Vox ER Bill Project

[Vandalia]

I don't think this has been mentioned previously, but Vox has started a project on "ER prices." A lot is predictable, but what is interesting is that hey are collecting actual patient bills for a comprehensive database.

Hospitals keep ER fees secret. We’re uncovering them.

 

[deleted245139]

I've been reading them. A lot of the content revolves around people pissed they didn't get anything tangible. A recent one covered an ice pack or something. They never discuss the overhead, paying for the evaluation, staffing costs, etc. It feels like a giant hatchet job Everytime I read one of their articles.

 

[Apollyon]

As I have said IRL in the past, "if you play the lottery and lose, do you ask for your dollar back?'

 

[Phil_Connors]

As I have said IRL in the past, "if you play the lottery and lose, do you ask for your dollar back?'

What's supposed to represent the a bad lottery ticket in this analogy? An expensive emergency department? Why not take the guesswork out of it and give the consumer some idea of what their services cost? If the hospitals themselves won't do it, then I love the idea of consumers and journalists teaming up to do it. What other industry exists where you have no idea how much you're going to pay for a service until a month after the fact?

A recent one covered an ice pack or something.

Yeah a woman paid $5,751 for an evaluation of an ear injury, for which she ultimately received an ice pack and a bandage. Obviously there needs to be a facility fee, a triage fee, compensation for the doc that examined her, etc, but if you think it's okay to charge that much for that kind of service, then I think your perspective on healthcare is absurd.

 

[EctopicFetus]

What's supposed to represent the a bad lottery ticket in this analogy? An expensive emergency department? Why not take the guesswork out of it and give the consumer some idea of what their services cost? If the hospitals themselves won't do it, then I love the idea of consumers and journalists teaming up to do it. What other industry exists where you have no idea how much you're going to pay for a service until a month after the fact?


Yeah a woman paid $5,751 for an evaluation of an ear injury, for which she ultimately received an ice pack and a bandage. Obviously there needs to be a facility fee, a triage fee, compensation for the doc that examined her, etc, but if you think it's okay to charge that much for that kind of service, then I think your perspective on healthcare is absurd.

let me say im a fan of what she is doing.. Your logic though needs to include EMtala. 15% of our patients get everything and pay us and the hospital 0. What other industry exists where you are forced by law to provide a service you may get no reimbursement for? (See how that works). As it is the AHA says they lose 10% on medicare admissions. So who is gonna fill the gap? Not medicaid.. That leaves 1 option.

Sure 5700 is stupid.. Sure it would be great if people knew how much their service would cost. How would you propose this? At what point during their ED visit?

When the 21 year old female comes in with abdominal pain how would you estimate her cost? Sure some things are simpler but most of those can go to the urgent care anyhow.

 

[Status Sciaticus]

I guess it depends on the rounds. Some rounds are horrible, last forever, learn squat, all that.

But I don't think rounding is always as bad as some people here make it out to be, not if you have a good attending that teaches well. For those kinds of rounds, I have learned a lot and felt very involved in patient care even as a dumb and ignorant med student. The whole thing was really intellectual and academic in the best sense. It was like learning from those older and more traditional physicians that everyone completely respects and being able to receive all their decades of accumulated wisdom. I felt like a young apprentice learning from a master in the guild and someday aspiring to become like this mentor. Maybe I am "romanticizing" medicine too much, but since we always hear all the negative things, it's encouraging to point out there are sometimes some good things about medicine today in my opinion.

let me say im a fan of what she is doing.. Your logic though needs to include EMtala. 15% of our patients get everything and pay us and the hospital 0. What other industry exists where you are forced by law to provide a service you may get no reimbursement for? (See how that works). As it is the AHA says they lose 10% on medicare admissions. So who is gonna fill the gap? Not medicaid.. That leaves 1 option.

Sure 5700 is stupid.. Sure it would be great if people knew how much their service would cost. How would you propose this? At what point during their ED visit?

When the 21 year old female comes in with abdominal pain how would you estimate her cost? Sure some things are simpler but most of those can go to the urgent care anyhow.

Standardized pricing sheets would be a step in the right direction. If a person knows how much a CT or MRI costs upfront, they can make an informed decision on whether its a smart idea. An itemized bill before discharge would be good too, to discuss and dispute any issue rather than waiting one month for it. In the example above, knowing where that ~$5700 went in an itemized bill would shed light on why ER visits are so absurdly expensive nowadays. I get that the billed cost is high due to the discounts offered to insurance companies, but the billed cost is still an issue since it affects the copay that patients pay.

If I came into the ER and I saw upfront that a CT scan cost $5000 in the ED vs. $1500 at a UC, it would make me think twice about using the ED even if my insurer covered it (at a 20% copay, I would pay $1000 for the ED CT scan vs. $300 at a UC).

