why do the uninsured cost us so much money

[radslooking]

Ok, so people always say how the uninsured cost us money. I realize this is a "stupid question" but i'd like someone to explain it to me in real terms.

How exactly do they cost us money, because if you assume they are uninsured because they can't pay, then gov't will be paying either way. Either for their insurance or their hospital bill.

If they could afford insurance, and just don't want to pay...then they will be saddled with whatever portion of the bill they can pay, and the rest may need to be paid by the gov't. (or will move them into bankruptcy or whatever)

How does insuring people have an overall cost savings to the average taxpayer?

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[runr5mi]

ok, so the very superficial and easy answer is very simple math.

Ear ache checkup at primary care physician = ~$60 retail without insurance

Ear ache examination at ER = $6,000 (grossly overestimated)

The easy moral of the story is that in most cases the uninsured misuse the system.

 

[radslooking]

Thanks.

Are self-pay patients unable to get office visits? do outpatient clinics ask them to put down a deposit before the visit or just refuse outright?

 

[DrMom]

They can get office appointments, but they have to pay. They know that they'll be seen in the ED even if they can't pay. I've been told many times by a patient or patient's parent that they came to see me in the ED because they have to pay to see other doctors.

 

[radslooking]

They can get office appointments, but they have to pay. They know that they'll be seen in the ED even if they can't pay. I've been told many times by a patient or patient's parent that they came to see me in the ED because they have to pay to see other doctors.

and they do this even though they know the bill will be 10x higher at an ED? I assume then, that most office visits ask for an immediate payment before leaving? because otherwise, its financially poor decision to come to the ED.

I'm just trying to separate what is actually a financial decision these people are making vs just a decision borne of habit, ignorance, and convenience.

 

[DrMom]

they don't really care about the higher cost of ED vs office treatment. They aren't paying it. Same reason they take an ambulance for their very clearly non-emergent complaint. They have to pay a taxi and they don't want to inconvenience their friends. They call the ambulance and it comes...and they never pay a bill.

 

[radslooking]

they don't really care about the higher cost of ED vs office treatment. They aren't paying it. Same reason they take an ambulance for their very clearly non-emergent complaint. They have to pay a taxi and they don't want to inconvenience their friends. They call the ambulance and it comes...and they never pay a bill.

so do you think if they had insurance this behavior would change?

 

[DrMom]

Hard to say for these folks as they have no intention or motivation to pay anyways. Maybe they'd still use the ED and not pay the remainder of the bill.

There are certainly some uninsured who would do the right thing, though. Heck, many do now, too. We have folks with large bills who are paying $5-10 a month on the balance. I have great respect for them as they are at least doing what they can and they're not coming in expecting totally free care.

 

[radslooking]

thanks drmom. I am trying to figure out how much 'savings' there would actually be if these uninsured were actually insured.

because even if they were insured, i'd reckon that a lot of them would still be taking ambulances and still not paying those bills--thus no real savings.

also, if they started taking ambulances for head colds, then i would assume private insurances will start charging them crazy premiums, which they won't pay...again gets defaulted back to government

i know it seems like...hey let's get these people insured, then we won't have to pay. but it seems like too simplistic an argument.

anybody else want to chime in?

 

[MOHS_01]

thanks drmom. I am trying to figure out how much 'savings' there would actually be if these uninsured were actually insured.

because even if they were insured, i'd reckon that a lot of them would still be taking ambulances and still not paying those bills--thus no real savings.

also, if they started taking ambulances for head colds, then i would assume private insurances will start charging them crazy premiums, which they won't pay...again gets defaulted back to government

i know it seems like...hey let's get these people insured, then we won't have to pay. but it seems like too simplistic an argument.

anybody else want to chime in?

My personal belief is that you are correct -- the premise that "getting everyone insured" will dramatically and instantly lower costs has little basis in fact as far as I am aware.

This is not the first time that we have been down this road -- in 1965 approximately 40% of America's seniors were uninsured, leading to the inception of Medicare, that glorious state run insurance that we all know and love, that ever shining beacon of hope for all of healthcare....

At the time of its inception in 1965 Medicare Part B was set up so that premiums were to cover 50% of it's costs. The first members were not enrolled until 1966... yet within one year's time the system had managed to outstip all projections requiring additional funding. In a few short years premiums were only covering 25% of costs, with the balance coming from general funds.

In more recent times a former Presidential candidate rolled out a form of Universal Healthcare in his state... which was nothing short of an echo from 40 years earlier... costs exceeded projections, strains were placed upon the system, and the tax paying public was saddled once again with the bill.

Then there was the resoundingly successful Medicare Part D...

