Hacker News Reader

Comment by denimnerd42 | Hacker News Reader

On the flip side.. as someone who pays their bills, the ER has become the #1 priority to avoid. I'd prefer not to pay 5000 or 6000 total - $3000 to a hospital and $3000 to an ER doctor agency for a small 2nd degree burn or small cut requiring stitches, or any other issue I may have been taken there in the past for. I'll sew my child up before I take them to a pediatric ER and I'll order the antibiotics from India or Mexico..

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.

View on HN

When we lived in Italy, my then toddler had one of these: https://en.wikipedia.org/wiki/Breath-holding_spell and as the article says "a breath-holding spell is a frightening experience for observers", which is actually a monumental understatement.

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.

but the USA has more millionaires

US taxpayers already pay, per capita, the most on earth for socialized medicine in terms of government spending[0], we just don't get universal coverage beacuse it is beyond the competency of our leadership.

[0]https://www.oecd-ilibrary.org/sites/154e8143-en/index.html?i...

I don't think it's beyond the competency of our leaders - I think our leaders know that not enough people actually want it. If politicians thought it was a winning strategy (defined by getting re-elected), they would be all over it.

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.

That’s if you assume election results are somehow correlated with citizen desires. With first past the post and gerrymandering, it’s not even close to that.

We do have socialized medicine for more people than are in the British NHS, if you add up medicare, medicaid, and the VA.

>we just don't get universal coverage beacuse it is beyond the competency of our leadership.

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...

After recently paying a fuck-ton for some stitches at an ER for a case that was a little hairier than urgent cares were willing to take on, but not at all life threatening, but also not something that could wait for a regular doctor... yeah, I'm seriously considering learning to apply sutures and buying a kit or something. I hate having to do "go, or don't and just hope it's OK?" when the best choice is clearly to go, and not having good options for taking care of it those kind of middle-grade problems myself.

(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 :-( )

A butterfly kit is a decent compromise that doesn't really require training. https://www.amazon.com/Sutures-Waterproof-Butterfly-Hospital...

The link isn't working for me, but FWIW buying medical supplies on Amazon is usually not the best option. Poorly made counterfeits abound and thanks to inventory comingling it doesn't necessary matter which seller you buy from.

During a vacation a couple years ago I dropped a glass in the sink while washing it and reflexively tried to catch it. My hand made contact just as it was shattering in the bottom of the sink, resulting in a really nasty, irregular gash that immediately began bleeding badly. I ended up wrapping it in paper towels and driving myself to the nearest supermarket (~15 minutes), where I bought some anti-septic and super glue. I looked pretty funny walking around the store with my hand wrapped up and raised in the air, and I sounded pretty funny as I applied the anti-septic and screamed profanities from inside my car in the parking lot. But with my hand glued back together I was able to pretty much go back to doing normal things within the hour. There's a scar, but it's actually a bit difficult to distinguish from the natural lines in my hand. Total bill: ~$10.

My wife was of course not amused. The kids thought it was cool, though.

Others have pointed these things out individually, but I wanted to say them all in one place:

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.

As an insured person, an urgent care costs the same as an ER visit and does less for me.

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.

I pay $80 for Urgent Care services such as this in the US, a civilized country, the trick being I pay out of pocket then send in the receipt to my insurance for credit.

Sorry to hear your girlfriend found a crap business.

https://www.holycitymed.com/primary-care/?gclid=EAIaIQobChMI...

It may cost you the same. With my insurance, if I'm admitted to a hospital, the time I spend in the ER is free to me, but if I'm not admitted, I pay for the time I'm in the ER. That doesn't make ERs cheaper when you get admitted.

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.

I've always been told ER is for _emergencies_, I'd never go there for a 2nd degree burn or a small cut.

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"

The thing is the doctor you would get to look at it tomorrow can simply decline to, the ER can't.

Exactly, and that's why when you go there you have to wait 8 hours because you have 38 non emergency scenarios before it's your turn.

ERs do triage on incoming patients. If you arrive with non-life threatening issues, you will be pushed to the back of the line repeatedly. Occasionally, a patient or intake nurse will misjudge the problem and the patient dies in the waiting room.

Greatest health care system in the world.

which health care system magically triages patients correctly 100% of the time and never makes mistakes?

Well we're not only talking about adults but also talking about children here. At 9pm you get a small AND deep cut requiring stitches. It won't stop bleeding if you take pressure off. what do you do? At 9pm your family member accidentally drops a kettle of of hot but not life threatening water on your child and they get a large blister on their chest, what do you do? These are probably not serious situations but the pediatrician will tell you to go to the ER even if you wait till the next morning.

Why not an urgent care?

Fine in theory, but the experiences I've had leave something to be desired. Ideally, I want to see doctors I have relationships with, aka my PCP, to facilitate and advise. But they are not interested in that.

Yes. The past three times I've gone to Urgent Care I have been punted to the ER for no good reason twice and received an incorrect diagnosis complete with a prescription that did nothing to alieviate my symptoms. If you get sick/injured in my area between 4pm Friday and 9am Monday...good luck.