 

[LaBusqueda]

I have worked at several hospitals that refuse to post signage to the effect that we will not refill pain medications etc... because why? Because it would keep patients away that would have otherwise sought emerg care and the lawyers felt it a risk from EMTALA standpoint.

I would think that making prices visible would have much more of a deterrent consequence two patients that legitimately need to seek emergency care.

Are the prices absurd? Yes. However absurd they do seem high actually do think that they are necessary. All I’m seeing is more hospitals close andI’m not seeing evidence of hospital growth. Perhaps I’m wrong but I don’t see hospitals popping up like Starbucks.

 

[Phil_Connors]

Sure it would be great if people knew how much their service would cost. How would you propose this? At what point during their ED visit?

The article states the following:
"The $300 fee that Wallace was charged is typically called a “facility fee,” the price of entering the facility regardless of what happens afterward... But experts who study emergency billing question how these fees are set and charged, noting that they are seemingly arbitrary, varying widely from one hospital to another. A Vox analysis of these fees, published last year, shows that the prices rose 89 percent between 2009 and 2015 — rising twice as quickly as overall health care prices. Facility fees typically are not made public, meaning patients only learn what their emergency room charges when they receive the bill. Patients who do not receive ER treatment often find that the facility fee is the only charge on their bill."

Seems like something that could be published on a website, put onto a placard in the waiting room, communicated by a nurse in triage, etc. Not the fee for every service provided in the ED, just the facility fee for the five levels of care. That would be incomplete but a good starting point.

15% of our patients get everything and pay us and the hospital 0.

That's not entirely true. It's true that these patients pay nothing, but the hospitals are paid a certain amount by the federal government for uncompensated ED visits, although apparently not enough to cover their full cost. Your point that hospitals need to make up the difference somewhere is well-taken. The biggest problem to me is not that hospitals charge too much however, but that they charge so inconsistently, both between different hospitals and for different services at the same hospital, and make no attempt to inform their patients about costs. In fact, as these articles have suggested, there seems to be an effort to conceal costs in order to remain competitive. No matter how educated a patient is, they can't be sure what they're about to pay. Seems very screwed up to me.

 

[Apollyon]

Who is "Phil Connors"? Seems like some guy (person) that just came out of the cobwebs with a specific axe to grind.

 

[Phil_Connors]

Who is "Phil Connors"? Seems like some guy (person) that just came out of the cobwebs with a specific axe to grind.

One of Pittsburgh's finest weathermen. Dropped the ball on the Punxsutawney blizzard of '92 though.

No, you're sort of accurate. Longtime lurker here but I'm about to start EM residency and want to learn more about my vocation. I read this article earlier today and it struck a chord, so I felt compelled to reply. I promise I have no affiliation with Vox.

 

[deleted245139]

You're not paying for an ice pack. You're paying for my/our expert evaluation. You're paying for my history taking, information synthesis, +/- some testing to tell you that your bruised eye is NOT a SDH, not a SAH, not an orbital fracture, not a globe inj, not a corneal abrasion, etc. I'm sorry all she 'got' was an ice pack.
I'm not arguing cost variance facility to facility. I'm arguing that people should not complain about lacking a 'goodie bag' when they walk out of the ED.

 

[GonnaBeADoc2222]

Please.

As stated above, you're not paying for the ice pack.

You're paying for my 8 years of post undergraduate education and training. You're paying for my determination that you have or don't have a life threatening condition. For non-emergent conditions, you can easily go on your insurer's website and see which local urgent cares are in network. For chronic / even more non-emergent conditions, you can wait the week to see your primary care doctor and a few weeks for an out patient imaging study.

Why isn't anyone collecting data on what your mechanic charges you? Or your lawyer, or your accountant?

Personal responsibility goes a long way.

 

[Status Sciaticus]

Please.

As stated above, you're not paying for the ice pack.

You're paying for my 8 years of post undergraduate education and training. You're paying for my determination that you have or don't have a life threatening condition. For non-emergent conditions, you can easily go on your insurer's website and see which local urgent cares are in network. For chronic / even more non-emergent conditions, you can wait the week to see your primary care doctor and a few weeks for an out patient imaging study.

Why isn't anyone collecting data on what your mechanic charges you? Or your lawyer, or your accountant?

Personal responsibility goes a long way.

Guess I'll play the devils advocate here.

Your expertise certainly warrants your 200-400/hr pay or whatever your employer pays you. It does not warrant a 5000k bill for your expert opinion.

Regarding the comment about comparing the EM doc to a mechanic or lawyer, both those professions tell you upfront what the cost of their services are. They dont bill you an absurd amount that is not commensurate to their expertise.

That said, both of you are right that patients personal responsibility goes a long way.

