the particular city I lived in at the time)
https://www.ncbi.nlm.nih.gov/books/NBK62584/table/ch9.t1/?re...
For heart attack survival, the US isn't the best, but ranks somewhere in the top 4 depending on the data and criteria.
There are a bunch of issues that adversely affect life expectancy in the US not directly related to the health care system. High violent crime rate, much greater dependence on driving cars, standard american diet, opioid crisis (maybe we can blame some of this on the health care system).
Note that survival rate is measured from when the cancer is diagnosed. For many of those cancers the US screens for them more frequently than they do in the rest of the world.
If Alice and Bob both get cancer in 2015 which will kill them in 2021, and Alice lives in a place where they screen for it every year she will survive for 5 years after diagnoses. If Bob lives someplace where they only screen every 4 years and he was last screened in 2014 he will only survive 3 years after diagnoses. Same cancer, same outcome in the same number of years, but Alice counts as a 5 year survivor and Bob does not.
Another thing to watch out for when comparing health systems across countries is different definitions. For instance the US generally has a higher infant mortality rate than other western countries, but at least part of that is because of different definitions.
For example, a very premature baby with very low birth weight has essentially no chance of survival. In much of the world this would be counted as a stillbirth. In much of the US, however, if it was not actually dead at birth it will be counted as a live birth. Result: a few minutes or hours later, when it actually dies, it is infant mortality in the US statistics and not infant mortality elsewhere.
(These definitional differences are not enough to explain the higher infant mortality in the US, but they do close the gap a bit).
And in the context today, a very high proportion of Americans can’t afford parts or all of tgeir cancer treatment costs, in spite of being insured.
Claims denial departments are exploding, they used to be 4-8 person teams for a major hospital five years ago. Today my partner has 32 direct employees at a much smaller, regional hospital.
Hospitals have come to the realization that it's basically impossible for insurance companies to deny ER claims. After all, the patient came in with an "emergency."
United Healthcare got in hot water for denying coverage for airlift EMS for MVA victims saying that the "trip wasn't preauthorized with the insurer"...
Then there are other issues that (supposedly) you have no control over. When I was hit on my bike, I refused the trip in the ambulance to a hospital. But when I got worse just an hour later, I ordered a taxi to go to an urgent care clinic. The clinic said I needed to be treated at a hospital, and then insisted that they would not let me leave except in an ambulance - which I then had to pay for.
Another thing that's stupid: apparently you have to pay for your ambulance ride in Pinellas County, Florida, but you never have to pay for your ride in Montgomery County, Maryland.
The reason you don't have to pay in Montgomery County? The state forced the county to shoulder tens of millions of dollars in teaching funds, and they had to come up with the money - so they made a law that county EMS could directly bill insurers, and this money goes directly to the county.
As an EMS provider, that is against the law. As long as you can show competence and comprehension, you are entitled (as you did with the ambulance in the first place) to refuse care, or any part of it ("You can dress my wounds, but not transport me"). They may wish to document your refusal AMA ("Against Medical Advice") for their liability / stave off abandonment claims, but "refusing to let you leave" is akin to kidnapping, no different to if anyone else had done it.
(Psych holds and such in my area require Law Enforcement involvement, even on scene, as they are the only people authorized to actually 'enforce' the involuntary transport/hold laws, though it's with our recommendation).
The average person doesn't have time to become enough of a medical expert to second guess their doctors about everything.
You can construct a narrative for a bunch of different situations for Hospitals:
* High ER costs in order to offset the large number of people who just can't pay, but need to be treated anyways. * High costs in order to deal with all the regulatory requirements on Hospitals (it seems everything is regulated in a hospital, down to the kind of TP in the bathrooms). * High costs because hospitals have local monopolies and can screw patients. * etc.
I don't have enough data to figure out which one of these is the "right" version of the facts. Does anyone else?
Not that this will solve the problem but it's better than finding out you owe $3k a week later.
You can download chargemasters for many (most?) California hospitals, over the past 10 years, in Excel format. I downloaded one sample and it has a list of 3700 prices, some of which are as high as $84,000.
I'm really happy to discover this resource exists, but is anyone republishing the prices in a format consumers can work with? These sheets need UX design.
