Emergency rooms are monopolies(vox.com)
vox.com
Emergency rooms are monopolies
https://www.vox.com/health-care/2017/12/4/16679686/emergency-room-facility-fee-monopolies
175 comments
Yep, it is appalling that these laws are still on the books in so many states. For those who live in CON states you should expect your healthcare bills to be about 10% higher with no increase in quality of care due to monopoly pricing. The FTC goes into further detail here about the history and reasoning behind why the laws exist and why they should be repealed here[0]
[0] https://www.ftc.gov/system/files/documents/public_statements...
[0] https://www.ftc.gov/system/files/documents/public_statements...
My father is an executive at a major hospital and this is only part of it. There is also issues of brands forming monopolies when appearing in communities. Mergers are also incredibly complex. Also lots (but not all hospitals) are nonprofits which complicates it further. ERs are required to treat patients if they come in which means some are making tons of money while some not at all. One person can significantly alter ERs profits[0].
[0] https://www.beckershospitalreview.com/finance/the-12m-patien...
[0] https://www.beckershospitalreview.com/finance/the-12m-patien...
Is very insightful to read those comments. So many people who, faced with socialized medicine, screamed "DEATH PANELS!"...
See premiums rising and all of a sudden, "We need to consider letting this person die a noble death."
It's like a paradigm shifting, without a clutch.
See premiums rising and all of a sudden, "We need to consider letting this person die a noble death."
It's like a paradigm shifting, without a clutch.
however this issue like the costs of health care are exaggerated by local and federal government rules. when you prevent competition, when you force coverage regardless of need, and you lock out more options, costs only go one direction.
just like tax laws, medical laws and implementation are done to favor specific groups to the detriment of others unfortunately
just like tax laws, medical laws and implementation are done to favor specific groups to the detriment of others unfortunately
> force coverage regardless of need
This is like, the main way to make insurance affordable.
https://www.investopedia.com/terms/a/adverseselection.asp
This is like, the main way to make insurance affordable.
https://www.investopedia.com/terms/a/adverseselection.asp
The link you provided doesn't say anything about ERs, much less ER profits. I can't imagine this patient with the severe genetic disorder is getting much of his $1M/month health care treatment in the emergency room.
A more common example are blood clot disorders. Literally a door or ball hitting a person can cause major life threatening issues and are incredibly expensive depending on the type of disorder. That is the most common situation at his healthcare system. Someone with a rare disorder has been been dubbed internally as the million dollar man because of this. In this case the man has been on and off insurance and has come to their healthcare system's ER multiple times.
Edit: The media only publishes the most extreme examples so I wasn't left with many options.
Edit: The media only publishes the most extreme examples so I wasn't left with many options.
> In order to open a new hospital in most jurisdictions, by law you need the permission of other local hospitals
That doesn't really have much of an effect these days, though, because if anything, we already have an excess of hospitals in most areas where this would come into effect.
That's why hospitals have been hemorrhaging money, and so many have either gone broke and closed up entirely or been consolidated into larger hospital systems. The independent hospital is a dying breed, and it's been dying for a very long time.
In other words, there just simply isn't really any appreciable desire to open hospitals in those regions. The Certificate of Need isn't the limiting factor; their ability to break even on their operating expenses is.
That doesn't really have much of an effect these days, though, because if anything, we already have an excess of hospitals in most areas where this would come into effect.
That's why hospitals have been hemorrhaging money, and so many have either gone broke and closed up entirely or been consolidated into larger hospital systems. The independent hospital is a dying breed, and it's been dying for a very long time.
In other words, there just simply isn't really any appreciable desire to open hospitals in those regions. The Certificate of Need isn't the limiting factor; their ability to break even on their operating expenses is.
If you take the time to look at the research you will find that it does have an effect.[0] Here is the money quote from that article
"More likely, CON has affected the intensity and speed with which hospitals pursue particular construction activities. For example, the absence of CON in Indianapolis is likely an important factor in its rapid build-up of new full-service hospitals and specialty facilities. In Seattle, where CON is present, multiple hospital organizations are seeking to build new facilities in population-growth areas, but they must await review and final approval. CON requirements in this community could explain why Seattle hospitals expressed greater interest in better management of their existing capacity in the face of growing demand, because they cannot move quickly to build more capacity."