 

[GonnaBeADoc2222]

My "expert opinion" is worth whatever you value your own life or quality of life at. If you come to my ED for your two weeks of morning time headaches , and my CT reveals an early stage glioblastoma, which leads to prompt downstream treatment and disease resoulution, and saves you years of life and income generation, then yes, I'd say that experience is worth 5k or 10k or whatever it is.

It is up to you to roll that probabilistic dice and decide if it's worth it to you.

Or....you can schedule a primary care appointment and get an outpatient CT maybe 4-6 weeks from now.

Up to you.

 

[Status Sciaticus]

My "expert opinion" is worth whatever you value your own life or quality of life at. If you come to my ED for your two weeks of morning time headaches , and my CT reveals an early stage glioblastoma, which leads to prompt downstream treatment and disease resoulution, and saves you years of life and income generation, then yes, I'd say that experience is worth 5k or 10k or whatever it is.

It is up to you to roll that probabilistic dice and decide if it's worth it to you.

Or....you can schedule a primary care appointment and get an outpatient CT maybe 4-6 weeks from now.

Up to you.

The issue is not the probability of downstream measures to save a life. Rather, it is the arbitrary determination of the cost of care provided to the patient. Given the wide variation of price points across hospitals in a given region, having a rough idea of the cost of an ED visit allows that person with two weeks of morning headaches to shop around for the most affordable ED visit, since he isnt actively dying and has time to compare prices.

 

[deleted245139]

You do realize the variable price points exist relative to payor mix to reflect variable cost compensation per case evaluated... I'm not saying it's a good thing. I'm not saying it's bad. I'm saying it reflects the fact that you have variable compensation for a variety of patient presentations, staffing to volume at each hour of the day, each day of the week.

The ED is an expensive place to receive basic care.
Also... I'd caution against the 'shop around' mentality here. It's hard enough on a daily basis having the conversation about risk benefit for things such as radiation exposure. I'm all for patient empowerment, but to hand a person a 'menu' of offerings with pricing invites a slippery slope. Now Mr Smith doesn't want the CT for his obtunded seizing wife who just fell... Tough to diagnosis that bleed now. Maybe she dies... Who owns that? Me? I didn't set the pricing.

And how would you even propose a pricing list? It could cost a million dollars for a CT, but If your plan covers 999,900 and it's only 100 for u, does that matter? What if they refuse the CT because I have NO IDEA what their plan covers. Then they die. And it would have been covered.

Look I don't have the answers, but pretending a price list will solve this is nieve at best

 

[GonnaBeADoc2222]

The issue is not the probability of downstream measures to save a life. Rather, it is the arbitrary determination of the cost of care provided to the patient. Given the wide variation of price points across hospitals in a given region, having a rough idea of the cost of an ED visit allows that person with two weeks of morning headaches to shop around for the most affordable ED visit, since he isnt actively dying and has time to compare prices.

If you aren't "actively dying and have time to compare prices" then you don't belong in an ED to begin with. If you "need to know now" then you pay a premium. You can go to an in-network urgent care for your laceration repair or cough or what have you. It's pretty simple.

 

[LaBusqueda]

You do realize the variable price points exist relative to payor mix to reflect variable cost compensation per case evaluated... I'm not saying it's a good thing. I'm not saying it's bad. I'm saying it reflects the fact that you have variable compensation for a variety of patient presentations, staffing to volume at each hour of the day, each day of the week.

Very true. I imagine the huge variability is tied to this.
Also, I remember reading that hospitals run on a relatively low margin. Much unlike ins companies or drug companies.

Also, we need to remember, and these type of articles never spell out, that the 5kish fees decried are mostly the faculty fee and hospital charges. Our fee/charges are much less.




Sent from my iPhone using Tapatalk

 

[Angry Birds]

I think this is a complex issue, with multiple stake holders involved: patients, physicians, hospitals, insurance, etc.

Vox will no doubt show a completely one sided picture: "I got charged for just an ice pack." Yeah well, you're actually paying me for my expertise: a decade's worth of training to give you reassurance, even if it means you didn't get any specific "treatment" more than an ice pack.

However, on the flip side, there is this game between hospitals and insurance companies, which is the real reason for the inflation of costs. Hospitals charge incredibly high prices, in order to then offer steep discounts to insurance companies. Meanwhile, people who are uninsured or underinsured can't afford these highly inflated artificial prices.

So, while I don't agree with the Vox narrative ("I got charged for just an ice pack"), I do think the American healthcare industry is running a big scam, which leads to runaway prices.

EDIT: By the way, I think the price list is a proposed solution to this problem. I think it might be a step in the right direction, but ultimately it doesn't deal with the heart of the issue, which is the crookedness of the health insurance industry.

 

[VA Hopeful Dr]

Guess I'll play the devils advocate here.

Your expertise certainly warrants your 200-400/hr pay or whatever your employer pays you. It does not warrant a 5000k bill for your expert opinion.