The "existing legislation and regulation" section is pretty interesting for wikipedia: https://en.wikipedia.org/wiki/Chargemaster
A random guy wakes up at 1am with a cramped muscle. Goes to facility that is equipped to deal with anything. On the spot surgeries, ability to break teeth safely to intubate and keep alive, drugs, cabinets with up to date equipment. Staffed with non-expired drugs that are regularly recycled. Staffed with people that can use all that round the clock, multiple backups. Staffed with people that keep the place reasonably sterile and safe. Staffed with all others to support an operation like that and expecting to get sued if it fails even a bit.
And then complains, he had to pitch in for all that. An engineer, most likely earning above 8k usd, had to give a weekly salary for something that he considered worth dragging his butt out of bed at 1 am.
The guy is delusional.
The US health care is, on the expensive side, and can be better, but nobody can argue it without taking into account all that goes into maintaining that, just so one can randomly walk inside with a spasm, or after a huge carcrash with 40 broken bones, and liters of blood lost, and probably stay alive.
I'm also amazed how most people here just ignore the reality of the scope of the overall operation, and claim that for a limited use case, it's too expensive.
I'm not even going to insert a car analogy here. If you can't see why health care by nature is socialized and a utilitarian model, I'm not going to argue with people from USA thinking that everything should be proportional to the service and their pocket.
Man up. You are not the center of the universe. This civilization was built for you, by people, and no matter if you like it or not, you will pay to maintain it for the people coming after you.
Humanity, is a social concept worth defending.
Grifters, middlemen, and oligopolies are why healthcare is expensive in America. There is no reason we can't fund expensive R&D and also get cheap medicine.
> Yes, emergency rooms are a marvel of modern planning and materials.
Additionally, they're not good enough.
I've helped a friend go through a traumatic ER experience where she suffered 3 strokes and they released her from ER 3 times saying she was fine before she called me for help. We got her psych-eval'd so that they couldn't release her for 72 hours, so they had to run tests, and lo and behold, they did the CT that showed she had 3 strokes. This was at a world famous hospital.
Sadly, this isn't an exceptional story. Most folks don't believe it until they've experienced something like this personally. While I hope most people never have to experience this, we need more people to understand that this is a real problem.
Anytime you're in a hospital, make sure you or someone close to you (ideally w legal authority to make decisions on your behalf) can fight for your care.
Point is, yes they are amazing compared to an alternative of nothing. We have come far. But we can do better. They are by no means a paragon. Pick any part of healthcare, and there's room for improvement.
There have been some immensely interesting articles about price variations in chargemaster documents between hospitals.
https://www.pbs.org/newshour/health/new-report-shows-stagger...
In isolation, those prices are meaningless and can't be compared between two different hospital - even two different hospitals in the same network.
Hospitals make a marginal loss on patients who are on Medicare and Medicaid. They mark up the list prices of everything else to private insurers in order to make up the difference. The way that those markups are distributed doesn't really reveal anything, and even the aggregate size of the markup doesn't reveal anything other than a vague correlation with the proportion of their patient population that is on public insurance.
(That's even assuming that the private insurers pay the prices they are charged, which is never true - they negotiate for lower prices, although they are still required to pay more than Medicare does).
It is so great that we have an ER available to most people here at all times. But we can still do better with it. If you get in a car crash and they have to rush you to the nearest ER you don't get to shop around or choose, which is why it's a monopoly. They can charge you whatever price they want very specifically because your life literally depends on it. There's no market freedom in that. That's why healthcare shouldn't be left to just the free market. That's why so many countries have social healthcare. Sure the engineer you mentioned could handle it, an engineer can handle most financial burdens but not everyone is an engineer. One ER trip can make fixing your credit nearly impossible, and then you can't get a car(required in many areas of the USA due to how cities are planned) or a house, certain jobs, emergency loans, etc.
It's not "a little on the expensive side", it's "How much can we milk you for with your life on the line?"
In most of the developed world those fixed costs are amortized over everyone, in the form of government subsidies of one sort or another. It's like the police or the fire department; everyone chips in some, via taxes, to keep the service running whether they currently need it or not.
In America, however, we amortize them over everyone who comes into the ER. That's good for the guy who never needs medical attention: he gets all the peace of mind of having state of the art care a phone call away for free. It's good for the lady who rolls in at 3am with a gunshot wound: she gets her very elaborate lifesaving care for only a few percent over the marginal costs. It really sucks, though, for the guy with a dislocated thumb: he's forced to either massively cross-subsidize both the other patients or to forgo necessary but relatively simple care because of the huge expense. That guy doesn't need to believe the system should be free to have a valid complaint that he, personally, is getting screwed over by it.
https://data.worldbank.org/indicator/SH.XPD.TOTL.ZS?end=2014...