Any form of nationalized health insurance crafted by politicians will likely be as monumentally problematic and costly.

I also believe that it is a little simplistic to assume that all unpaid bills are ultimately paid by the government, for this simply is not the case. In reality, these bills truly go unpaid, ultimately absorbed by the providers of the service. One can argue on the point of cost shifting, etc -- but this amounts to nothing more than a rationalization of the cost escalation that has gotten us into the mess that we are in.

 

[cpants]

I doubt it. Most people don't want to take an ambulance or go to the ED if it's not necessary. Going to our ED with a head cold will cost you 6++ hours in a waiting room chair most days. If a patient had the option to go to a primary care office for little or no cost, he would take it.

Something needs to change, because hospitals are being forced to close their doors. Why? Because they are mandated by law to see and treat patients for no payment. The government doesn't pay for it, the hospital has to eat it. So the government needs to either repeal EMTALA, or start paying for the treatment. We are the only industry that is forced to provide service for no compensation.

 

[1 Up]

The question I have is why does the ED cost so much more for the same problem (i.e. ear infection)? I mean, you'd think that finding a solution in the ED vs. in an outpatient clinic would cost about the same amount of money. Doctor + X minute checkup + prescription medicine. Finish. Ammirite?

 

[radslooking]

The question I have is why does the ED cost so much more for the same problem (i.e. ear infection)? I mean, you'd think that finding a solution in the ED vs. in an outpatient clinic would cost about the same amount of money. Doctor + X minute checkup + prescription medicine. Finish. Ammirite?

yeah, its an interesting question. obviously it costs more to staff someone at night, along with the appropriate personnel, but it does seem a bit excessive. i was seen for an external otitis that i couldnt wait to be seen outpatient because it was throbbing so bad and about to close up. i think that cost about 700 if i remember correctly. and all i did was sit in triage and see somebody for about 10 min.

 

[edmadison]

Doctor + X minute checkup + prescription medicine. Finish. Ammirite?

Here is the flawed logic. The ED isn't the Walmart NP clinic. You are paying to have the Docs, Nurses, Equipment, Rads, Surg. available at a moments notice. If you are in an exam room, you are using that facility. Your earache might not be bad, but it still has to be evaluated and treated at the same place. All of those people and that equipment must be paid for.

The single biggest problem here and with the system in general is that we use third party payors. The consumer of the health care does not weigh the economic incentives or care. Frankly, we don't do it well either. I saw a two year-old with a mild temp in the ED; her mother's only reason for brining the child in was to get a script for Motrin which medicaid will only pay for with a script. She said she didn't care that medicaid had to pay $500 for her to get $3 worth of medicine -- it wasn't her money. That's the problem. Government isn't the solution, it's the problem.

You want a solution? Co pays. Give everyone on medicaid a copay account of $250 each year. Every office visit is $25, Every ED visit $50. You keep what's left over at the end of the year. We'd save millions.

Ed

 

[radslooking]

i agree with that ed. although it would be even better if you could charge them upfront instead of giving them money at the end of the year. that would really hit home. having to pull out the wallet before services are rendered. but unfortunately, our legal system would never let that happen because one person will die while looking for their wallet.

 

[docB]

Interesting discussion. Hopefully this won't degenerate into just another socialized healthcare debate. First the OP's initial question made a very flawed assumption:

How exactly do they cost us money, because if you assume they are uninsured because they can't pay, then gov't will be paying either way. Either for their insurance or their hospital bill.

When an uninsured person (who can't pay the bill on their own) gets medical care in an ED and then in a hospital if they require admission the government does not step in and pay the bill. No one pays. The docs lose money and time because even though they don't get paid they are liable and have to pay for insurance to cover the services. The hospital doesn't get paid and they eat the costs. Hospitals usually book the unpaid bills as "bad debt" and the huge amounts of bad debt are the main thing cited as causing financial instability in hospital systems.

As for people using the ED for primary care the uninsured have no where else to go if they truly have no cash. It costs $40-$100 to go to an urgent care and when they don't have it they go and are sent (a seperate problem with the system) to the ED. Interestingly most of the data that's being gathered on ED overcrowding, which is a real hot topic in EM research, shows that the overcrowding is NOT due to the use of the ED by the uninsured. This includes a recent article in Annals of EM:

http://www.annemergmed.com/article/S0196-0644(08)00365-X/fulltext

This data doesn’t seem to correlate well with what those of us working in the ED see every day but it does take into account the high volume of patient with insurance and PMDs who are referred into the ED due to liability concerns, pre authorization issues and plain laziness.

 

[Josh L.Ac.]