Anecdotally, there has been a 10 year long fight near where I live over opening a hospital with CON laws being at the center of state supreme court litigation[1]
As someone who works in healthcare and understands the economics of the system your perception cannot be further from reality.
[0]https://www.healthaffairs.org/doi/full/10.1377/hlthaff.25.3.... [1] http://www.charlotteobserver.com/news/local/article126222794...
"More likely, CON has affected the intensity and speed with which hospitals pursue particular construction activities. For example, the absence of CON in Indianapolis is likely an important factor in its rapid build-up of new full-service hospitals and specialty facilities. In Seattle, where CON is present, multiple hospital organizations are seeking to build new facilities in population-growth areas, but they must await review and final approval. CON requirements in this community could explain why Seattle hospitals expressed greater interest in better management of their existing capacity in the face of growing demand, because they cannot move quickly to build more capacity."
Anecdotally, there has been a 10 year long fight near where I live over opening a hospital with CON laws being at the center of state supreme court litigation[1]
As someone who works in healthcare and understands the economics of the system your perception cannot be further from reality.
[0]https://www.healthaffairs.org/doi/full/10.1377/hlthaff.25.3.... [1] http://www.charlotteobserver.com/news/local/article126222794...
> As someone who works in healthcare and understands the economics of the system your perception cannot be further from reality.
As someone who's also worked in healthcare and also has an actual degree in economics, I stand by my point. In general, the CoN requirement doesn't have much of an end impact on prices for patients.
As someone who's also worked in healthcare and also has an actual degree in economics, I stand by my point. In general, the CoN requirement doesn't have much of an end impact on prices for patients.
I too have a degree in both Math and Economics. I started a medical clinic with the goal of reducing the cost of healthcare in the US by 50%. Our patients' out of pocket expenses for primary care are less than a typical cell phone bill on a per month basis. All of our prices are transparent and available up front. I know a bit about reducing costs.
However, I will not fall back on my credentials since I prefer evidence instead of grandstanding.
Here are a few links that I think could help change your mind.
https://www.mercatus.org/system/files/mercatus-mitchell-con-... http://www.econtalk.org/archives/2012/11/cochrane_on_hea.htm... http://www.econtalk.org/archives/2017/10/michael_munger_4.ht...
I've excerpted the following quote from the first link as I think it summarizes my viewpoint quite well.
"A review of 19 peer-reviewed academic studies finds that CON laws have worked largely as economic theory predicts and that they have failed to achieve their stated goal of cost reduction. The overwhelming weight of evidence suggests that CON laws are associated with both higher per unit costs and higher total expenditures. The evidence is mixed on whether CON laws have increased the efficiency of particular hospitals by channeling more patients through fewer facilities, and there is no evidence that CON decreased overall investment as its proponents had hoped. The weight of evidence suggests that CON regulations persist because they protect politically potent special interests from competition"
However, I will not fall back on my credentials since I prefer evidence instead of grandstanding.
Here are a few links that I think could help change your mind.
https://www.mercatus.org/system/files/mercatus-mitchell-con-... http://www.econtalk.org/archives/2012/11/cochrane_on_hea.htm... http://www.econtalk.org/archives/2017/10/michael_munger_4.ht...
I've excerpted the following quote from the first link as I think it summarizes my viewpoint quite well.
"A review of 19 peer-reviewed academic studies finds that CON laws have worked largely as economic theory predicts and that they have failed to achieve their stated goal of cost reduction. The overwhelming weight of evidence suggests that CON laws are associated with both higher per unit costs and higher total expenditures. The evidence is mixed on whether CON laws have increased the efficiency of particular hospitals by channeling more patients through fewer facilities, and there is no evidence that CON decreased overall investment as its proponents had hoped. The weight of evidence suggests that CON regulations persist because they protect politically potent special interests from competition"
Really? I can't speak for the country as a whole, but in my area (Raleigh/Durham, NC) the major healthcare providers have been battling each other for years over when, where, and what types of new hospitals they can open. These laws have been and continue to be central to the fight.
Just a few days ago: http://www.newsobserver.com/news/business/article188329569.h...
Just a few days ago: http://www.newsobserver.com/news/business/article188329569.h...
The medical industry has done a superb job of convincing everyone that “patients are their number one priority” when in reality they have all worked to have their own little monopolies.
From physicians to pharma companies, everyone is focused on leverage and ensuring they control the supply in their vertical.
