In order to open a new hospital in most jurisdictions, by law you need the permission of other local hospitals [0]. That's like being required to get the permission from Google to start a new search engine.
EMTALA is also a huge welfare cliff. Let's say Antius and Grasshoppedon both work at McDonald's. In accordance with the wisdom of the prophets, Antius saves 20% of his paycheck every month (somehow) eventually accruing... oh, say, $9001 in savings, or way more than the average US household. Grasshoppedon spends all his money, because that's how the fable goes. One day they're both injured in a workplace accident and rack up a $25000 medical bill. Antius's savings are wiped out, he goes bankrupt, no credit for seven years, etc; Grasshoppedon meets exactly the same fate as Antius, i.e., Antius's fiscal prudence amounts to diddly-squat.
And then economists wonder why the savings rate is so low.
At night the ED is the only place open. I believe there should be 24/7 Urgent Care centers, where people like the person in the opening of this article could go and receive care that (1) is not life-threatening but (2) can't wait till dawn.
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.
The only way to get widespread 24 hour urgent care in the US is to make it a billing code in the emergency room. There's often already 24 hour urgent care available in major urban centers.
Of course, this raises the question. Why isn't urgent care a billing code in small emergency departments?
For costs: medical service + profit + profit accounting overhead + cost shifting overhead > medical services
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.
It's a mystery why hospitals are still considered worthy recipients of large gifts. People donate tens of millions of dollars for a hospital building, inside which the hospital proceeds to rapaciously overcharge its patients.
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.
It's not a monopoly, it's a cartel. There are a dozen hospital networks near me, but they all have opaque pricing and billing, so they all charge like this.
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.
Something I've noticed are advertisements for ERs. Really. I was a little shocked when I saw one on the way to work.
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.
If you live in California, consider writing or calling your State Assemblymember in support of the Healthy California Act (http://www.healthycaliforniaact.org), which is stuck in the State Assembly right now. It would establish a single payer system for the state and let people get emergency care without these outrageous bills.
The insured pay the price. Hospitals will never turn away a patient with a medical emergency - the inability of certain patients to pay is factored into hospital finances, raising the price for those who do pay.
Putting aside the often absurd costs for a moment...
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.
We pay a far lesser portion of our GDP in Europe for health care and we have a longer life expectancy, higher chance of survival for the majority of cancer and cardiovascular diseases.
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?
I always find it very odd that your average American puts up with the current system instead of revolting
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
Gasoline is an inelastic good but its price is relatively low and affordable because of the abundance of suppliers. In the US, local monopolies provide health care.
The 5-year survival rate for cancers is much better in the US than Europe. It's what you'd expect for all the money spent, whether it is worth it is unclear.
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).
ERs are one of the few places where hospitals actually earn a profit. My partner fights on behalf of hospitals when insurance companies deny a claim. And over the past years, insurance companies have taken to denying valid claims just to get out of paying. An egregious example being a patient that needed heart surgery and the insurance company deemed it medically unnecessary because they claim he should have been observation only.
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."
> An egregious example being a patient that needed heart surgery and the insurance company deemed it medically unnecessary because they claim he should have been observation only.
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"...
If you are interested in the various failures of the American health care system, I recommend reading Catastrophic Care by David Goldhill. It's a bit depressing, but eye-opening.
One of the ways consumers can push back on this is by becoming educated on health care practice. I would never have let a hospital give me a CT scan for a simple throat problem.
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.
> and then insisted that they would not let me leave except in an ambulance - which I then had to pay for.
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).
> One of the ways consumers can push back on this is by becoming educated on health care practice. I would never have let a hospital give me a CT scan for a simple throat problem.
The average person doesn't have time to become enough of a medical expert to second guess their doctors about everything.
Anyone have any good data on the profitability of hospitals? I've always gotten the feeling that they are generally not making a whole lot of money, but I don't have much data to back it up. Is this kind of data even public?
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?
I like the concept in general but it's infeasible here in the US for a third party to survey prices and post results. Insurance plans renegotiate individual prices with providers, and each plan decides on coverage. The only way it could change would be if providers (and insurers) were to do it on their own, but they have no motivation to do so. I think only regulation or a seriously disruptive/innovative competitive force could do this.
I'm amazed at the stupidity permeating this thread ( and wiling to burn karma to defend against it).
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.
False dichotomy. Yes, emergency rooms are a marvel of modern planning and materials. But just because they are impressive does not mean they need be expensive, or that such efficiency must be difficult to implement. The initial costs for the mediine is all front-loaded, in the R&D. The actual manufacturing of previously discovered medicine is cheap and trivial. The same is the case for many of the efforts of nurses and doctors (not to belittle their jobs), but they aren't doing R&D. They are following memorized checklists of knowledge, triaging based on information that was discovered elsewhere, then imported to their classrooms. All of this cost is also front-loaded.