If part of the problem is that hospitals and providers escalate their fees to make up for the large number of patients that don't pay, would their fees drop if everyone was required to pay for their services?

 

[radslooking]

Interesting discussion. Hopefully this won't degenerate into just another socialized healthcare debate. First the OP's initial question made a very flawed assumption:

When an uninsured person (who can't pay the bill on their own) gets medical care in an ED and then in a hospital if they require admission the government does not step in and pay the bill. No one pays. The docs lose money and time because even though they don't get paid they are liable and have to pay for insurance to cover the services. The hospital doesn't get paid and they eat the costs. Hospitals usually book the unpaid bills as "bad debt" and the huge amounts of bad debt are the main thing cited as causing financial instability in hospital systems.

As for people using the ED for primary care the uninsured have no where else to go if they truly have no cash. It costs $40-$100 to go to an urgent care and when they don't have it they go and are sent (a seperate problem with the system) to the ED. Interestingly most of the data that's being gathered on ED overcrowding, which is a real hot topic in EM research, shows that the overcrowding is NOT due to the use of the ED by the uninsured. This includes a recent article in Annals of EM:

http://www.annemergmed.com/article/S0196-0644(08)00365-X/fulltext

This data doesn't seem to correlate well with what those of us working in the ED see every day but it does take into account the high volume of patient with insurance and PMDs who are referred into the ED due to liability concerns, pre authorization issues and plain laziness.

yes, you're right, that was flawed logic--i am not sure why I explained it that way because i know of course all bills do not get paid, many are eaten. But those costs are spread out amongst everyone else, driving up everyone else's cost of service, so i'm not sure this description is wholly different. Either way, you are going to have increased costs to medical care and higher premiums. Most of these costs are going to get passed on to the paying individuals one way or another. With the exception being some hospitals that are losing money, and some docs making below what they could because of poor reimbursement but yet do not increase their cost of services. But do you think if everybody paid our incomes would go up much? Or would cost of service just go down?

 

[1 Up]

Here is the flawed logic. The ED isn't the Walmart NP clinic. You are paying to have the Docs, Nurses, Equipment, Rads, Surg. available at a moments notice. If you are in an exam room, you are using that facility. Your earache might not be bad, but it still has to be evaluated and treated at the same place. All of those people and that equipment must be paid for.

Here's the part that hasn't made sense to me about that. Aren't all of these doctors constantly getting paid whether or not they are being used? Maybe the extra cost is becuase of the fact that that have to work long hours, which is in turn due to the fact that people with ear aches are using them.

So, to be clear, if people with petty ailments, stopped going to the ED, then costs would go down simply because ED employees wouldn't have to work such long hours. Correct?

 

[docB]

But do you think if everybody paid our incomes would go up much? Or would cost of service just go down?

It depends (doncha love that answer?). If everyone paid or was covered by some socialized system (seriously, I don't want this discussion to turn into one of those rants for and against socialized healthcare like every other thread does eventually unless it's about circumcision) it would depend on how much they paid. If the payments or reimbursement via the government was as much or more than the gross receipts now then doc incomes would stay the same or go up. If they were less, which is more likely, then doc incomes would go down.

If the question is about doc income it doesn't matter if everyone is covered, only how much a doc collects at the end of the day for the payer mix at large.

 

[edmadison]

So, to be clear, if people with petty ailments, stopped going to the ED, then costs would go down simply because ED employees wouldn't have to work such long hours. Correct?

There's more to ED costs that just personnel costs. ED folks think differently. We want them to. That's how they save lives. Routine matters seen in the ED are more likely going to get a lab/rad workup than at an outpatient's docs office. That costs money.

Let me run with your insightful point just a little bit:

Any given ED you will have patients of various acuities. This can be anywhere from emergent to routine. We know that many people use the ED for routine and minor acute visits which do not need the ED resources. The MBAs running the place know this. That's why most big EDs now have acute clinics with primary care docs and/or midlevels. It lets the hospital reroute those services to their own version of the Doc-in-the Box. In theory, this works because you save your high overhead resources for the ED half and can run a more office-like environment on the clinic side. Unfortunately, there are insurance reimbursement issues here. Further, for those who don't pay, making it easy for them to get primary care 24/7 for free will just increase the demand for the services.

This is all about economics. If the consumer of the good or service pays their own bill they make good choices (if they have good information). We've taken that all out of the system. I cringe every time I hear a politician talk about how the market or capitalism has failed when the government has caused the problem and limited the free market. When the government backs crappy mortgages permitting the underwriting bank to sell it quickly and easily, it removes the incentive for the bank to make sure its a good loan.


Government is the problem, more government is not the solution.