Everyone pretends like the next round of drugs will make us so much healthier/live longer/etc. But we could have 0 innovation in medical/pharma technology in the next 20 years and if we instead focused on innovating in efficiency, expanding supply of docs and healthcare workers, and building a sustainable system, we would all be better off for it.
The next new procedure or pharmaceutical can’t do jack shit when most people that need them can’t get them in a timely and affordable manner.
Raise the bars for what you contribute to, folks!
From physicians to pharma companies, everyone is focused on leverage and ensuring they control the supply in their vertical.
Everyone pretends like the next round of drugs will make us so much healthier/live longer/etc. But we could have 0 innovation in medical/pharma technology in the next 20 years and if we instead focused on innovating in efficiency, expanding supply of docs and healthcare workers, and building a sustainable system, we would all be better off for it.
The next new procedure or pharmaceutical can’t do jack shit when most people that need them can’t get them in a timely and affordable manner.
Raise the bars for what you contribute to, folks!
Like turning away cancer patients? Sadly this happens too often
http://www.cbs46.com/story/34481437/local-hospital-says-its-...
http://www.cbs46.com/story/34481437/local-hospital-says-its-...
EMTALA is also a huge welfare cliff. Let's say Antius and Grasshoppedon both work at McDonald's. In accordance with the wisdom of the prophets, Antius saves 20% of his paycheck every month (somehow) eventually accruing... oh, say, $9001 in savings, or way more than the average US household. Grasshoppedon spends all his money, because that's how the fable goes. One day they're both injured in a workplace accident and rack up a $25000 medical bill. Antius's savings are wiped out, he goes bankrupt, no credit for seven years, etc; Grasshoppedon meets exactly the same fate as Antius, i.e., Antius's fiscal prudence amounts to diddly-squat.
And then economists wonder why the savings rate is so low.
And then economists wonder why the savings rate is so low.
At night the ED is the only place open. I believe there should be 24/7 Urgent Care centers, where people like the person in the opening of this article could go and receive care that (1) is not life-threatening but (2) can't wait till dawn.
However, in the mean time there are ways to help.
1. If you don't already have one, get a Primary Care Physician. Go for a wellness visit, get their practice to know you. Then if something like that happens at 1am, you can call the office, leave a message and get a callback from a nurse within 15-30m who can help you through your options and help with over-the-counter options to make it through the night until the office opens (or until urgent care opens). Or of course they can counsel you to go to the ED if they think there's a risk. But the point is, you can already weed out some unnecessary ED visits that way.
Note: not all providers have that service, so it's best to enquire when selecting a physician.
2. Many insurers have a nurses hotline but few people know about it. Check your policy. In the same way, they can help triage your situation, though it's less ideal since they don't know your medical record so they will tend to play it safer (ie. higher likelihood to send you to the ED). But it's better than nothing.
3. If the issue is pain management, you can also try your neighborhood 24/7 pharmacist. They can't diagnose you but again they might have tips to help you through the night until you can get proper care.
However, in the mean time there are ways to help.
1. If you don't already have one, get a Primary Care Physician. Go for a wellness visit, get their practice to know you. Then if something like that happens at 1am, you can call the office, leave a message and get a callback from a nurse within 15-30m who can help you through your options and help with over-the-counter options to make it through the night until the office opens (or until urgent care opens). Or of course they can counsel you to go to the ED if they think there's a risk. But the point is, you can already weed out some unnecessary ED visits that way.
Note: not all providers have that service, so it's best to enquire when selecting a physician.
2. Many insurers have a nurses hotline but few people know about it. Check your policy. In the same way, they can help triage your situation, though it's less ideal since they don't know your medical record so they will tend to play it safer (ie. higher likelihood to send you to the ED). But it's better than nothing.
3. If the issue is pain management, you can also try your neighborhood 24/7 pharmacist. They can't diagnose you but again they might have tips to help you through the night until you can get proper care.
The only way to get widespread 24 hour urgent care in the US is to make it a billing code in the emergency room. There's often already 24 hour urgent care available in major urban centers.
Of course, this raises the question. Why isn't urgent care a billing code in small emergency departments?
Of course, this raises the question. Why isn't urgent care a billing code in small emergency departments?
> Of course, this raises the question. Why isn't urgent care a billing code in small emergency departments?
Because it's still emergency physicians performing the work, for the same cost (both marginal and overhead).