Come here in France and appreciate that you can go to the ER for ANYTHING (went 4 times last year for my kids because of bad cough and head injury), and not pay a dime. And they have the same kind of infrastructure to maintain here too, CT scanners, emergency rooms, surgeons and all.
You cannot tell people that the guy is hallucinating hidden costs. It is the health system that is hallucinating these costs. It is a race to the top of who is going to charge the most.
By world standards France is doing fine.
I'm not sure anyone is arguing that he should be paying the unit cost without anything going to overhead, but it seems reasonable that strep throat could be treated with antibiotics and be labelled a Category 1.
I had this same situation play out with my daughter where we were concerned with appendicitis and it turned out to be gas. Still was considered a Level 5 even though I protested. Nothing you can do about it. What are you going to do negotiate with the staff at 9pm while your daughter is hurting? What leverage does anyone have in that situation?! You going to risk being a social parriah and risk your family relationships to save money?
To use another example: You have a lump on your breast. It's either cancer or a benign cyst. Would you bill these differently for the diagnosis work on the doctor's part? Maybe I'm misunderstanding what happened in your situation, but if the same exact steps are taken in diagnosing appencitis vs gas, wouldn't you bill the same?
Edit: Oh I forgot to mention the main reason I commented. I have also heard that billing less (like level 4) even if you completed all the steps for level 5 but do not want to get flagged by the system for overbilling can in turn actually get you flagged for underbilling, and can be cause for an investigation/audit.
https://en.wikipedia.org/wiki/Healthcare_Common_Procedure_Co...
Edit: also note that CPT codes are part of the HCPCS
It'd be nice if patients didn't have to worry about these sorts of issues when receiving emergent care, but such is the country we live in.
The article touched on this, and I also discovered this through my own research when I attempted to dispute what in fact a Level 5 was. Add to the fact, that by entering into the hospital you are asked to enter into an arbitration agreement.
Compound this with the monopoly nature of an ER, and the only thing keep prices from spiraling out of control is the sheer benevolence of the hospital employees.
Additionally, insurance companies would be understandably upset if a hospital was charging them more than they should have been, so potential investigations that shed more light on this could help stabilize this part of the market. I appreciate your insight!
and willingness to push back against intense economic pressure from management.
It's not about how amazing ERs are and therefore expensive. It's about horrible allocation of resources across the entire system. If you don't have insurance, guess what, the ER becomes your clinic. If your child is screaming in pain at 2am with an ear ache, guess what, urgent care is closed, you have to go to the ER.
From personal experience, people will go to an ER knowing full well it's not life threatening and don't need the full services, knowing full well it's going to cost them a small fortune. But they just can't reasonably wait 6-12 hours to get treatment. Would you let your 3 year-old scream in agony until the next day because that's what time the Urgent care re-opens, so an MD cay say "Yup, that's an ear infection, here's your script, off you go"? It's a silly system that doesn't provide reasonable options to such common occurrences. People should dam well complain about it until there are better options.
It's not your only option. Chances are, it's not even your best option.
Urgent care clinics are much more appropriate for the bulk of things people are discussing in this thread. Not only are they cheaper for the patient, but they'll get treated faster, and they'll receive better care, because most of these things aren't what emergency physicians are actually trained to deal with.
Just because the hospital has a bunch of equipment and training doesn’t mean it’s efficient to charge everyone that goes in there for all of it. There is such a thing as marginal cost. The marginal cost of this guys visit was next to nothing, but they shook him down for all kinds of other crap, much of which has dubious health value.
I went to the hospital for a slipped disk. From cursory inspection the doctor could tell I had a slipped disk, but they gave me an x Ray. I said “does the x Ray show my slipped disk?” the doctor said “it doesn’t show that. I just gave you the x Ray to be on the safe side.” Then I had to get an MRI and they gave me a ton of opiates that I threw in the trash, after reading about them online. In the end, the physical therapy that got me back to health cost less than the ER visit.
On top of everything, what really gets me is the gall of the medical shake down industry to bring up “costs.” They use the government to make everything as expensive as possible: the absurd licensing and education requirements, the restrictions on foreign practitioners and nurses, the “certificate of need” BS, the lax anti trust treatment as hospitals consolidate into regional monopolies under the laughable excuse of “efficiency,” the use of regulation to restrict suppliers of even generic drugs, the abominable statistical malpractice and pharm rep industry and stupid commercials used to push useless and harmful drugs on everyone—many of them paid for by government in both research and point of sale. At every level the whole system is by design a shamanistic and monopolistic ritual that achieves very little. Look at the failure to replicate of all these stupid studies, the way doctors respond to reimbursements in their use of quack drugs and surgeries, the flatlining of real quality of life stats even as expenditures explode, the power of the various professional associations.