Ed

 

[Pharmavixen]

In the article linked to by docB:

Moreover, ED visits are also increasing swiftly in countries with universal health insurance. Nevertheless, scientific journals and otherwise well-informed media continue to cite the uninsured as a major source of the rise in ED visits.

Some people will always mis-use the ED whether they have to pay or not.

It could be, as physicians, that your impressions are skewed, because you never see those uninsured folks who don't go to the dr.

On this site I've read all sorts of speculation on how a person's health insurance (or lack thereof) influences their use of health care services. A worthwhile study would be one that compares the use of health care services between similar population groups in two countries: one that has UHC, and one that doesn't (eg Canada and the US).

Edmadison says it's all about economics, and that's probably important. But surely people make health care decisions on the basis of more than just the money in their pockets.

 

[radslooking]

There's more to ED costs that just personnel costs. ED folks think differently. We want them to. That's how they save lives. Routine matters seen in the ED are more likely going to get a lab/rad workup than at an outpatient's docs office. That costs money.

Let me run with your insightful point just a little bit:

Any given ED you will have patients of various acuities. This can be anywhere from emergent to routine. We know that many people use the ED for routine and minor acute visits which do not need the ED resources. The MBAs running the place know this. That's why most big EDs now have acute clinics with primary care docs and/or midlevels. It lets the hospital reroute those services to their own version of the Doc-in-the Box. In theory, this works because you save your high overhead resources for the ED half and can run a more office-like environment on the clinic side. Unfortunately, there are insurance reimbursement issues here. Further, for those who don't pay, making it easy for them to get primary care 24/7 for free will just increase the demand for the services.

This is all about economics. If the consumer of the good or service pays their own bill they make good choices (if they have good information). We've taken that all out of the system. I cringe every time I hear a politician talk about how the market or capitalism has failed when the government has caused the problem and limited the free market. When the government backs crappy mortgages permitting the underwriting bank to sell it quickly and easily, it removes the incentive for the bank to make sure its a good loan.


Government is the problem, more government is not the solution.

Ed

thanks Ed for that nice post. actually all the posts on here are of surprisingly high quality.

it's taking me an embarrassingly long time (frustrating because i have a poor background in economics) that this "free market" isn't free market at all. As you say, the consumer does not know the cost of service, and thus isn't making intelligent choices based on that. Almost as bad, the providers of the service (us) frequently don't know the cost either. Moreover, you have a gov't entity, Medicare which sets prices on about 30-50% of the people out there, and the remaining 50% is private, yet still based off of a percentage of Medicare. None of this, to my knowledge, is truly "free market". And, as someone alluded to in other posts--prices from Medicare (RVU's) are determined in closed door meetings that have inordinate specialty influence. (Its the Senate, not the House--with every specialty getting one vote, despite primary care being 30-40% of the total) Thus procedural specialties win out. Again, prices aren't being set at what the market will pay. They are being set by who can play the political game best.

I realize these are generalizations. Of course there are corrections that happen (i.e. if they dropped colonoscopy reimbursement to 500$ nobody would do them, etc) but it still doesn't seem to be the best system.

I wish I knew more about this type of thing.

 

[radslooking]

Here's the part that hasn't made sense to me about that. Aren't all of these doctors constantly getting paid whether or not they are being used? Maybe the extra cost is becuase of the fact that that have to work long hours, which is in turn due to the fact that people with ear aches are using them.

So, to be clear, if people with petty ailments, stopped going to the ED, then costs would go down simply because ED employees wouldn't have to work such long hours. Correct?

good question. I think that yes, if the less acute cases stopped showing up (let's say 10-15% less volume) I would think that would mean you could staff it less and it would be somewhat cheaper. However, I think the problem is that even with somewhat less staffing, overhead is extremely high. Somebody is going to have to be on call overnight, with a triage nurse, with radiologist reading films, with a lab tech doing u/s, ct's, and appropriate specialists on call. All those costs of paying somebody to be ready at a moment's notice to wait on you. So I think you're paying for those people even if you come in for a head cold. Maybe it's like ordering a limo to drive you to your friend's house 2 blocks away. Expensive, and not worth it if you only need a little help. I dunno.

 

[docB]

Here's the part that hasn't made sense to me about that. Aren't all of these doctors constantly getting paid whether or not they are being used?

No. Docs don't get paid to do nothing. The vast majority of docs make their money by billing patients for services. It's a small minority who get a salary from a hospital. That includes all specialties, not just EM.

