The ER has become a sanctuary for society’s unmet needs
seattletimes.com
seattletimes.com
An ER doctor makes $150-300/hr. I'll pay double or triple or 10x that but in my experience you are billed something like 100x that. 10 minutes is 3k. We can meet at a Holiday Inn. We'll arrive by Uber.
Our healthcare system is our white-collar/middle-class jobs program.
Honestly after many decades of technological growth, extreme offshoring, and the workforce nearly doubling due to women entering it, I'd estimate that 80% of positions are bullshit jobs.
Doctors do accomplish real work, but I'd say most of their time is wasted - dealing with paperwork and financialization slicing most of their time up into useless 15 minute chunks.
Speaking of the trades though, it's a plain illustration of the dynamic. Simple jobs end up with massive bills these days, and you know the guy doing the actual work isn't seeing much of it. Rather that money is going to the administrators that have congregated around his work - scheduler, billing, manager, owners, insurances, etc etc. So even for a straightforward concrete real-world physical job, there is still a huge amount of overhead!
We called the equivalent of 911 with no thoughts whatsoever about money because it's simply not a factor there. He was fine before the ambulance pulled up (very quickly) but they took him and my wife to the hospital to check him up.
Didn't pay a dime for any of it, although of course you do pay higher taxes there. But the peace of mind is worth it and overall, Italy spends less of its GDP on health care than the US.
[0]https://www.oecd-ilibrary.org/sites/154e8143-en/index.html?i...
People that already have subsidized insurance (i.e. thru employers), and are happy with it, see no reason for it to change. Especially people who have good health insurance and/or don't get sick very often.
A large fraction of people are predisposed to attempt to solve the problem by incrementally throwing more money and more power at those leaders and then checking if the problem is solved.
Follow the incentives...
(I did try superglue—growing up rural didn't teach me nothing about avoiding paying doctors—but one of the cuts was too big and too bleed-y for that to take :-( )
My wife was of course not amused. The kids thought it was cool, though.
Emergencies as in "if I don't go there _now_ I might suffer _grave_ long term consequences" not as in "ouchie it'll be painful until I get it looked at tomorrow"
Greatest health care system in the world.
Waited a few days to be seen at an ortho office once I had a referral from my primary care physician in place.
Expensive machines and complex diagnostics are really the only big things an ER can do that you can't.
My spouse has some minor heart issues. She wasn't feeling well one day and went to urgent care, but urgent care didn't have the equipment to assess her and rule out any major concerns. Urgent care suggested seeing a cardiologist, but they also said she should go to the ER. Of course seeing a cardiologist on the same day, or even within a week, is virtually impossible. After talking about it, we decided to go to the ER because of the literal life-threatening consequences of ignoring a potentially big issue. We go to the ER, and she waits for hours for them to run some basic tests. The tests come back negative, and the ER medical staff treated her like she shouldn't be in the ER.
And they aren't wrong... but what's the alternative? When there's a 90% chance you're OK, but a 10% chance of a serious issue, and you have nowhere else to go to rule it out? Urgent care tells you to go to the ER, but you can't weigh how much that's them covering their own liability VS genuine medical advice. Then you go to the ER and they wonder why you're at the ER.
Just curious what kind of equipment the Urgent Care didn't have (if you know). I went to the doctor last year, mentioned that I thought some heart palpitations. The doctor said, we'll lets do an EKG. I was thinking this would be something I schedule for later, but to my surprise, the nurse rolls in a machine, and the hooked me up to some electrodes and the whole thing was done in like 5 minutes.
In the US, this is what urgent care is for. If there's an urgent care clinic in the area, you should absolutely not go to the ER for that kind of stuff. The price of the ER reflects the fact that it's for major, life-threatening emergencies; if you go there for a cut requiring stitches, then you're not using the medical system efficiently, and that's why the costs are what they are.
Personally, I've found the urgent care clinic I've gone to to be a better experience than both the ER and my primary care physician. It's gotten me in and out with quick, high-quality care, and it's cheap.
I decided to risk one of the better reviewed places. It was empty and I was completely ignored by the staff who were on their phones. My worst taxi experience was better. At least I left before they could rip me off.
Ended up going to the ER and the nurse told me the urgent care place would have just sent me to the ER anyway.
It's not really just for life-threatening emergencies. If you cut your toe off at 2 AM you probably want to go to an ER to see if there's a chance it can be reattached.
An urgent care is well suited to needing a couple stitches or a cast. At the ER, you're also paying for:
* A facility and staffing equipped to handle serious trauma and critical illness.