Regarding the comment about comparing the EM doc to a mechanic or lawyer, both those professions tell you upfront what the cost of their services are. They dont bill you an absurd amount that is not commensurate to their expertise.

That said, both of you are right that patients personal responsibility goes a long way.

Yes lawyers tell you their hourly fee, but they can't guarantee how many hours something should take them to do.

 

[Vandalia]

As I said most of this reporting is nothing new. However, I am particularly interested in this database of ED charges. If it is made public, it could be interesting and beneficial for us. The good news is that most of the blame is being placed on "hospitals" rather than "physicians."

Yes lawyers tell you their hourly fee, but they can't guarantee how many hours something should take them to do.

Not that it is important, but most lawyers these days charge a fixed fee for most services rather than billing based on time. According to my old college roommate, with billed hours, there is always the chance the client will stiff you. If you ask for a retainer, you have to keep the money in an escrow account until it is actually earned, but with a fixed fee, the lawyer can access the funds as soon as the check clears.

 

[VA Hopeful Dr]

Not that it is important, but most lawyers these days charge a fixed fee for most services rather than billing based on time. According to my old college roommate, with billed hours, there is always the chance the client will stiff you. If you ask for a retainer, you have to keep the money in an escrow account until it is actually earned, but with a fixed fee, the lawyer can access the funds as soon as the check clears.

For wills and real estate closings maybe, but the three lawyers I used to help set up my practice, sell it, and help me get out of a bad employment contract all were hourly without a retainer.

 

[bravotwozero]

Ok, for all the guys that said 'you are paying for my clinical judgement and not an ice pack etc.', the women in that particular case left, without being seen or evaluated or screened by a physician or midlevel, if I read that story correctly. So unless I am missing something here, she certainly was not paying for anyone's clinical judgement with that 5k bill...

 

[deleted480308]

I have worked at several hospitals that refuse to post signage to the effect that we will not refill pain medications etc... because why? Because it would keep patients away that would have otherwise sought emerg care and the lawyers felt it a risk from EMTALA standpoint.

I would think that making prices visible would have much more of a deterrent consequence two patients that legitimately need to seek emergency care.

Are the prices absurd? Yes. However absurd they do seem high actually do think that they are necessary. All I’m seeing is more hospitals close andI’m not seeing evidence of hospital growth. Perhaps I’m wrong but I don’t see hospitals popping up like Starbucks.

In certificate of need states they literally aren’t allowed to pop up

 

[deleted480308]

Ok, for all the guys that said 'you are paying for my clinical judgement and not an ice pack etc.', the women in that particular case left, without being seen or evaluated or screened by a physician or midlevel, if I read that story correctly. So unless I am missing something here, she certainly was not paying for anyone's clinical judgement with that 5k bill...

What ED treats and discharges without a doc or midlevels signing off? Something is missing from that story

 

[VA Hopeful Dr]

What ED treats and discharges without a doc or midlevels signing off? Something is missing from that story

You can leave without being seen but still get charged for everything that happened before you left.

 

[deleted480308]

You can leave without being seen but still get charged for everything that happened before you left.

Then it seems like posters are discussing different things because someone referenced an evaluation fee.....can someone link that specific ed visit referenced?

 

[VA Hopeful Dr]

Then it seems like posters are discussing different things because someone referenced an evaluation fee.....can someone link that specific ed visit referenced?

Ah, I see what you're saying - after re-reading the article apparently the $5,000 ice pack lady left after getting the ice pack but before seeing a physician so the physician's expertise part of the bill shouldn't apply.

I'm just guessing here as the article didn't go into incredible detail, but to have gotten the ice pack I'm guessing she at least checked in and and was likely triaged as well. In that case, you have to pay for the staff that does all of those things. ED's typically have higher staffing than regular hospital floors for the obvious reasons. So part of the bill is having to cover the cost of higher staffing 24/7/365. You also, as someone else previously stated, have to take into account the known percentage of people who will pay 0% of their bill.

Now I would agree that $5000 for that is a bit steep. Last fall we took one of my kids to the ED (woke up with croup at 1am). Got racemic epi neb treatment, decadron, and monitoring for about 2 hours. It was the 1 week between jobs for wife and I so we were technically self pay. After the 40% self-pay discount and the 20% fast pay discount, we ended up paying I think $600 for the facility fee/meds and $200 for the ED doc's time. So less than a grand for actual treatment. That does make this woman's story seem a bit ridiculous.

 

[deleted480308]

Ah, I see what you're saying - after re-reading the article apparently the $5,000 ice pack lady left after getting the ice pack but before seeing a physician so the physician's expertise part of the bill shouldn't apply.