It's not the long hours that drive up costs. Talking about ED staffing, and therefore we're really talking about nursing, it's cheaper to staff 1 person for 12 hour shifts than 1.3 people for 8 hour shifts. That's one of the main components of the high bill and it doesn't include the doc's bill (interestingly doc billing is largely independent of hours). Most ED nurses are critical care level capable and are expensive. The "nurse" at a clinic where the patient should be for their ear ache is probably a min wage medical assistant.

One way to look at it is that the system expects people to triage themselves based on the costs. They shouldn't go to the ED for their ear ache. Since few people pay their bills themselves, the insured have insurance and the uninsured don't pay, that cost triage has failed.

When you go to the ED for your earache you are paying for the capability of the team there to code you should you turn out to have a real emergency, that means staff, training and equipment (not to mention liability, infrastructure, drugs, etc.). That's why it costs so much.

 

[1 Up]

No. Docs don't get paid to do nothing. The vast majority of docs make their money by billing patients for services. It's a small minority who get a salary from a hospital. That includes all specialties, not just EM.

It's not the long hours that drive up costs. Talking about ED staffing, and therefore we're really talking about nursing, it's cheaper to staff 1 person for 12 hour shifts than 1.3 people for 8 hour shifts. That's one of the main components of the high bill and it doesn't include the doc's bill (interestingly doc billing is largely independent of hours). Most ED nurses are critical care level capable and are expensive. The "nurse" at a clinic where the patient should be for their ear ache is probably a min wage medical assistant.

One way to look at it is that the system expects people to triage themselves based on the costs. They shouldn't go to the ED for their ear ache. Since few people pay their bills themselves, the insured have insurance and the uninsured don't pay, that cost triage has failed.

When you go to the ED for your earache you are paying for the capability of the team there to code you should you turn out to have a real emergency, that means staff, training and equipment (not to mention liability, infrastructure, drugs, etc.). That's why it costs so much.

Aha! Now it makes sense!

 

[167649]

Cost shifting effect:

An uninsured patient receives medical care at an ER. The hospital has to pay its bills, so it has to increase its income from one of the three main groups that are paying: government, private payers, and employer-based payers. Although some of the burden does go through the government (aka taxes), government health care programs are more restricted than the others. Most in the private pay category do not use hospital based health care as much as the others. That leaves the employer based plans, companies like GM. The hospital/network essentially charges them more. And as a result: the employers charge you more, make their product crappy, or it all contributes to moving the plant to out of the country, where there is no union demanding benefits for their employees. When you buy a $ 20,000 American car, 3,000 of it ultimately goes to employee health insurance. When you buy a 20,000 Japanese car, only about $400 of that goes to health care. You do the math. It puts those domestic companies at a big disadvantage to those overseas.

You help pay for someone's ER bill just about everytime you buy something, a 20,000 car or a 3.00 latte from starbucks.

It's not as simple as "the government will pay for them either way."

 

[cpants]

In the article linked to by docB: Some people will always mis-use the ED whether they have to pay or not.

It could be, as physicians, that your impressions are skewed, because you never see those uninsured folks who don't go to the dr.

On this site I've read all sorts of speculation on how a person's health insurance (or lack thereof) influences their use of health care services. A worthwhile study would be one that compares the use of health care services between similar population groups in two countries: one that has UHC, and one that doesn't (eg Canada and the US).

Edmadison says it's all about economics, and that's probably important. But surely people make health care decisions on the basis of more than just the money in their pockets.

Another factor is that hospitals are closing or closing their ED's because of low reimbursement or nonexistent reimbursement per EMTALA. The number of hospitals is decreasing, the number of emergencies (and non-emergencies) presenting in the ED is increasing. So even though the uninsured patients don't represent a higher proportion of the ED visits, they indirectly contribute to longer waits since there are less ED's to go around now.

 

[Llenroc]

I'm a resident doing an ER rotation this month.

These stories people about uninsured people taking the ambulance to the ED to get checked out for knee pain or a rash aren't isolated cases. This kind of BS is the vast majority of what comes in, along with the losers that want pain medications.

In my last 3 shifts, the most appropriate pt. I saw was a guy who left his diabetes meds at someone's house who wasn't available until the evening and wanted some insulin in the ED. That was the *most* appropriate, BTW, not the least appropriate. So you can imagine what the other kinds of cases are that I saw.

 

[Sunfire]

I'm in between schools at the moment, and so am also in a lapse of insurance. I had chest pain a few weeks ago and had to go in, it was too acute and came on after exercise. My bills are:

$5900 for the ER
~1000 for Rad
~500 for Doc
~ 50 for something or other

When I called the ER ombudsman and explained I have no insurance and wouldn't be able to come up with 6k for anything, they lowered my bill...to five hundred. Thankfully, the others offer a 30% discount as long as it's paid in full. I will barely be able to handle all of it with my loan refund...just might have to double up and not get a new winter coat.

