As ER Wait Times Grow, More Patients Leave Against Medical Advice
khn.org
khn.org
Comparable stats from the UK: https://www.kingsfund.org.uk/projects/urgent-emergency-care/...
> By September 2017, the median waiting time had increased to 2 hours 28 minutes, and 95 per cent of patients departed A&E within 7 hours of arrival.
So not only do Americans get to wait twice as long, but they have to pay for it as well? You have to pay for ambulances? Why is this not politicized more?
Mind you, where ever you go and however the system is run, queues will be worse in the evening especially at weekends. Some queueing is unavoidable and best dealt with by triage.
Americans have come to accept many things about how their country functions as just normal, and they don't realize it can be, and is, so much better in other parts of the world.
I'm visiting after three years of going around Africa, and it's staggering to see how the USA functions and what people have accepted. (I've spent time in about 10 states so far this time around, East coast and West. I will hit another 20 or so this summer)
Oh, it's politicized all right. Reforming America's health care system has been one of the biggest political fights of the last decade. At this point it's ideological, and in the era of fake news, ideology beats facts.
Not everywhere in America / California. Sometimes it's city by city, city versus county. It's actually quite complicated.
When they do charge, they charge a drop rate, then per mile - much like a taxi. They also try to get the semi-conscious patient on the gurney to sign a whole bunch of forms about liability and payment.
It is! It has been politicized by telling "hard working, red blooded Americans" that the government has no business "taking" money out of their pocket because it will just go to help freeloaders.
Emergency services are run by the cities, or sometimes the states. And that's a completely reasonable thing to do -- if you have a heart attack in Los Angeles, they don't take you to an emergency room in Boston. Local people should control local stuff.
So you're asking the wrong question. It's not a matter of what happens in America, it's a matter of what happens in California, or Los Angeles. Other US cities have free ambulance service or shorter wait times.
The local people can change their local laws whenever they like.
It would be possible to have emergency services organized nationally. I wonder if cities that overlap two or more states share emergency services. Seems like that would be ideal so that you'd always end up in the closest hospital.
Well for one thing, because it's more than 500 miles away.
> I wonder if cities that overlap two or more states share emergency services. Seems like that would be ideal so that you'd always end up in the closest hospital.
Of course. It's the same as people who visit another state can still use the roads in that state. It's easier to cover a non-majority percentage of usage from out of state residents in exchange for implied reciprocity than to do a bunch of two-way accounting that in practice will generally just net to zero anyway.
The services are organized and funded locally because the local people are the ones with the strongest interest in them. Most of the people who use emergency services in Los Angeles will be people from Los Angeles, so they're the ones with the greatest interest in whether they're implemented competently and efficiently.
The problem with nationalizing things like this is that they have no real economies of scale, so all you're doing is adding unnecessary bureaucracy and creating wasteful arbitrage opportunities. Because then it's in the interest of the majority of states who pay less in taxes than they receive in benefits to inflate costs on purpose because it brings federal money into their state. California and New York -- and Texas -- have been getting screwed by this for years across a wide variety of federal programs that don't actually need to be federal programs.
I went to an urgent care clinic. The friendly staff told me they did not take my insurance, but could do it immediately for $380 in cash. As I was hoping to find someone who took my insurance, I declined. I went across the street to the emergency room. The person at check-in heard "pain" and "back" and seemed to immediately decide I was a drug addict. 30 minutes later I talked to some decent check-in staff who told me they would give me surgery for it.
I ended up waiting in the ER for over 3 hours. When they finally did the surgery, it took about 10 minutes. Somehow, they messed up the billing. The charges were over $1,200 for the 10-minute surgery that the Urgent Care offered to do for $380. After moving out of state, I called multiple times to get them to properly charge my insurance. They failed to do so, and sent the entire bill to collections 90 days later.
One aspect of the service that gives us a lot of piece of mind is that they can confidently and immediately tell you how much the NHS would charge you for their recommended course of action. I do wonder how you would build a similar system that could tell you what your medical insurance would cover and what your copay would be.
This is literally impossible, by design, under the current system in the US. Neither the provider nor the insurer is able to tell you what something costs until they've had a few rounds at the dartboard to determine that.
Unrelated to ER, I recently got charged almost $400 for a visit to a primary doctor that should cost $35. Had to go back and forth with doctor bill, hospital bill (apparently if doctor has an office in a hospital zone, they will also issue a bill, even though you don't really use the hospital) and the insurance company. I was going back and forth either side was either everything is correct and that's how much I should pay, or saying that the other side categorized it wrong. After attempting it multiple times. Eventually I gathered enough evidence that when talking to person from insurance she couldn't find excuse, then she suggested that I can submit request to review it. Why didn't they suggest that from the start. Based on information that I collected looks like the doctor's office and hospital categorized everything correctly (despite what insurance person said), I even had to figure out what the medical codes mean on the bill. And the issue is that the insurance company made a mistake.