I'm just guessing here as the article didn't go into incredible detail, but to have gotten the ice pack I'm guessing she at least checked in and and was likely triaged as well. In that case, you have to pay for the staff that does all of those things. ED's typically have higher staffing than regular hospital floors for the obvious reasons. So part of the bill is having to cover the cost of higher staffing 24/7/365. You also, as someone else previously stated, have to take into account the known percentage of people who will pay 0% of their bill.

Now I would agree that $5000 for that is a bit steep. Last fall we took one of my kids to the ED (woke up with croup at 1am). Got racemic epi neb treatment, decadron, and monitoring for about 2 hours. It was the 1 week between jobs for wife and I so we were technically self pay. After the 40% self-pay discount and the 20% fast pay discount, we ended up paying I think $600 for the facility fee/meds and $200 for the ED doc's time. So less than a grand for actual treatment. That does make this woman's story seem a bit ridiculous.

then yeah, if they disappeared pre-workup, I'm not sure what happened there

 

[RustedFox]

Wow.
It's almost like you shouldn't use the ER as your primary care office and then not expect a bill that reflects emergency services.

Hmm.

Welp. Today's shift is going to suck now that I've opened my mouth.

 

[erdoc00]

I once had a pipe that was leaking for three months. I suffer from insomnia and it was 2 am but since I was already up, I called the emergency plumbing service to have it evaluated. Could you believe that they charged me 10 times their usual rate for "emergency service". They also only used a wrench and tightened the pipe screw. Is there a way I can submit this to vox? I am outraged!

 

[RuralEDDoc]

I think we (Emergency Physicians) should take the sentiment of the article seriously. Make no mistake - many EDs are absolutely fleecing patients and charging extreme fees for simple evaluations. While the hospital portion of the bill is typically 85-90% of the overall bill a patient receives, the provider portion still matters. And (earmuffs) many of us are trained to participate by charting to a level 5 chart no matter the actual acuity and letting the billing company figure out what’s appropriate to bill. Guess what? Sometimes they overbill. We are therefore participants in a reimbursement game in which we directly benefit. The public and politicians have said that enough is enough and will no longer allow this to occur, regardless of the cost shifting necessary to keep departments afloat.
So let’s not ignore the pain of some of the victims in this system. Sometimes, we are the victims - total nonpayment for caring for ultrasick high need and high risk patients, mandated by federal law, which we receive no compensation for but we still have to pay for malpractice and billing coverage. Sometimes we are the villains. As a specialty, let’s try to be the villains less often.

 

[siliso]

The gal in the story was doing everything right in terms of trying to be an informed consumer, actually needed a surgical repair of an injury, left to go elsewhere when finding out the plastic surgeon was not in network, and still got dinged with giant bill from the place that she left (reasonably written off later but seems like a predatory let’s just see if she’ll eat it move). This is more informed agency than like 85% of the patients I see would be capable of. I understand that the ed overhead and physician evaluation aren’t free...but they aren’t reasonably worth $5000 either.

 

[Perrotfish]

I once had a pipe that was leaking for three months. I suffer from insomnia and it was 2 am but since I was already up, I called the emergency plumbing service to have it evaluated. Could you believe that they charged me 10 times their usual rate for "emergency service". They also only used a wrench and tightened the pipe screw. Is there a way I can submit this to vox? I am outraged!

You call the plumber. As soon as you open the door he pushes past you to fix your pipe. Then he hands you a $50,000 bill. You say you never would have agreed to his services if you knew the price. He says that's not his problem. Are you outraged?

You call the plumber. He tries to run in the door to fix your pipe but you body check him and ask him the price. He mumbles something about $50,000, so you throw him out of your house. You get a bill for $10,000 because you asked for a quote. Are you outraged?

Your helpful neighbor notices your house is filling with water while you're asleep. He calls the plumber, who fixes your pipe. You wake up and he's standing over you with a $50,000 bill. You have apparently agreed to pay this bill despite being unconscious. Are you outraged?

You need a plumber to fix your pipes. Every plumber in your neighborhood charges the local office buildings $50 to fix a pipe. However they all signed contracts with those office buildings that they'll never charge a business more than 0.1% of what they charge individuals. Therefore the minimum price for you to get a pipe fixed in your house is $50,000. Are you outraged?

Industries get socialized when people feel like they can't deal with that industry as consumers. If someone can't access same day emergency care for a scary abdominal pain, without losing their house, then the government is just going to start running medicine.

 

[deleted480308]

You call the plumber. As soon as you open the door he pushes past you to fix your pipe. Then he hands you a $50,000 bill. You say you never would have agreed to his services if you knew the price. He says that's not his problem. Are you outraged?

You call the plumber. He tries to run in the door to fix your pipe but you body check him and ask him the price. He mumbles something about $50,000, so you throw him out of your house. You get a bill for $10,000 because you asked for a quote. Are you outraged?