* (In the US) A facility that legally cannot turn away people for inability to pay. Exacerbated by being in a national medical system where lots of people can't pay for basic care, so they go to the ER to receive it.
If you don't need those things, then don't go to an ER if you can help it. Some large hospitals essentially operate an urgent care with the same waiting room as the ER in order to lower their costs, but I've only seen that at the largest of hospitals, and I've been to at least one large hospital that didn't work that way.
My equally insured girlfriend had to pay several hundred dollars to an urgent care facility for a rapid strep and rapid covid tests, about $50 in a civilized country.
Sorry to hear your girlfriend found a crap business.
https://www.holycitymed.com/primary-care/?gclid=EAIaIQobChMI...
ERs are more expensive to operate then urgent care. Even when the ER is treating something that could be treated at an urgent care. That doesn't change just because some people's insurance hide that detail from them.
The ER might bill $6k for a cut requiring stitches, but most people have insurance, they will have a lower negotiated rate. A typical copay with insurance is more like $250, plus another $10-$20 copay to pickup medication.
Something not immediately life threatening like a cut requiring stitches could go to urgent care, they might bill $400, and your copay is under $100.
But then again, I can't believe hospitals don't have to have a 'menu' on their web site that shows their cash and average insurance cost of their 20 most common procedures.
I know almost nobody pays cash price, but I don't want my medical care to be treated like Kohls or JC Pennys where they show me a $7 t-shirt is "regularly $27" so I feel like i'm saving, even though we both know they never, EVER charged $27 for that t-shirt..
For what it's worth, about 5 years ago I was without insurance and went to the ER to get 5 stitches in my finger. The total bill came out to $150. This was in America.
I think if I had insurance then, they would have billed the insurance company 10x that at least.
Depending on the relative negotiating strength of the carrier or caregiver network, that might be higher or lower.
It's the uninsured who are far more likely to be billed the maximum amount, in the US, as they have no negotiating power, most especially in the moment urgent care is required.
It seems most Americans with limited or no healthcare is:
1. Go to the ER and pay $X000
2. Wait in line at a free clinic for 9+ hours and maybe/maybe not see a doctor
This seems like a gigantic need for a middle ground to be filled.
I know that CVS and WalMart have done things like the $60 Physician's Assistant visit at retail locations but that always seems as though it's only available in a small percentage of locations.
Are the fixed costs of having even 2-3 doctors so high that this just not an economic option at anything less than $X000 per visit?
I would also imagine that if you take a Total Cost of Ownership approach, it's in society's best interest to subsidize some of this cost. I'm basing this on past articles/studies that show that some huge portion of medical care costs go to issues that were largely left unaddressed at first presentation.
P.S. As I wrote this, I thought of Urgent Care providers but even those seem high cost for folks with no healthcare.
My guess is that, despite in some sense being a "free market" system, US health care is hyper regulated, and almost everything is either mandatory or forbidden, sometimes both.
Agreed most people think that the ER is $X000. What people don't realize is that the hospital then attempts to recoup the cost by charging paying patients and their insurance companies more. This is where those $20,000 ER visits comes from. While insurance companies push back, the other folks paying out of pocket lose. Some of them go bankrupt. Hospitals lose too and ultimately the community. Because emergency services almost always lose money for the hospital, many rural hospitals also go bankrupt or get bought out by private equity groups (https://www.nbcnews.com/health/health-care/private-equity-fi...).
The key to addressing what you’re pointing at is mostly fixing the scam that US college education has become. It’s the crazy tuition that gets trickled down in the bill, and acts as a bottleneck guaranteeing scarcity of doctors and thus super high wages. A doctor in the US makes BANK, like lawyer money, not so much the case in Europe, where they’re upper class but not crazy rich.
http://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope-...
In addition, in many states in the US you have to get permission to open a new medical facility:
https://en.m.wikipedia.org/wiki/Certificate_of_need
Often the people on the board own existing medical facilities, so you literally have to get permission from your potential competition to compete with them.
https://www.justice.gov/archive/atr/public/press_releases/20...
For example from the above link:
“ In 2006, the Antitrust Division alleged that a hospital in Charleston, West Virginia used the threat of objection during the CON process, and the potential ensuing delay and cost, to induce another hospital seeking a CON for an open heart surgery program not to apply for it at a location that would have well served Charleston consumers.”
Some states have really good healthcare for the poor but even they have exorbitant costs for everyone who's too well off to quality. You'd think at least one of them would tackle this.