I like Kaiser model it makes things easy to know in terms of billing, but I don't like that Kaiser give bonuses for doctors for minimizing costs. It encourages so called marginal care. For example you generally won't learn about new kind of treatments available from your Kaiser doctors. They will generally suggest them if you're not responding to the cheaper solutions. For example if you have an autoimmune disease they will prefer you to use DMARDs and NSAID type of drugs (even with their side effects) and won't mention biologics, which are much more expensive, but work much better and can often reverse the effects of the disease.
That's because the answers are "nothing", "the ~$10 prescription charge", or one of the fairly short list of allowed price bands for dental work.
We have used the out of hours GP service 10+ times over the last three years with a sick toddler, only referred on to A&E once, definitely helps keep A&E free. When we did go to A&E there is a separate waiting room for young kids to keep them away from the trauma/drunks/crazies. If you go straight to A&E without a GP referral it costs approx €110, if you have a letter from GP its free.
Our health system is far from perfect but the out of hours GP/referral system and the free kids works for us.
So when you need urgent medical attention you won't have to do the research. Sometimes it can be really time consuming to figure it out.
My assumption is that people are unable to pay their medical bills, but I was wondering if there were other factors involved too.
Creating more EDs doesn't actually solve that problem.
Markets can handle this, but the answer is to have the specialists standing around waiting for something to happen and then charge enough when it actually does to cover the idle time, and use insurance to spread the risk of being the one to incur that high cost. But this handles people without insurance poorly.
This is also the same basic issue that causes cities to have fire departments, and could be handled the same way, i.e. the city operates an emergency room the same way it operates a fire house and then pays for it from local taxes. But then emergency rooms are still really expensive to operate and meanwhile the feds still have a bunch of tax provisions encouraging employer-provided health insurance so most people do actually have health insurance, which creates a lot of pressure for the city to stop funding it and let the insurance companies pay for it, and we end up back at the first option.
So ironically, the problem is caused by too many people having health insurance.
2) Liability.
3) Special interests (not just pharma and insurance, hospitals, doctors, nurses as well).
4) Supply constraints from the above listed reasons.
5) People who go to ER instead of primary or urgent care, some who can't afford it others just from ignorance or panicking.
Probably more reasons I'm unaware of.
You need permission to build a hospital in most jurisdictions.
BUT WAIT... THERE'S MORE!!
The new hospital must get approval......from the incumbent hospital. Yes, Burger King must seek permission from McD to open across the street.
They nixed the idea that a local clinic could run a surgery center, and threw up every road block they could in the process.
Their argument was that the increased competition from the other surgery center would drive prices up.
The local county and city board tasked with deciding whether or not to allow it listened to them for two years. Two years of this nonsense.
The board gets mostly replaced by new members because of this issue and the new surgery center gets approved. . . and the prices at the existing surgery center drop to half of their previous levels overnight.
WTF
There is also a law (that was good intended, but causes more issues) that ER can't reject anyone who comes to ER, no matter what the issue is.
Anyway when seeing doctor depending on urgency you should ask for same day appointment, if it is weekend or same day appointment is not available you go to urgent care. Even if you have terrible pain if it is not threatening your life urgent care is better.
If you have something that threatens your life (you shouldn't go to urgent care of you have problems breathing, bleeding etc), but also broken bones, giving birth go to ER. Anything that calling an ambulance doesn't feel like an overkill.
There is a law in the US that an ER can not turn down someone that needs care. So emergency rooms end up flooded with non emergency issues, but have to staff like it is all emergencies.
It is essentially the most inefficient method of health care. Hospitals typically lose money on emergency room services on the whole because of the uninsured that will not pay at all and the government funded insurance that pays much lower than the hospital's actual cost to provide the care.
Or, you know, cannot.
You don't just get a medical bill will a statement at the bottom that says "Only pay this if you feel like it". There is no one that does not pay a medical bill that can actually pay it. You are derailing this discussion on language semantics. Why?
The question was "What's broken about the economics of ERs such that more are not being created to satisfy demand?" My response was to illustrate that ERs lose money. How are your comments in any way productive in providing any insight into that question?
Customers would self select between ER, Clinic, and primary care visits if all 3 were priced accordingly.
HOwever, since ER = Clinic = Primary visit in price, people go to the most-available choice. ER.
We have a similar problem in Quebec (where healthcare is "free"):
> 35 per cent of patients in Quebec — one in three — waited five hours or more for help in an emergency ward [1]
I was personally discouraged to receive public health care on 3 different occasions, after initiating the process myself. Waiting times were always the problem.
[1] https://montrealgazette.com/news/quebec/quebec-has-worst-eme...
Please have insurance, and don't give up getting checked because it doesn't look serious or you don't have insurance, and always schedule a follow up with you GP as the ER only address urgent things for until you follow up.