The answer is to open up actual urgent care practices, which are cheaper to run, not to change the billing codes used in emergency room settings.
Because it's still emergency physicians performing the work, for the same cost (both marginal and overhead).
The answer is to open up actual urgent care practices, which are cheaper to run, not to change the billing codes used in emergency room settings.
I remain unconvinced that running an entire separate practice is obviously cheaper than adding primary care doctors to ERs. I'm sure it makes more financial sense given the current regulatory and reimbursement regimes.
I mean, when I've been in the local ER it hasn't exactly been a hive of urgent activity, you chat with the intake nurse and then watch her sit there and do things other than interact with patients for half an hour.
I mean, when I've been in the local ER it hasn't exactly been a hive of urgent activity, you chat with the intake nurse and then watch her sit there and do things other than interact with patients for half an hour.
> I remain unconvinced that running an entire separate practice is obviously cheaper than adding primary care doctors to ERs. I'm sure it makes more financial sense given the current regulatory and reimbursement regimes.
Emergency medicine and primary care are completely different settings. "Adding primary car doctors to ERs" doesn't really make any sense. The structure of care delivery is completely different.
Emergency medicine and primary care are completely different settings. "Adding primary car doctors to ERs" doesn't really make any sense. The structure of care delivery is completely different.
Is the structure of care delivery different for good reasons or is it different because ERs don't make accommodations in their care delivery for the many non-emergency cases that walk into ERs?
(and of course they don't because they aren't going to bill insurance companies any less than they can consistently get them to pay)
(and of course they don't because they aren't going to bill insurance companies any less than they can consistently get them to pay)
> Is the structure of care delivery different for good reasons or is it different because ERs don't make accommodations in their care delivery for the many non-emergency cases that walk into ERs?
Yes, the actual structure of care that is delivered is entirely different. You can't just stick primary care inside an ER and expect it to work. The two aren't similar.
Yes, the actual structure of care that is delivered is entirely different. You can't just stick primary care inside an ER and expect it to work. The two aren't similar.
Pushback lobbying from healthcare companies and the American College of Emergency Physicians, to be blunt.
Is that a rhetorical question?
>...receive care that (1) is not life-threatening but (2) can't wait till dawn.
How often does this happen? If it's not life threatening, why can't it wait until dawn?
How often does this happen? If it's not life threatening, why can't it wait until dawn?
For costs: medical service + profit + profit accounting overhead + cost shifting overhead > medical services
There was a period in time where there were very high losses in emergency rooms because there are legal obligations for conferring care in that setting. Many emergency rooms were getting closed down and that's also a big problem for communities. So it's in a way understandable (not necessarily excusable), because some of this I would infer is cost shifting to meet those obligations. Maybe it's shifted to too much profit now.
Both sides of the problem, IMHO come from completely disconnected cost/profit transaction loops in America's healthcare. It's one big reason why single payer systems cost so much less. There is a much more straightforward relation between costs, care, and budgets in those systems so you can actually manage the direct problems instead of managing multiple red-tape layers each trying to competitively maximize, minimize different areas.
There was a period in time where there were very high losses in emergency rooms because there are legal obligations for conferring care in that setting. Many emergency rooms were getting closed down and that's also a big problem for communities. So it's in a way understandable (not necessarily excusable), because some of this I would infer is cost shifting to meet those obligations. Maybe it's shifted to too much profit now.
Both sides of the problem, IMHO come from completely disconnected cost/profit transaction loops in America's healthcare. It's one big reason why single payer systems cost so much less. There is a much more straightforward relation between costs, care, and budgets in those systems so you can actually manage the direct problems instead of managing multiple red-tape layers each trying to competitively maximize, minimize different areas.
We are talking about ER rooms here: people who need ER services are not in a position to do any sort of shopping around. When seconds count you cannot afford the minutes needed to get to the next ER. In theory it is possible that one is significantly better and so it would be worth the time, but in practice all the ERs in any given area are going to be not very different in ability to provide care. Even if the closer ER transfers you to the other getting to the first in time started care sooner.
> We are talking about ER rooms here: people who need ER services are not in a position to do any sort of shopping around.
Yup. In 2006, I was in a serious bicycle accident in San Francisco w/ some head trauma. SF General was the only hospital in the area with a (Level 1?) ER that treats head trauma. I also had two broken arms. Even though I was in shock, I remember very clearly asking everyone involved in getting me from the accident site to the ER if SF General accepts Blue Cross, my insurance carrier. I was more concerned with facing a giant bill than my own health. Eventually someone said they do take Blue Cross, and I stopped worrying.