Not the people going to hospital thing - that happens all the time. It's just that nobody is ever charged thousands of dollars for it.
If there are cheaper ways of providing healthcare, what would have to change in the US to implement it?
For example, if there are three hospitals in a region, and they worked out an agreement among each other to not have overlap in specialized equipment (where hospital A sends all MRI patients to Hospital B just down the road), this is currently illegal (anti-collusion laws).
Another example -- a patient comes in with a headache. Well there could be a number of potentially fatal conditions that could be the cause, and due to liability reasons, they have to run tests to rule these out before giving the patient an aspirin (yes, this is an issue, in lower-income areas people go in for non-emergency issues that most likely doesn't need a doctor).
https://ourworldindata.org/the-link-between-life-expectancy-...
https://www.kff.org/health-costs/issue-brief/snapshots-healt...
https://www.pbs.org/newshour/health/health-costs-how-the-us-...
This will never happen in the US, however, because the US is obsessed with concentrating power in private enterprise and refusing to fund social services. We have more than enough money to ensure the health and welfare of all of our citizens. We just don't actually care to do that, and would rather have rich companies and uneducated, sickly, indebted people.
http://www.ncsl.org/research/health/con-certificate-of-need-...
As a Canadian, I gladly fork over a few thousand a year to avoid tens to hundreds of thousands in one sitting should something horrible happen to mine/my family's health.
1. The US healthcare system is pretty good for some people in some places.
I broke a shoulder this week in a bad fall. All local urgent care had JUST closed so I went to a local ER, the only kind of place available with imaging, to confirm the nature on the injury.
ER trip was a little slow (I was triaged appropriately behind people with emergent issues) but within a few hours I got a sling, confirmation from X ray images that no immediate surgery was needed, and followup instructions.
When I left the ER I got a referral to the hospital's orthopedic group, and was able to get an appointment the next day with a PA & MD who specialize in sports medicine and broken shoulders. My GP confirms that this is a trustworthy referral.
So within 18 hrs of injury I got an expert to review the injury and they decided there was enough info from existing diagnostics to avoid additional tests (no more X ray views, no CT) and understand the pros/cons of further intervention.
I also scheduled a follow-up at T+36 from injury with my GP to make sure nothing ELSE was broken (mindful that shoulder experts will only look at the shoulder), and was reassured that nothing else is wrong and conservative management is ok.
So that's 3 healthcare visits within 36 hours of an injury, with almost immediate post-ER triage to (I am reliably told) a high-quality local expert.
This all felt really good and probably slightly faster than I would have been treated when I lived in the UK (with NHS London-area A&E as well as employer private insurance).
No complaints about the US system if you have employer provided insurance. I'm fully expecting to see a $4000 bill for these 3 trips and to pay significantly less than that because I carry a traditional high-premium low-coinsurance health plan. Overall it seemed pretty good, but only because I was fairly confident that paying for care wouldn't permanently ruin my finances.
Would have felt pretty painful to be uninsured. EMTALA keeps people alive but the medium term financial impact of the US's high quality of ER care is not to be taken lightly.
Also would have felt pretty painful if I had been in SF and been taken to SF General Hospital post injury as they are notorious for being extremely convenient to access but out-of-network to all insurance providers: https://www.quora.com/Why-does-San-Francisco-General-Hospita...
I do note that although US care is pretty great it can seem a little over the top sometimes:
2. This article gives an example of a patient with strep throat visiting an ER and being diagnosed using a CT scan … why? That seems like an odd choice.
I once visited an NHS urgent care clinic with a bad sore throat and I was told "you Americans come in for every sore throat, this is just a virus, go away." They didn't even run a strep test, just ruled it out from symptoms. No antibiotics or other treatment etc. Felt kinda harsh but was dirt cheap for the NHS and I think the outcome was the same as a similar US urgent-care visit.
(Actually, I visited an NHS urgent care clinic twice for that sore throat. The first time they told me that because I had an American passport they would charge me £60 to be seen. I was incredulous -- are you sure about that? I'm a UK taxpayer here on a work visa -- and got an apology from a service manager a week later.)