 

[docB]

This thread reminded me of a thread we had in EM waaaaay back. But it's still applicable here:

Cost of the Uninsured on EPs

Here's the premis:

We had a thread a while back and someone made the comment that they way I complain about the uninsured it sounds like I'm paying their bills out of my own pocket. Well we all know that we are. I was thinking about how much that is. Here are my musings:
My group = 30 docs
We all absorb the cost of seeing the uninsured equally so that cost is /30
An average ER visit that we dont get paid for = $150
$150/30=$5, My group pays/loses $150 per uninsured visit and I personally lose $5 per uninsured visit.
My group sees ~ 100000 pts/ year
If our payer mix is 25% uninsured (which is conservative) that = 25000 uninsured visits per year.
$150x25000=$3,750,000 cost to my group
$3750000/30=$125000 cost to me personally per year to treat the uninsured.
This assumes you're in an eat what you kill setting and doesn't take into account overhead costs.
As an added bit of irony if I could have 2 years of those losses back I could pay off my loans.

 

[radslooking]

Cost shifting effect:

You help pay for someone's ER bill just about everytime you buy something, a 20,000 car or a 3.00 latte from starbucks.

It's not as simple as "the government will pay for them either way."

Your argument. Uninsured patient comes to ED. Said ED loses money. Hospital raises costs for insured patients to compensate. GM, Starbucks, who provide employee health insurance, must raise the cost of their products to compensate for the increased health care costs of their employees. Lattes go from $2.70 to $3.00. A Ford Focus goes from 20,000 to 22,000.

 

[radslooking]

I'm
When I called the ER ombudsman and explained I have no insurance and wouldn't be able to come up with 6k for anything, they lowered my bill...to five hundred. Thankfully, the others offer a 30% discount as long as it's paid in full. I will barely be able to handle all of it with my loan refund...just might have to double up and not get a new winter coat.

It's a travesty many self-pay patients don't know they can slash their bills so heavily. There are millions of poor saps who didn't negotiate lower prices and are paying triple or more what their insurance would have paid. Again, rather perverse to charge the hell out of a single person, who can't financially survive it, and give a better rate to a corporation, who usually can.

 

[radslooking]

This thread reminded me of a thread we had in EM waaaaay back. But it's still applicable here:

Cost of the Uninsured on EPs

Here's the premis:

Interesting. You are also assuming that that 25% isn't paying a penny on that 150$. Is that true? That you have 25% that pay essentially nothing?

 

[MOHS_01]

It's a travesty many self-pay patients don't know they can slash their bills so heavily. There are millions of poor saps who didn't negotiate lower prices and are paying triple or more what their insurance would have paid. Again, rather perverse to charge the hell out of a single person, who can't financially survive it, and give a better rate to a corporation, who usually can.

Please don't succumb to the line of BS that "corporations are rich and can afford to pay....", and here is why: this is little more than liberal poppycock, amounting to nothing more than the bashing of corporate entities that provide (at some point in their life cycle, at least) a needed and valued good or service.

Everyone should pay a fair and appropriate amount. Everyone. No more, no less. Government plans. Private plans. Self pay. This would still allow for charity care to be provided at the provider's discretion. Any deviation from this generates cost shifting, barriers to access across different payor classes, etc.

What constitutes a fair and appropriate reimbursement? Well, ideally it would be market determined. It should be sufficient to cover the services costs and allow for a reasonable profit. The exact price point is whatever the market allows -- if you price yourself out of line with the competition, you had damn well better be better than the competition, else you lose business. That is the American way. To quote a helluva line from a pretty good movie, "That's how dad did it, that's how America does it..... and it has worked out pretty well so far."

Things really went downhill fast once we abandoned these principles.

 

[edmadison]

Your argument. Uninsured patient comes to ED. Said ED loses money. Hospital raises costs for insured patients to compensate. GM, Starbucks, who provide employee health insurance, must raise the cost of their products to compensate for the increased health care costs of their employees. Lattes go from $2.70 to $3.00. A Ford Focus goes from 20,000 to 22,000.

The flaw in this logic is that insurance doesn't increase what it pays. Your example is what happened 15 years ago. Now, most insurance companies are linking their payments to the medicare/medicaid rates. Thus, the hospital has to find money elsewhere. This can be done either by increasing revenue (e.g. aggressively marketing profit centers like labor & delivery) or cutting expenses (e.g. decreasing floor staffing to minimum, aggressively discharging patients). Hospitals are facing difficulty from everywhere, many are going under. Private surgical centers are skimming the cream off the top too. The situation is ugly and is getting uglier by the day.