The US doesn't have single payer healthcare. For every medical professional actually helping a patient, there's a legion of bureaucrats (administrators, insurers, accountants and lawyers, along with all their support staff) spread over a huge network of businesses adding their cut. Go to the ER and you'll be getting bills for it 2 years later. This massive overhead needs to go away to enable price transparency and reasonable costs.
As compared to what? someone that may or may not have gone to college, learned to code and now makes 400-700K per year working at a tech company?
I for one think doctors deserve to 'make BANK' and people creating apps to post cat or people dancing videos should make a whole lot less.
I'm a martial artist, so it's not uncommon for me to go to the Dr. when all I really need to know is if an injury is a normal "take a break and let it heal" injury or one that needs actual treatment.
I imagine there's similar cases for questions like "is this the common cold or something else?" or "is this something babies just do or a sign of a problem?".
(1) people in the US will balk at paying others' healthcare if you ask them directly, so it "has to" be subsidized in a roundabout, inefficient way. ER is obliged to treat you regardless of money (and people do go there with routine concerns from my limited experience), but someone has to pay, so other patients get charged extra. That is really annoying in a way, and it's pure politics - nobody can come out and say "hey, you are paying for the poor anyway, so why don't we at least cut out all the middlemen - private and public, and just pay them openly"?.
(2) But the main one I think is that public option is basically impossible as long as you allow a viable private option, because everyone will take private option if they can and public option will get the worst-off, health-wise and financially, and as it gets worse as a result more people will bail, etc. You can look at schools as an example - private school parents literally pay double price, public system is easy to abuse via de-facto neighborhood class-based segregation, and private schools STILL thrive because private option is just THAT MUCH BETTER (in the consumers' opinion, at least).
If you really consider the implications of the 2, you can understand also how regulation drives up cost in another way than its actual overhead and supply-limiting effects - it regulates options out of existence. If I could go to a "private semi-ER" where they (1) get a good doctor, pay him double, but are let's say (2) not obliged to treat before payment and do not take Medicare, or maybe any insurance, (3) aim for 20-80 principle as far as equipment is concerned (i.e. somewhere in between ER and Urgent Cares), it would be the obvious, better, and cheaper choice. I'm pretty sure an "uber for Urgent Care" based on this would make bank AND benefit tons of people. Of course, it's regulated out of existence. Or consider a startup that would offer "Indian/Russian/Turkish/..." quality facilities, with an obvious price trade-off - it's impossible, because if it were possible the existing public-private frankenstein would simply die. You can see the same with schools, with activists constantly trying to stifle school choice, because with viable school choice public schools will simply die.
As a result, the system is both terribly inefficient and creates the worst incentives. Take me as an example. If I decide to retire early, I'd be helped greatly by ACA, and would optimize paper income and (ab)use it to the max. I do feel like it's justified because I am paying for it now in taxes; but I didn't do the math, so mostly it's just bad incentives + it was the govt who screwed up healthcare in the first place. So hey, ACA is good for me. If they had universal healthcare I'd stop working even earlier. But is that good for society?
To be clear, I support a fully free market option for both healthcare and schools, and the only redistribution allowed should be cash, and catastrophic insurance limiting total spend.
I am aware of a number of studies which looked for a negative correlation between preventative care spending and overall healthcare spending, but all (of which I am aware) failed to find it.
When you allow lobbying this is the kind of issue that becomes rampant.
It's not so much a minor thing turned into an emergency (that is a problem of course) but rather the patient has no other venue for minor needs without money or insurance.
If triage were able to turn away non-emergency cases legally it would gradually change, but for people with more time than money the ER basically ensures you'll be seen.
Due to freedom of movement around the US, population wide benefits such as healthcare, housing, and in some ways, education, require federal level solutions.
Otherwise, someone is going to end up being the sucker that foots the (giant) bill for everyone else.
On the federal level, there is quite a bit of gridlock, so what we have is an intractable problem at the non federal level where it is every man/neighborhood/city/county/state/hospital for themselves.
Yeah, okay.
At another nearby "nonprofit" local hospital, not atypically: (https://www.nytimes.com/2023/01/25/podcasts/the-daily/nonpro...)
> The centerpiece of this program were a series of scripts, like theatrical scripts, that outlined in this play exactly how employees should try to get money from patients, even those who are supposed to receive free care. And these documents were distributed to anyone at the hospital who might interact with patients and talk to them about payment.