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.
Plenty of countries provide emergency and late night/weekend care without putting people into massive debt for it. Of course there are places where people are worse off than us, but there are places better off than us too. I'm not going to eat the exact same Tostino's pizza every night and say "That's good enough" just because in some countries people are dying of thirst and starvation. You don't stop improving things just because it's worse off elsewhere.
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?"
Yeah, you're totally right. Running an ER has huge fixed costs. Running an ER will inevitably have huge fixed costs because emergencies are, by definition, unexpected so they have to be ready for anything.
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.
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.
I'm not entirely sure you read the article. The article discusses that there are 5 categories of care and that step throat is billed equally as a gun shot wound due to market failure and lack of competition.
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?
The problem is that at 1am, with whatever horrible pain prompts you to drag yourself, or your child, to seek out medical care, your ONLY option is often an ER.
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.
This is absurd. Look at the cost escalations over time. Were ER’s not well equipped ten years ago? No they have just ratcheted up the cost because they can. Consider that, given their bargaining position, wouldn’t it be a surprise if they didn’t take advantage of it? What’s holding them back from shaking everybody down for as much as they can? Morals? Lol.
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 addressed in the article is the collections part of the equation - as ERs can’t turn people away, they often end up treating many people that are uninsured and/or can’t pay for their care - causing ER’s to try make up the difference on patients that can pay...
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.)
[+] [-] mbroshi|8 years ago|reply
0. https://en.wikipedia.org/wiki/Certificate_of_need
[+] [-] scythe|8 years ago|reply
And then economists wonder why the savings rate is so low.
[+] [-] athenot|8 years ago|reply
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.
[+] [-] maxerickson|8 years ago|reply
Of course, this raises the question. Why isn't urgent care a billing code in small emergency departments?
[+] [-] gozur88|8 years ago|reply
How often does this happen? If it's not life threatening, why can't it wait until dawn?
[+] [-] dv_dt|8 years ago|reply
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.
[+] [-] tlb|8 years ago|reply
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.
[+] [-] ohazi|8 years ago|reply
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.
[+] [-] trgv|8 years ago|reply
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.
[+] [-] selimthegrim|8 years ago|reply
[+] [-] panic|8 years ago|reply
[+] [-] refurb|8 years ago|reply
The chance of that bill ever going anywhere is effectively zero.
[+] [-] HappyKasper|8 years ago|reply
[+] [-] DoodleBuggy|8 years ago|reply
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.
[+] [-] pimmen|8 years ago|reply
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?
[+] [-] blibble|8 years ago|reply
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
[+] [-] rukittenme|8 years ago|reply
[+] [-] WillPostForFood|8 years ago|reply
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).
[+] [-] jellicle|8 years ago|reply
[+] [-] mywittyname|8 years ago|reply
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."
[+] [-] FireBeyond|8 years ago|reply
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"...
[+] [-] oftenwrong|8 years ago|reply
[+] [-] peterwwillis|8 years ago|reply
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.
[+] [-] FireBeyond|8 years ago|reply
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).
[+] [-] sumeno|8 years ago|reply
The average person doesn't have time to become enough of a medical expert to second guess their doctors about everything.
[+] [-] spott|8 years ago|reply
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?
[+] [-] firefoxd|8 years ago|reply
Not that this will solve the problem but it's better than finding out you owe $3k a week later.
[+] [-] wyldfire|8 years ago|reply
[+] [-] smacktoward|8 years ago|reply
[+] [-] elicash|8 years ago|reply
The "existing legislation and regulation" section is pretty interesting for wikipedia: https://en.wikipedia.org/wiki/Chargemaster
[+] [-] BrainInAJar|8 years ago|reply
[+] [-] quickben|8 years ago|reply
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.
[+] [-] Afforess|8 years ago|reply
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.
[+] [-] Jemmeh|8 years ago|reply
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?"
[+] [-] vec|8 years ago|reply
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.
[+] [-] xgbi|8 years ago|reply
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.
[+] [-] supercanuck|8 years ago|reply
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?
[+] [-] gricardo99|8 years ago|reply
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.
[+] [-] tedunangst|8 years ago|reply
[+] [-] lewis500|8 years ago|reply
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.
[+] [-] unknown|8 years ago|reply
[deleted]
[+] [-] rbcgerard|8 years ago|reply
[+] [-] peterwwillis|8 years ago|reply
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.
[+] [-] guelo|8 years ago|reply
[+] [-] gruez|8 years ago|reply
[+] [-] mherdeg|8 years ago|reply
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.)
[+] [-] moonbug22|8 years ago|reply