Ed

 

[radslooking]

Please don't succumb to the line of BS that "corporations are rich and can afford to pay....", and here is why: this is little more than liberal poppycock, amounting to nothing more than the bashing of corporate entities that provide (at some point in their life cycle, at least) a needed and valued good or service.

Everyone should pay a fair and appropriate amount. Everyone. No more, no less. Government plans. Private plans. Self pay. This would still allow for charity care to be provided at the provider's discretion. Any deviation from this generates cost shifting, barriers to access across different payor classes, etc.

What constitutes a fair and appropriate reimbursement? Well, ideally it would be market determined. It should be sufficient to cover the services costs and allow for a reasonable profit. The exact price point is whatever the market allows -- if you price yourself out of line with the competition, you had damn well better be better than the competition, else you lose business. That is the American way. To quote a helluva line from a pretty good movie, "That's how dad did it, that's how America does it..... and it has worked out pretty well so far."

Things really went downhill fast once we abandoned these principles.

No, I don't think its fair to overcharge anyone, and no I don't think corporations should be stuck with overpaying either. My point is they are taking advantage of people's ignorance by charging them triple what it should cost, and not telling them that they could negotiate much lower fees. Obviously corporations aren't getting stuck paying those high fees. It's preying on individual people's ignorance. Perhaps there should be a required disclaimer that says, "if you are paying out of pocket you may be able to negotiate lower fees". Please contact such and such number if this is the case.

 

[Sunfire]

That actually was told to me by the person who registered me at my bed, she pointed out a number to call in case of financial difficulty (I had already told her that I had no insurance). However, when I called that number, the woman on the phone said that it was the Grievances department and she had to look for the correct number for me to call (which I believe was simply Billing).

I think that such a large amount is charged, because that's what insurance companies pay. Isn't that right? Either way, the system is sorely flawed in more ways than one.

 

[radslooking]

That actually was told to me by the person who registered me at my bed, she pointed out a number to call in case of financial difficulty (I had already told her that I had no insurance). However, when I called that number, the woman on the phone said that it was the Grievances department and she had to look for the correct number for me to call (which I believe was simply Billing).

I think that such a large amount is charged, because that's what insurance companies pay. Isn't that right? Either way, the system is sorely flawed in more ways than one.

No, it's absolutely not what insurances will pay. Some insurances base what they pay as a percentage of the total charges. Thus the exorbitant fees from the hospital because they will only get a percentage of what they charge. Unfortunately, for John Q Public, they don't know this.

 

[Sunfire]

Good to know.

 

[NonTradMed]

My friend's mother was uninsured (had a history of psych problems and eventually went on disability) and when she went into one of her psychosis, she ended up in the hospital. The bill was $1000 for overnight observation but she arranged for a small copayment to chip away at the bill.

I don't think a pay-as-you-go system would work well for those that are the most sick because many can't hold down the good jobs that will allow them to pay for their own care. Chronically ill patients are in a bind. If they don't work, they can't afford care for themselves, and if they don't get care, they can't afford the medications to keep them healthy. I have a friend in that conundrum. She works and gets good insurance now but she's terrified that one really bout of sickness will leave her without a job. In between the time she gets some sort of medical assistant and/or a new job, she's afraid her meds will run out. Without insurance, her medications runs into the hundreds per month. Not something she can afford without a job.

I don't believe in a complete free market on health care system because it will create it's own problems. I believe in a combination of financial incentive and penalities with some sort of free market underpining it. I also like the idea of a co-pay, however miminal, to remind people that everything has a cost attached to it.

Everyone has health issues. Sadly enough, irresponsible people, if health care is a huge problem, will just not take care of it. But if we just have the free market take care of everything, what we end up with are public health care issues because a few selects kids are not immunized and seriously ill adults who can no longer work and become a drain to society because they didn't have their diabetes treated when it ws in in its early stages.

We could say, 'well, let them suffer'....only if polio and diptheria becomes common place again, that becomes a drain on society and if people are dying at high rates from preventive diseases and treatment ailments, that's a waste of human resource. And as my macroeconomics prof says, in an post-industrial society, our most valuable asset is human capital.

 

[Miami_med]

As one of the biggest (if not the biggest) advocates of free market healthcare on SDN, even I usually argue that controlling infectious disease and basic public health and sanitation are still government responsibilities. The control of infectious disease is a defense issue, and unlike diabetes and heart disease, infectious disease directly puts other people at risk.