Later I came to find out that SF General bills Blue Cross, but they do not have a contract with Blue Cross. 100% of my treatment was out of network. Then I got a bill for about 50,000 USD. Between that, trying to pay for physical therapy, and a disruption to ability to earn a living at the job that paid for my healthcare, I struggled for a long time after the accident.
Yup. In 2006, I was in a serious bicycle accident in San Francisco w/ some head trauma. SF General was the only hospital in the area with a (Level 1?) ER that treats head trauma. I also had two broken arms. Even though I was in shock, I remember very clearly asking everyone involved in getting me from the accident site to the ER if SF General accepts Blue Cross, my insurance carrier. I was more concerned with facing a giant bill than my own health. Eventually someone said they do take Blue Cross, and I stopped worrying.
Later I came to find out that SF General bills Blue Cross, but they do not have a contract with Blue Cross. 100% of my treatment was out of network. Then I got a bill for about 50,000 USD. Between that, trying to pay for physical therapy, and a disruption to ability to earn a living at the job that paid for my healthcare, I struggled for a long time after the accident.
Were you able to negotiate that 50,000 bill down?
Eventually, yes. It took more than a year, and I eventually had to ask Gavin Newsom, the Mayor of San Francisco, for help. I highly recommend never having to negotiate how much you owe to multiple healthcare providers, unless you enjoy red tape & misery.
Isn't that in category of fraud? They lied you about pricing.
The people I was asking were ambulance drivers, paramedics, nurses, etc. They weren't prepared to answer questions about the nuances of insurance agreements the hospital has with random insurance companies. I can't blame them. And it's completely possible I was not asking the question in a precise enough answer to get the information I needed.
My main point was that your basically screwed before you arrive, and you're just gonna have to cope with it after the fact. Expecting a patient going into an emergency room to understand, or have the capacity to, navigate "the fine print" stuff is not realistic, yet that's exactly what they expect that patient to do. It is quite lame.
My main point was that your basically screwed before you arrive, and you're just gonna have to cope with it after the fact. Expecting a patient going into an emergency room to understand, or have the capacity to, navigate "the fine print" stuff is not realistic, yet that's exactly what they expect that patient to do. It is quite lame.
That does not really excuse the institution and a company might be fined in similar circumstance. It is not really random that you don't have a choice and nurse can't answer pricing issues correctly. Both don't just randomly happen to be beneficial for hospital. A lot of financial fraud by larger I stitutuon work exactly that way - put low level employees into situation where they are frauding either without knowing or by default or under pressure.
If all management has to do is look the other way and collect benefit (and eventually blame paramedic), they will look the other way and punish employees who took longer to get you to hospital - cause you prefered cheaper one a bit further away.
I don't expect injured patient to protect himself perfectly. However, I think we would all benefit if we labeled what happened to you accurately - a kind of fraud - instead of pretending it is ok, because system works that way.
If all management has to do is look the other way and collect benefit (and eventually blame paramedic), they will look the other way and punish employees who took longer to get you to hospital - cause you prefered cheaper one a bit further away.
I don't expect injured patient to protect himself perfectly. However, I think we would all benefit if we labeled what happened to you accurately - a kind of fraud - instead of pretending it is ok, because system works that way.
If you're using ERs for what they should be used for, then yeah, you're in shock, or bleeding out, or in mortal peril.
Many people do not use them correctly; I can't blame them sometimes, when that's the only option around, but there's a whole host of issues people drift into ERs for that ought to be solved by an aspirin and a night's sleep, or an urgent care clinic. In the past five years, there's been a huge explosion of Convenient MDs and the like springing up everywhere; honestly, if you just had a nurse practitioner or PA assigned or on-call at Rite-Aids or CVSs to write scripts for no-brainer prescription medications, you'd solve half the healthcare problems people deal with.
Many people do not use them correctly; I can't blame them sometimes, when that's the only option around, but there's a whole host of issues people drift into ERs for that ought to be solved by an aspirin and a night's sleep, or an urgent care clinic. In the past five years, there's been a huge explosion of Convenient MDs and the like springing up everywhere; honestly, if you just had a nurse practitioner or PA assigned or on-call at Rite-Aids or CVSs to write scripts for no-brainer prescription medications, you'd solve half the healthcare problems people deal with.
