An ER visit, a $12,000 bill – and a health insurer that wouldn’t pay

> The doctors in the emergency room did multiple tests including a CT scan and ultrasound. They determined that Cloyd had ovarian cysts, not appendicitis. They gave her pain medications that helped her feel better, and an order to follow up with a gynecologist.

> A few weeks later, Cloyd received something else: a $12,596 hospital bill her insurance denied — leaving her on the hook for all of it.

For a few tests, the hospital charges 12,000 dollars. How is this sane? People should be rioting over this.

Imagine if your car insurance decided to cover oil changes, but not at fault collisions. That would be asinine.

> insurance companies are dropping support for expensive ER visits, and instead supporting "preventive care" by only covering a $100 annual checkup instead

This is quite far from the facts of the story and does not belong in an honest discussion (note: I'm not arguing that Anthem is in the right at all, I'm just arguing that this is not a good description of the situation at all).

Anecdata: I have never had my insurance company cover anything in the last three years.

The best they ever do is claim to negotiate a slightly lower price, for which I still pay out of pocket.

And when the annual "maximum out of pocket" gets surpassed, they gamble (correctly) that I won't incur the costs associated with litigation when they inevitably continue to deny claims after "maximum out of pocket".

There's very very little we can do.

The insurer takes the view that it's _their_ money, that they earned. When it's their customers that are paying, in the insurance pool, after, and only after, Anthem has already taken its cut.

Yes, it's not as black and white as that, and part of that administration cost is ensuring efficient use of the pool's money, but nonetheless, to read insurers defense of these policies, you'd think they were just trying to defend against lazy/greedy customers and ERs trying to milk them out of their money (and with good reason, because they absolutely do view it as their money once your premiums are paid, and the less they pay out, the less they get to keep - pop quiz, say a pool of 1M people pay $5,000/yr for insurance, with a pool of $5B for benefits, and an insurer takes 10% administration costs. Say this insurance pool only pays out $4B that year. What are the odds that the insurer pays out that $500M back to the pool, or as a dividend/rate reduction? Of course you know the answer. Of course the reality is that in theory such money could be kept in the pool "for a rainy day", leaving aside concepts of reinsurance, etc., but that often doesn't happen either, not when there's bonuses to be paid...).

Social Darwinism has been a running trope with the Cs. The problem is, Social Darwinism is fun until you're on the chopping block...... and so we now see some odd backpedalling in the 2010s now that some have gotten old.

I'd rather pay more to ensure everyone's livelihood is okay.

CT scan is expensive. Each scan (CT, ultrasound) is reviewed by a radio-logical expert (i.e. doctor), plus taking up an ER bed for many hours, lab work, IV medications, etc... It adds up pretty quickly.

I'd love to know how much this actually costs in say Canada, or the UK, and I don't mean to the patient (I know they wouldn't pay much if anything), but the actual cost on the system.

If you look at the per-hour breakdown it’s insane, even when you consider doctors making $500k+/yr . Consider also the actual hours in contact with a surgeon or doctor vs most of the time that was spent laying in their bed.

I also wanted to note that in every instance I’ve seen where the possibility of insurance is involved, medical care providers will give you a no-questions-asked “cash discount” of 30-40% (typically) just because you’re not the insurance. I basically read this as “we charge them more because we can”.

Also in the US: http://mashable.com/2017/12/14/study-shows-people-call-uber-...

If you go to urgent care and there's no waiting x-ray tech or radiologist, you will wait in line until the local guy clears the backlog, which might take awhile, but you're not at urgent care unless its not a medical emergency, patient in stable condition, etc. Stable condition does not mean you're perfectly thrilled and happy with your health, it means you're not in the dying process.

At the ER they're paying on call for zillions of people and if you need an x-ray and they're busy, then as fast as a radiologist can drive in, one will magically appear. This is very expensive, my buddies obgyn wife got $600 per day just to carry a phone and it takes a heck of a lot more than one OBGYN to do everything an ER could possibly need, and the patients as a group will amortize that cost. My wife's friend's husband is an anesthesiologist and they get closer to $2K per day on call. It adds up and you get maybe two of each of the village people and by the time you're done, running a real hospital means you're burning $100K per day on people who aren't working that day... The patients will pay, of course.