Your helpful neighbor notices your house is filling with water while you're asleep. He calls the plumber, who fixes your pipe. You regain consciousness, and he's standing over you with a $50,000 bill. Are you outraged?

You need a plumber to fix your pipes. Every plumber in your neighborhood charges the local office buildings $50 to fix a pipe. However they all signed contracts with those office buildings that they'll never charge a business more than 0.1% of what they charge individuals. Therefore the minimum price for you to get a pipe fixed in your house is $50,000. You have apparently agreed to pay this bill despite being unconscious. Are you outraged?

Industries get socialized when people feel like they can't deal with that industry as consumers. If someone can't access same day emergency care for a scary abdominal pain, without losing their house, then the government is just going to start running medicine.

the govt interfering in the machine is why it's so expensive right now...

 

[Perrotfish]

the govt interfering in the machine is why it's so expensive right now...

Sure it is. That's why every country with socialized medicine pays less overall for healthcare, has better outcomes, and no one gets a bill.

You can chant libertarian mantras all you want, but if things stay this bad you will eventually be working for the government. There is a good reason that most industries learn to regulate themselves.

 

[siliso]

Health care is never again going to work as a free market, because it isn’t a market. In a market you have choices to buy or not buy something after you find out what its going to cost, without the threat of death if you don’t buy. If you can’t afford steak and lobster you can buy rice and beans instead. If you can’t afford to get your gunshot wound or perfed viscus treated, you have no choices - and you won’t even find out if you can afford it until after the fact. Maybe when your choices were Dr. Quack with the leeches vs Dr. Nick with the snake oil, ie early last century, you could be a free market consumer. But it’s not like that and hasn’t been for a century and won’t be again, until the road war/zombie apocalypse. Or you can move to a 3rd world country where it’s still cash on the nail or GTFO.

 

[deleted480308]

Sure it is. That's why every country with socialized medicine pays less overall for healthcare, has better outcomes, and no one gets a bill.

You can chant libertarian mantras all you want, but if things stay this bad you will eventually be working for the government. There is a good reason that most industries learn to regulate themselves.

they absolutely get a bill.....they just get it via tax

but when the govt mandates that everyone can walk into any hospital at 3am and get worked up without having to figure out how to pay, it gets expensive

 

[Perrotfish]

they absolutely get a bill.....they just get it via tax

but when the govt mandates that everyone can walk into any hospital at 3am and get worked up without having to figure out how to pay, it gets expensive

Again, we know the percentage of GDP that those countries spend on healthcare, and we know the percentage of our GDP that we spend on healthcare. It turns out that sick people overusing healthcare uses up fewer resources than useless administrators fleecing the sick to pay themselves insane salaries.

 

[deleted480308]

Again, we know the percentage of GDP that those countries spend on healthcare, and we know the percentage of our GDP that we spend on healthcare. It turns out that sick people overusing healthcare uses up fewer resources than useless administrators fleecing the sick to pay themselves insane salaries.

And making people pay for themselves would cut costs even further

 

[Vandalia]

A couple of points:

1) Someone mentioned a plumber deciding to charge you $50,000. There is a legal principle in contract law that if a price is not specified in an agreement, the "reasonable and usual" price of the service will be used by a court. For example, you have your neighbor's kid mow your lawn and pay him $20. The next spring he calls and asks if you want him to mow the lawn again, and you agree. A week later he sends you a bill for $10,000. If he sues, a court will almost certainly decide that the "reasonable and usual" fee would be $20 and might award the kid $25 to account for inflation. So if a price is not disclosed as part of the contract that does not mean that a party (i.e., the hospital, or a plumber, or the "robber baron" neighbor kid) is free to stick you with any amount they want. (Well, they can; it just will not hold up in court.)

The question is what is the "usual" fee in a healthcare setting? The Supreme Court in my state addressed the issue recently. First, they affirmed that the standard contract law analysis applied, and the fee was limited to the "usual" amount. The parties disagreed as to what that would be. The hospital argued that it was the chargemaster. The patient argued that since that document was confidential, it would be the "usual and customary" amount provided by the insurance company. The court ruled that the chargemaster rate was the appropriate rate, and they gave great weight to the fact that the chargemaster had to be approved by the state in reaching that conclusion.

So there are limits on what can be charged even without an agreement on price and fee. Also, it appears (and I am not a lawyer and every state is different) that if you want to propose a "usual" charge in this scenario, there must be some rational basis behind that charge, even if it is just state approval.

2) Healthcare today is a "zero-sum" game. In other words, whoever is in the spotlight loses. I have heard some rumblings that primary care groups are debating a proposal to eliminate the "emergency department visit" CPT codes (i.e,, 9928x) and require EM physicians to use the standard outpatient E&M codes with the "savings" being used to raise the reimbursement for these codes. In other words, there are strong reasons for EM physicians to be aware of and address these issues.