And you have conservatives in this country saying that the poor have access to health care anytime they want by using the emergency room. These are the same people who complain about the poor buying steaks with food stamps and still suggest the poor use the most expensive form of health care rather than ensuring a basic minimum of care be allowed for all citizens.
Be careful of that though. I recently went to the ER for "chest pain" it wasn't a heart attack, and I had every reason to believe before I went that it was just a listed side effect of my medication. However since it was chest pain I couldn't ignore it. This is not unusual, ~60% of ER chest pain visits are nothing. (I suspect that increasing that number to 75% would be a good thing as it would mean a few more people come in when it is something)
It turns out this isn't the case. London recently reorganized stroke services because it was shown that survival rates were much better if patients could be taken directly to a specialist unit, and now if you're suspected of having a stroke you'll go straight to one of 8 hyper-acute centers.
It's a perfect candidate for a socialized program. We all pay a tax to guarantee that ERs are available and equipped for everyone at a moment's notice.
Not to mentioned it's already a socialized program... who foots the bill when nobody pays? Me & you.
This is something that really bugs me about the socialized medicine debate in the US. We've had socialized medicine since the law was passed in 1986 that said ERs couldn't turn people away. Everything since then has just been a debate about how to socialize it and how to pay for it.
I would say the current rules are not socialized in any sort of good faith method. Certainly not in a way that provides transparency of costs and effectiveness. Nor in any way how a socialized universal healthcare system would approach it.
I 100% agree with you. Our capitalist overlords are resisting the intelligent socialization of an already poorly socialized program.
Medicare pays cost based rates (for all services) to small rural hospitals in part to ensure this. "Critical access hospital" is the keyword if you want to read more.
> Medicare pays cost based rates (for all services) to small rural hospitals in part to ensure this. "Critical access hospital" is the keyword if you want to read more.
They pay extra to small hospitals that don't receive enough privately-insured patients to break even on standard Medicare reimbursement rates. For other hospitals, they pay rates that are below-cost, and hospitals charge private insurers extra to make up the difference.
They pay extra to small hospitals that don't receive enough privately-insured patients to break even on standard Medicare reimbursement rates. For other hospitals, they pay rates that are below-cost, and hospitals charge private insurers extra to make up the difference.
Then what happens is everyone without insurance will go to ER for every little issue. Which is kind of what is informally happening now anyway.
Was this for another comment? I don't think I was suggesting any sort of shopping around solution...
Emergency departments are still loss leaders, at least at the hospitals I’ve worked with as a consultant. The hospitals make up for it through the referrals and imaging procedures generated by it.
If you can't choose to get your referrals and imaging done at a different hospital, then it's a bundle deal, not a loss leader. If you can transfer to a different hospital/clinic for referrals and imaging, it's a loss leader.
It's a mystery why hospitals are still considered worthy recipients of large gifts. People donate tens of millions of dollars for a hospital building, inside which the hospital proceeds to rapaciously overcharge its patients.
It's true that most hospitals themselves are non-profits, but the service providers in the hospital range from moderate capitalists to very predatory ones. Donating to the hospital just means they charge less overhead, and the medical corporations operating within them keep more. Doctors are great and all, but I don't feel like they need my charity.
It's true that most hospitals themselves are non-profits, but the service providers in the hospital range from moderate capitalists to very predatory ones. Donating to the hospital just means they charge less overhead, and the medical corporations operating within them keep more. Doctors are great and all, but I don't feel like they need my charity.
It's not a monopoly, it's a cartel. There are a dozen hospital networks near me, but they all have opaque pricing and billing, so they all charge like this.
You can try to regulate these facility fees, or force them to be made public, but as it stands there's no reason for them to go anywhere but up, indefinitely.
You can try to regulate these facility fees, or force them to be made public, but as it stands there's no reason for them to go anywhere but up, indefinitely.
Something I've noticed are advertisements for ERs. Really. I was a little shocked when I saw one on the way to work.
It says:
"Trouble breathing? Nausea and fever? Stomach pain? Our ER can help."
"What's your body telling you? Any one of these symptoms could be a warning sign of something serious. Our emergency room offers fast, expert care 24/7 to keep you healthy."
I had never really thought of hospitals, especially ERs, as a business before I saw that. I guess that was naive.