 

[Sunfire]

I'm in between schools at the moment, and so am also in a lapse of insurance. I had chest pain a few weeks ago and had to go in, it was too acute and came on after exercise. My bills are:

$5900 for the ER
~1000 for Rad
~500 for Doc
~ 50 for something or other

When I called the ER ombudsman and explained I have no insurance and wouldn't be able to come up with 6k for anything, they lowered my bill...to five hundred. Thankfully, the others offer a 30% discount as long as it's paid in full. I will barely be able to handle all of it with my loan refund...just might have to double up and not get a new winter coat.

It gets better, I pressed and found out that I qualified to apply with County Medical Services (CMS). I had my appointment last week and found out that I won't be owing a penny.

The woman who interviewed me said that she gets exasperated with the suggestion that we need socialized medicine, because she feels that's the area she already works in and that if the government would just increase funding to her type of program that we'd all be where we need to be without too much extra restructuring.

Still, what a shame that I had to press for such an opportunity, and that I wasn't supplied with the information in the first place without having to go through the fear of thinking I had a 8000 bill I'd have to deal with. For someone with lesser investigative skills, they might have very well been stuck in a bad spot.

 

[San_Juan_Sun]

It gets better, I pressed and found out that I qualified to apply with County Medical Services (CMS). I had my appointment last week and found out that I won't be owing a penny.

Congratulations on living the American Dream: being an apparently able bodied person but still scamming the system for free healthcare. And going into healthcare to boot.

 

[Sunfire]

Wow, thanks for the judgment? If you scroll up and read a bit, you might see that I'm between schools and have no health insurance. Since it's relevant to the conversation, let me explain a bit further.

I've been working over the summer, making about a thousand a month before taxes. Work has been slow over the last month or so, my paychecks have been averaging about 150. I was without insurance when I went in to the ER, and have about 800 saved to my name. I need to move across the United States in about a week, into an unfurnished apartment. I hope that explains that I'm actually not an "able bodied person" at all, not so far as being able to pay a large medical bill.

Anything else I need to help you out with, as far as understanding? Your comment was very rude, I hope that you're able to learn some manners in your current and upcoming training.

 

[Tired]

I hope that explains that I'm actually not an "able bodied person" at all, not so far as being able to pay a large medical bill.

Actually quite the opposite.

What you've explained is that you think your health care should be free because you don't make a lot of a money.

 

[Sunfire]

Tired, no I dont make a lot of money, and I don't have a lot of money. The cut off for a single person to receive the benefits was 2000, I have well below that. I offered to pay a smaller portion, and was told that wasn't an option.

You state, "actually quite the opposite". What exactly are you referring to?

 

[San_Juan_Sun]

Wow, thanks for the judgment? If you scroll up and read a bit, you might see that I'm between schools and have no health insurance. Since it's relevant to the conversation, let me explain a bit further.

I've been working over the summer, making about a thousand a month before taxes. Work has been slow over the last month or so, my paychecks have been averaging about 150. I was without insurance when I went in to the ER, and have about 800 saved to my name. I need to move across the United States in about a week, into an unfurnished apartment. I hope that explains that I'm actually not an "able bodied person" at all, not so far as being able to pay a large medical bill.

Anything else I need to help you out with, as far as understanding? Your comment was very rude, I hope that you're able to learn some manners in your current and upcoming training.

I'm not interested in your excuses or explanations. By your own admission, you aren't in school. You should get another job, etc. to do whatever it takes to pay only a small portion of your medical bills. Take some accountability for yourself and quit shuffling to cost to someone else.

I can barely take this stuff from the general public. But it absolutely blows my mind that someone in healthcare will pull this nonsense.

 

[Sunfire]

Well, if you're not interested in carrying on a two-way conversation, San_Juan_Sun, then you can keep your thoughts to yourself. Your opinion, when not based on fact, is worth absolutely nothing.

 

[tkim]

Well, if you're not interested in carrying on a two-way conversation, San_Juan_Sun, then you can keep your thoughts to yourself. Your opinion, when not based on fact, is worth absolutely nothing.

The fact is, that you can work, and make payments toward your bill, but choose not to and instead investigated a way to not have to pay.

This is what 'able-bodied' means - can work. You can work, you just choose not to, and instead move away and start school. You could have easily put a couple of bucks a month toward the bill while you went through school and paid off the rest when you graduated.

Instead you applied for and got this county relief and walked away from the bill that the rest of us will have to eat. Thanks a lot. No, really. It's a real scumbag thing for you to do.

I hope, that as you go through your medical training and start into a conversation criticising how peope with no insurance waltz into the ED and don't pay a dime, you realize what a HUGE hyprocrite you are.

But you probably won't.