> So in one training document, for example, the employees were told, do not accept the first no. And then staff are led through a series of questions to ask patients. The first was, how would you like to pay that today? If that question didn’t work, employees were told to ask for half the balance. If that didn’t work, staff could offer to set up a payment plan, like the kind that Alexandra went on. And what’s critically missing from this collection program is any way of screening patients to determine whether they should qualify for free care.
What's with the attitude? Do you think it's ED staff that created those training documents?
Do you think ER physicians who spent years jumping through hoops to get accepted into medical school, then spent 4 years in medical school followed by 4 years working 100 hour weeks for minimum wage as a resident do all of that so they can gouge patients for money?
Do you think RNs who jump through years of hoops and school, who sign up to help people during the worst times of those people's lives get off by upselling them on treatment?
There is a massive amount of misplaced vitriol toward medical providers that should instead go towards hospital admins and their profiteering ways.
The vulnerability to this kind of exploitation takes a different from than the emergency room. The Internet, search engines, Google, and so on created a kind of identity crisis in the library world, partially stemming from the people who think that they're going to learn with any depth from a quick search, but also self-inflicted, "Who are we in a 'digital age'?" sort of wailing. And so libraries are forever giving away their lunch money hoping that someone will be their friend, stick up for them, validate their existence. This is especially true at the academic level.
Interesting, too, that one of the other big societal institutions open to all comers, the churches, have largely dwindled.
Churches (at least in the US) haven't been open to all for many decades now, they're highly exclusive places. Yes, technically anyone can usually walk through the door on a Sunday morning for free, but other than that literal hour, Churches usually have a lot of restrictions before a person is allowed to meaningfully participate in any way (restrictions on income, location, wealth, lifestyle, etc)
US Christian Churches are basically political country clubs pretending to be non-profits by way of their religious veneer. I would argue they're almost the complete opposite of a Public Library or Emergency Room.
Some or most of them probably do operate like you say but I don't think it's evenly distributed because I never ran into that in cities. Usually if they didn't want to provide services they were just closed except during worship hours. But evangelical megachurches are underrepresented in urban cores compared to their national presence, which may play a role in my experiences.
There are plenty of churches where looking after the less-fortunate is still a serious priority. Unfortunately, there are no "Faux Xian" disclaimers posted on the doors of the other sort of church.
Libraries for numerous social services.
The cops should not be placed in this position in the first place. They train for a different job.
8 years ago, I managed to stab myself with a little shrubbery snipper, mid-day on a holiday-weekend Sunday. Wound was maybe 1/3" deep, with a trivial amount of blood. I just needed the wound cleaned out, a tetanus shot, and maybe 3 stitches.
I was in Ann Arbor, MI - home to 2 huge hospital complexes and a zillion MD's.
The front desk nurse at the ER really didn't want me treated there - because of the insane ER cost overhead - for something that she probably could have handled in 5 minutes at her kitchen sink. Eventually, she gave up on trying to find an Urgent Care clinic that was actually open at ~2pm on a sunny Sunday afternoon.
Before insurance, the ER bill was well over $1,000.
Checking Google Maps for "Urgent Care Ann Arbor" just now - most of 'em are open 7 days a week (some as few as 5 days). And at most, they're open for 12 hour/day. No quick way to tell if some of the "7 days" ones would close on a holiday weekend.
Vs. ER's are 24-hour, every day of the year.
And then I got the bill few weeks later of a couple of grands, for hand X-ray and a small splint and speaking for 5 mins with a doctor.
I’ll leave it at that.
People are busy and don't have time for people who aren't their friends.
The Salvation Army is a church, admittedly not a huge one: https://en.wikipedia.org/wiki/The_Salvation_Army
At least in cities I'm familiar with (mid-western US), things like charity for the homeless have become church specialties. Most churches in an area will not do it themselves - but instead provide volunteers/donations/etc. to support a few local churches which offer free meals to the needy, shelter for homeless families, etc. Consider the economies of scale if only St. Matthews's is serving free hot breakfasts 365 days a year. Vs. if the dozen or two individual churches which support the St. Matthews Breakfast Ministry each tried to serve up daily breakfast. Or the confusion and redundant facilities if they rotated, and everyone had to remember "Breakfast is at 1st Baptist this week, then Redeemer Lutheran next week, then St. Mary's Catholic, then...".
The Salvation Army? They have both shelter and soup kitchens.
ER docs that can deal with incoming gun shot victims etc are a scarce resource and ER beds are expensive. There really should be a secondary channel people like this can flow into & the lack of this is a societal failure.
Leaning on the good heart & caring of ER gang is the wrong answer.