It says:
"Trouble breathing? Nausea and fever? Stomach pain? Our ER can help."
"What's your body telling you? Any one of these symptoms could be a warning sign of something serious. Our emergency room offers fast, expert care 24/7 to keep you healthy."
I had never really thought of hospitals, especially ERs, as a business before I saw that. I guess that was naive.
I saw a lot of these in Houston for some reason.
If you live in California, consider writing or calling your State Assemblymember in support of the Healthy California Act (http://www.healthycaliforniaact.org), which is stuck in the State Assembly right now. It would establish a single payer system for the state and let people get emergency care without these outrageous bills.
Wasn't that tried before and the estimated cost was more than the entire State of California budget?
The chance of that bill ever going anywhere is effectively zero.
The chance of that bill ever going anywhere is effectively zero.
I think I'd be in favor of introducing a public option and seeing how it competes with other commercial insurance options. Going completely single payer seems very risky, and could upset a large percentage of californians due to the subsequently necessary rise in taxes.
I wonder just how big those increases would be though. I've seen several informal surveys of my Facebook friends with respect to the cost of their health insurance, and numbers range from $400-$1200/mo. And keep in mind that many of these are subsidized by their employer. That seems like a lot of money that could be taxed. (i.e. you'd pay the tax instead of a health insurance premium)
The rational thought process is that yes, tax what would have been spent on health insurance premiums. However, in practice I'm not so certain that it would interpreted as such by taxpayers.
The problem there (but not necessarily a show stopping problem), is that private insurance could then pick out and kick out groups of customers according to profitability. The public option would likely end up picking up the most costly cases.
I pay (more precisely, my employer pays for me) more in health insurance premiums than I do in income taxes, so this isn't really surprising. Unless you're commenting on the magnitude of the project, then yes, it's something usually attempted by nations.
> it's something usually attempted by nations.
California has a larger economy than all but five nations in the world, so that doesn't seem like a major problem.
California has a larger economy than all but five nations in the world, so that doesn't seem like a major problem.
The cost was higher than the budget, but more relevant, lower then the cost of Californian's getting the same care from the current healthcare market.
The insured pay the price. Hospitals will never turn away a patient with a medical emergency - the inability of certain patients to pay is factored into hospital finances, raising the price for those who do pay.
Those who can't pay don't get their care for free. They'll be hounded by debt collectors the rest of their life, whatever credit they had will be trashed, and some will be pushed into bankruptcy. We are all paying for it.
Not when they just lie about their identity.
I don't see why you're getting down-voted. If you've got "bad" insurance that fake ID from college and memorizing 12 random digits is probably more useful when it comes to emergency care. Sad but true.
It has zero to do with problems of people who don't lie. None at all. And mojority don't. It amounts to "situation is ok, because I can point to some fraudster that is not suffering".
What exactly that has to do with someone being haunted for debt? Or is he suggesting you should fraud ER and you are suckers if you don't?
What exactly that has to do with someone being haunted for debt? Or is he suggesting you should fraud ER and you are suckers if you don't?
I wish I could upvote you twice to help with the other downvotes. I know of at least 3 cases so far where folks walk into ER and lie about who they are when they leave. All of the cases are because of no health insurance, but they aren't hounded by any debt collectors.
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The health care system has arbitrarily chosen the "hospital" as the place where nobody can be turned away.
If your kid has a possible ear infection or broken arm, and you have insurance, you go to an urgent care clinic. If you don't have insurance, you go to a hospital. In all other respects, the care is the same.
If your kid has a possible ear infection or broken arm, and you have insurance, you go to an urgent care clinic. If you don't have insurance, you go to a hospital. In all other respects, the care is the same.
If you go to urgent care you are seen in order of arrival. In the ER you are seen based on need. This results in very different care experiences. Also you should expect that urgent care is more familiar with the types of things people should go to urgent care for - while the ER can deal with them they may take longer.
The kid with the simple ear infection will wait longer in the ER. (Note that I added simple: if the ear infection is complex the ER may see the kid sooner, but those are cases where when Urgent care finally gets to the kid they transfer to the nearest ER)
The kid with the simple ear infection will wait longer in the ER. (Note that I added simple: if the ear infection is complex the ER may see the kid sooner, but those are cases where when Urgent care finally gets to the kid they transfer to the nearest ER)
> If you go to urgent care you are seen in order of arrival.