3) The fundamental problem is that people are receiving benefits that they are not paying for. If I am sitting in one of our rural EDs at night surfing the web, the community still receives a benefit from our being there, even if they never set foot in the facility. The idea that people will pay $10K if they need the facility is not realistic. We know it does not work on the roads, which is why people are required to have auto insurance. I would propose that there needs to be mandatory "true insurance" for true catastrophic/emergency care. No opt outs... unless you are willing to have "no care" tattooed on your forehead and agree that you will not receive any emergency care in any circumstance. The problem of course is that immediately every special interest group will add in their "critical" service, e.g., mammograms, substance abuse treatment, etc., etc. But the idea that people receive a benefit without paying for it will never work.

 

[sum dude]

Seems like something that could be published on a website, put onto a placard in the waiting room, communicated by a nurse in triage, etc. Not the fee for every service provided in the ED, just the facility fee for the five levels of care. That would be incomplete but a good starting point.

You realize if you post prices in ED, you are violating EMTALA, right? Even if we knew the prices of stuff (which let's be honest, we don't), it would be illegal to state the price of them, b/c it implies you are asking for payment before full ruling out of emergency condition has finished. So the "post the prices" of ED piece is out the window.

How about instead, when shopping insurances, insurances state how much it will cost out of pocket before you get your benefits. Eg. if average ED bill is $5000, you will pay all of it until your $9000 deductible is met. Might make you think twice about high deductible plans, no?

That's not entirely true. It's true that these patients pay nothing, but the hospitals are paid a certain amount by the federal government for uncompensated ED visits, although apparently not enough to cover their full cost. Your point that hospitals need to make up the difference somewhere is well-taken. The biggest problem to me is not that hospitals charge too much however, but that they charge so inconsistently, both between different hospitals and for different services at the same hospital, and make no attempt to inform their patients about costs. In fact, as these articles have suggested, there seems to be an effort to conceal costs in order to remain competitive. No matter how educated a patient is, they can't be sure what they're about to pay. Seems very screwed up to me.[/QUOTE]

Part of reason for chargemaster shenanigans is fact that insurances use the prices they charge as part of a negotiation. It benefits insurances as well--the higher the chargemaster price, the "better" the negotiated rate your insurance has gotten you. Hence, ridiculous prices benefit the "insurance benefit" portion. I'd be fine making a law where uninsured get charged Medicare rate, but insurances can't use Medicaid/medicare as a negotiation point for reimbursement. Then it really might be cheaper to not have insurance.

Also, remember ED physicians do not get compensated for uncompensated care. The extent to which we get "compensated" for medicare is negotiating insurances for higher rates from insured patients. Medicare/Medicaid/uncompensated make up 60-70% of our clientele, but we lose money on that group. If we give preferred rates on uninsured patients, insurances would use this in calculating market rate. Hence the "markdown" shenanigans for uninsured patients that hospitals, physicians, and insurances play.

 

[VA Hopeful Dr]

Health care is never again going to work as a free market, because it isn’t a market. In a market you have choices to buy or not buy something after you find out what its going to cost, without the threat of death if you don’t buy. If you can’t afford steak and lobster you can buy rice and beans instead. If you can’t afford to get your gunshot wound or perfed viscus treated, you have no choices - and you won’t even find out if you can afford it until after the fact. Maybe when your choices were Dr. Quack with the leeches vs Dr. Nick with the snake oil, ie early last century, you could be a free market consumer. But it’s not like that and hasn’t been for a century and won’t be again, until the road war/zombie apocalypse. Or you can move to a 3rd world country where it’s still cash on the nail or GTFO.

That's not entirely true. You should instead say "Some parts of health care can't work as a free market", with emergency care being one of them.

I owned a cash-only FP practice for a few years that was as free market as you can get. My fees were posted on my website. I had a list of lab prices and every time I ordered a lab, I told the patient the price up front. Same with the medications I dispensed from the office or the imaging studies I got from the local free standing imaging center.

Up front all inclusive surgery pricing is becoming quite popular.

Now none of that works for emergencies since a) you don't know walking in the door what tests/how complicated a patient will end up being b) often times the patient in unconscious/altered c) since every single insurance company has different allowable prices (and usually even different plans within the same company) you can't know what someone will owe even if you knew exactly what you were going to do.

 

[VA Hopeful Dr]

You call the plumber. As soon as you open the door he pushes past you to fix your pipe. Then he hands you a $50,000 bill. You say you never would have agreed to his services if you knew the price. He says that's not his problem. Are you outraged?

You call the plumber. He tries to run in the door to fix your pipe but you body check him and ask him the price. He mumbles something about $50,000, so you throw him out of your house. You get a bill for $10,000 because you asked for a quote. Are you outraged?