That has been my experience as well - best advice, don't get really sick or really hurt outside of regular business hours. Broke my foot a few months back and called all the urgent care outfits in my area for an appt - none of them were seeing patients due to lack of staffing.

Waited a few days to be seen at an ortho office once I had a referral from my primary care physician in place.

Urgent Care has an annoying habit of charging a bunch of money to punt to the ER for liability reasons. Stitches and X-rays to see if you broke a bone are about the only thing they're good for.

Pretty much anything up to and including a non-life threatening bullet wound can be solved with readily available drugs, a good back country/extreme sports first aid kit and the internet.

Expensive machines and complex diagnostics are really the only big things an ER can do that you can't.

Except if you try to get medical treatment for a minor injury the response is often 'no go to the ER' because people want to avoid liability.

I mean if you simply call up a doctor's office to check on an appointment, one of the prerecorded announcements they waste your time with is generally a suggestion to call 911 or go to the ER. The entire medical system is "not my job" turtles all the way down.

I agree that the ER should just be for emergencies. The problem is that there isn't anywhere else where you can get same-day care for many types of needs.

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.

>but urgent care didn't have the equipment to assess her and rule out any major concerns.

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.

They are wrong to treat her like that. If she stayed after the test results then sure, but until those tests are done they don't know any more than your wife does.

It is robber baron type stuff. It is absolutely nuts. I completely understand people escaping ambulances to avoid a $10K Aspirin. I avoid going to the US on the off chance that I might need medical care.

There's expensive insurance products for a short term trip. They'll even fly you back to wherever you're from if it's serious enough.

I do get the extra insurance, it’s still a major hassle I’d rather not deal with. Plus I don’t trust insurance companies who have a strong incentive to weasel out of their obligations. A commonly known strategy is Deny, Delay, Defend. You have to make sure you have enough money saved to hire a lawyer for when you need to sue the insurance company to get them to pay. Which is an extra hassle I’d rather not deal with.

Somebody has to pay for all the "free" care.

And also for the profit margins of the owners of the hospital, and for the doctors' dachas, and for the administrative bloat in medical schools that leads to a medical education costing a million bucks, and, and...

Hospitals in the US (just like a lot of other market participants) have no incentive to save money. This is what universal healthcare would give you: more money spent on care, less on bullshit. Obama famously said you couldn't do universal / single payer healthcare in the late 2000s because it would destroy too many jobs in billing.

The military is our blue-collar/lower-class jobs program.

Our healthcare system is our white-collar/middle-class jobs program.

Don't forget Wall Street! I guess that's the jobs program for the upper class.

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.

Adtech?

And its cousin, Fintech.

Have you noticed how your light switches still work and your toilet still flushes? Yeah? Turns out there are real jobs. Being a doctor is a real job too. It's a huge commitment and they deserve to be well compensated. But of course they're not, it's the administrators capturing all the economic rents.

Yeah, I left 20% there for a reason.

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!

> I'd prefer not to pay 5000 or 6000 total - $3000 to a hospital and $3000 to an ER doctor agency for a small 2nd degree burn or small cut requiring stitches, or any other issue I may have been taken there in the past for.

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.

Of course.. and that's what happens most of the time but it's not that simple still. I've found urgent care experiences are highly variable even between same location. The ER is more a guaranteed thing with set standards.

Urgent care varies a lot. Going to one around here is not a good idea. I don't think any of them has more positive reviews than negative ones.

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.

> life-threatening emergencies

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.

My daughter has needed to go to the ER several times, after 3 crap experiences with the ER nearby we now drive 40 miles to have a better experience. It is not only the billing issues, especially with the wave of 'Revenue Management' services providers are using, it is the patients in the ER. Dealing with the crazies, the people acting up to try to get attention, waiting for hours in this fun with a child, no thanks.

Half of children are covered by Medicaid and there would be zero copay. It is a great program that has saved and improved many lives.

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.

Well. We have insurance. The insurance is also for emergency situations. It's high-ded at 3000 and the out of pocket max is something like 12,000. So yeah one ER trip a year is going to cost me 3000-12,000+. Urgent care is great in theory but I've not had great experiences. I'll also be paying the complete bill there too so 400+ which is fine. The problem is if they are too scared then it will be the $200 plus an ER bill and I'm back to where I started.

It bothers me to no end that the cash price I pay is drastically higher than the cost the insurance company pays. especially since insurance is a royal pain to deal with, and requires specialists for billing, etc.

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..

Plus deductible and coinsurance, which which are often much more…

> I'd prefer not to pay 5000 or 6000 total - $3000 to a hospital and $3000 to an ER doctor agency for a small 2nd degree burn or small cut requiring stitches

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.

Insurance has negotiated rates with providers. These typically start with the facility's chargemaster billing and are negotiated off of it.

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.

Reply on news.ycombinator.com