A side dish is the capex, merely replacing a CT scanner machine every 8 or so years will cost about $500/day. Not to run it, not to buy supplies, not to power it, not the real estate cost per square, just buying a new machine every 8 years is $500/day and thats a mid-range cost, obviously MRI are more expensive or ultrasound imaging is a bit less. Regardless if you need it or not, because there's like 200 other machines also very expensive and someone has to pay for all that. Then there's the medication expiration scam, can't ever run out of Advil but when it expires annually you buy more. Departments get remodeled or newly built every decade or so and the going rate seems to be around $10M for a new or remodeled department every decade or two. I would guess its another $100K per day to stock an empty building with the capital goods, even if you barred the doors. The patients will pay, of course.

In tech terms a good analogy is you can get a password reset by the helpdesk at 2am for not too much money, but if you expect a level of service such that you can call at 2am on Christmas morning with a wishlist bug and a new bug free safety-of-human-life qualified release will be shipped immediately while you're on the phone, this is possible only because there are people that really like money... lots and lots and lots of money.

Another way to look at it, is its nice to visit an ER where they never ever say "yeah we could in theory save your life, but we had to save money so no XYZ machine or medication or treatment, too bad" but however nice it is to visit, you're not gonna like the bill. The best medical care money can buy is going to be expensive.

I did not have an epidural or any pain medication during labor and had a relatively uneventful birth once things actually started moving. The doctor was great, but was only there intermittently until the very end. I needed some stitches but was walking unassisted within a few hours and was discharged early (after a week in the hospital, we really wanted to go home).

Total "bill": over $100,000, most of it covered by insurance. It did not cost them almost $15,000 per night for me to stay there. That's just what they send to the insurance company in this absurd game they play with each other.

> A list of codes from Missouri is significantly longer, with more than 1,900 diagnostic codes that could indicate non-emergency visits. The list includes multiple types of “unspecified injuries” and “chest pain on breathing.” When asked about the Missouri list, an Anthem spokesperson said the latter diagnostic code regarding chest pain has since been removed from the list, which has been updated and revised.

The ER department should redirect people to less expensive alternatives if they think the patient isn't actually in an emergency situation. If they can't figure out if it's an actual emergency just by asking a few questions, then how is the patient supposed to know?

As far as ER overuse is concerned, sure there are folks who may go to ER for everything but majority don't because ERs are a pain the ass. You may have to wait hours before a real doctor actually sees you unless you are literally bleeding to death on the floor. Nowadays there are urgent care centers that are supposed to be ER replacement for smaller issues but they are severely limited. My wife had a severe headache and we wanted to go to urgent care first but they said to go to ER preferably because they don't have CT scan machines. Not to mention that most urgent care centers are not opened after a certain hour in the evening.

Probably not, because that river water could've killed your daughter, depending on the condition of her immune system and the biological composition of the river water (slower and warmer = more bacteria).

The health insurer in this case is actually changing the incentives for the better. Now the hospital risks not getting paid because they didn't triage up front. Unfortunately the patient is caught in the middle here and doesn't have any good option until a less expensive triage option is developed. Hopefully hospitals will respond to insurers denying ER visits to improve their triage as you've suggested.

Potential for improvement aside, health insurance is a solved problem in countless countries and the US is refusing to learn from others in this matter. It's painful to watch, even from afar.

The industry term is uncompensated care. It is currently at its lowest levels in decades, about 4.2%.†

I suspect the ACA has something to do with that, so we might expect to see the uncompensated care rise in the coming years as enrollment in insurance shrinks.

␄

† http://www.healthcarefinancenews.com/news/uncompensated-care...

They're fun and costly ambulance rides up until that hidden blood clot goes unnoticed.

While the minor issues (constipation, and the like) are indeed resolvable in urgent care, any serious issue is likely to require some form of surgical intervention.

Additionally, the diagnosis of such issues is likely to require sophisticated imaging. While Urgent Care can use US (ultrasound), CT, possibly with contrasts, and such, are still best handled at an ER.

Most likely this patient would have presented at Urgent Care and be transferred, likely by ambulance, to ER anyway.

Now, do I think there is massive reform required to the healthcare _model_ in the US? Absolutely, including the use of more urgent care models.

I work in the system as a paramedic, and I definitely agree with that, and I realize that your question was more broad, but in this instance, ER was the right place to go, even if the final diagnosis was benign.

But hospitals and medical insurance are for-profit businesses. If you're running an ER to maximise profit, and today you make $12,000 off a visit, why would you spend money on urgent care facilities that would make you less money?