Your helpful neighbor notices your house is filling with water while you're asleep. He calls the plumber, who fixes your pipe. You wake up and he's standing over you with a $50,000 bill. You have apparently agreed to pay this bill despite being unconscious. Are you outraged?

You need a plumber to fix your pipes. Every plumber in your neighborhood charges the local office buildings $50 to fix a pipe. However they all signed contracts with those office buildings that they'll never charge a business more than 0.1% of what they charge individuals. Therefore the minimum price for you to get a pipe fixed in your house is $50,000. Are you outraged?

Industries get socialized when people feel like they can't deal with that industry as consumers. If someone can't access same day emergency care for a scary abdominal pain, without losing their house, then the government is just going to start running medicine.

You realize plumbing isn't the same as emergency medicine, right? The same methods of quotes and whatnot could apply for primary care, but not for ED care.

 

[Brigade4Radiant]

The plumber example is inadequate because doctors don't know how much the bill is for. How much do you make for a level 5 visit? Its about 150 and some of that goes to nursing and so on. So the majority of what you bill doesn't go to the physician. Also you can't have it both ways a plumber who doesn't take your call won't be sued but the ER doc doesn't see can be sued. ER docs are often sued for not ordering tests and have to deal with patient satisfaction (patient's get upset if you don't order a CT head for a fall because after all they are here).

Also the government made physician owned hospitals practically illegal so we have hospitals pushing level 5 every visit.

 

[littlejuan]

You can leave without being seen but still get charged for everything that happened before you left.

The article states that they wanted her to see a plastic surgeon for the lac repair and she left before seeing them. I have never seen an ED where the nursing staff determines whether an emergency physician can repair a laceration or whether it needs to be repaired by a plastic surgeon. She must have seen someone that determined it was beyond the capabilities of the treating physician or midlevel.

Pell left the ER when she discovered the plastic surgeon who would see her was out of network for her insurance.

Maybe that hospital has ED plastic surgeons that see all face lacs. Who knows... :/

 

[Perrotfish]

You realize plumbing isn't the same as emergency medicine, right? The same methods of quotes and whatnot could apply for primary care, but not for ED care.

That's kind of the point. Primary care has the same dynamics as other free market services, so no one is outraged when they get their (reasonable) bill after seeing their primary care doctor. If the ER can't find a way to relate to people in a way that's kind of close to other free market services (posting their prices, only charging people for services they agree to, somewhat consistent prices between customers) then they shouldn't be able to send people individual bills like other free market services.

We don't need to socialize all of our healthcare system to socialize some of it. It might be that emergency services need to be government run while primary care and elective surgical services make sense in the free market.

 

[VA Hopeful Dr]

That's kind of the point. Primary care has the same dynamics as other free market services, so no one is outraged when they get their (reasonable) bill after seeing their primary care doctor. If the ER can't find a way to relate to people in a way that's kind of close to other free market services (posting their prices, only charging people for services they agree to, somewhat consistent prices between customers) then they shouldn't be able to send people individual bills like other free market services.

We don't need to socialize all of our healthcare system to socialize some of it. It might be that emergency services need to be government run while primary care and elective surgical services make sense in the free market.

As someone else mentioned previously, if you post prices for things you run the risk of being in violation of emtala. Generally speaking, people are only billed for things they accept. They just don't realize they're going to be billed for everything before they agree to it, and I don't know how to fix that other than saying "I would like to order a cat scan on you, but you will be responsible for paying for it at some point". Not sure that will work.

As for consistent pricing, blame the insurance companies. It is entirely their fault.

 

[deleted480308]

As someone else mentioned previously, if you post prices for things you run the risk of being in violation of emtala. Generally speaking, people are only billed for things they accept. They just don't realize they're going to be billed for everything before they agree to it, and I don't know how to fix that other than saying "I would like to order a cat scan on you, but you will be responsible for paying for it at some point". Not sure that will work.

As for consistent pricing, blame the insurance companies. It is entirely their fault.

I'll chime in here and make sure we're all noticing the govt is why the EDs can't advertise their prices

 

[Brigade4Radiant]

That's kind of the point. Primary care has the same dynamics as other free market services, so no one is outraged when they get their (reasonable) bill after seeing their primary care doctor. If the ER can't find a way to relate to people in a way that's kind of close to other free market services (posting their prices, only charging people for services they agree to, somewhat consistent prices between customers) then they shouldn't be able to send people individual bills like other free market services.

We don't need to socialize all of our healthcare system to socialize some of it. It might be that emergency services need to be government run while primary care and elective surgical services make sense in the free market.

Primary care is not emergency care. The EMS system is apart of us being a civilized country. Also Emergency care costs about 4% of healthcare costs and considering the services provided and the jobs provided not to bad. There is such outrage about ER bills because the general population has access to it.