Most "decent" urgent care facilities will triage. That's one of the reason why you're asked why you're there on check-in (and also to ensure you're not complaining of something acutely emergent).
Most "decent" urgent care facilities will triage. That's one of the reason why you're asked why you're there on check-in (and also to ensure you're not complaining of something acutely emergent).
Will a privately operated urgent care clinic take somebody who has no insurance or means of paying?
Waiting time is a matter of how the facility is managed. If an ER is handling a lot of noncritical cases, they can set up a facility for handling those cases, which would look just like an urgent care clinic. In fact, I once had a minor injury and went to the ER, and was transferred to an urgent care clinic in the same building. I had insurance.
Waiting time is a matter of how the facility is managed. If an ER is handling a lot of noncritical cases, they can set up a facility for handling those cases, which would look just like an urgent care clinic. In fact, I once had a minor injury and went to the ER, and was transferred to an urgent care clinic in the same building. I had insurance.
The health care system has also chosen the hospital as the only place that's actually open. The nearest urgent care closes at 5 … which is worse than my bank.
> Hospitals will never turn away a patient with a medical emergency
No, but if you can't pay, and you won't drop dead in the next eight hours, they will try their best to toss your ass out onto the street after prescribing you a $900 bottle of aspirin.
No, but if you can't pay, and you won't drop dead in the next eight hours, they will try their best to toss your ass out onto the street after prescribing you a $900 bottle of aspirin.
US health care expenses per head are on the order of 2-3 times every other country on the planet.
Wen you're that far out of alignment, something is seriously wrong.
The US could scrap Medicare and use the savings to fund European style healthcare for everyone. You still get the option to top up with private health care, which can be pricey - $150 a month for a family, but there's always a base line to fall back to.
Wen you're that far out of alignment, something is seriously wrong.
The US could scrap Medicare and use the savings to fund European style healthcare for everyone. You still get the option to top up with private health care, which can be pricey - $150 a month for a family, but there's always a base line to fall back to.
You are correct, and there is something the US can do about high drug costs. We pass a law requiring Big Pharma to sell drugs in the US at the planet's lowest negotiated price. This will help shift R&D costs onto Europe, Canada, and Asia, because Big Pharma will of necessity spread that cost around.
> You are correct, and there is something the US can do about high drug costs. We pass a law requiring Big Pharma to sell drugs in the US at the planet's lowest negotiated price
So if a big drug company sells a drug very cheap in some poor third world country, they have to sell it for the same price in the US?
Wouldn't the most likely outcome of that be that they stop selling their drugs in poor countries?
So if a big drug company sells a drug very cheap in some poor third world country, they have to sell it for the same price in the US?
Wouldn't the most likely outcome of that be that they stop selling their drugs in poor countries?
> Wouldn't the most likely outcome of that be that they stop selling their drugs in poor countries?
And the poor countries would just make knock-offs, and sell them to other poor countries. The US as a whole would lose out because much of the US economy is based on the dubious concept of 'intellectual property'
And the poor countries would just make knock-offs, and sell them to other poor countries. The US as a whole would lose out because much of the US economy is based on the dubious concept of 'intellectual property'
> You are correct, and there is something the US can do about high drug costs. We pass a law requiring Big Pharma to sell drugs in the US at the planet's lowest negotiated price. This will help shift R&D costs onto Europe, Canada, and Asia, because Big Pharma will of necessity spread that cost around.
A way less intrusive way to ensure the same end result is to allow reimporting of prescription drugs.
There was a bill to do this last year, but unfortunately it was killed in the Senate.
A way less intrusive way to ensure the same end result is to allow reimporting of prescription drugs.
There was a bill to do this last year, but unfortunately it was killed in the Senate.
How is this less intrusive? I'd just reimport the hell out of drugs from the cheapest country I could find.
Instead the US is planning on cutting Medicare to pay for tax breaks for the rich. It will only get worse.
Putting aside the often absurd costs for a moment...
Many ERs are also severely overburdened, understaffed, and overcrowded often with very high ratios of non-emergency patients to emergency patients. This creates huge wait times for patients and puts significant stress on medical staff.
Talk to your friends, family, coworkers, almost everyone has a bad story to share, whether about absurd wait times, wild costs, billing screw-ups, insurance debacles...
And talk to your doctors and nurses too, they are just as frustrated.
Many ERs are also severely overburdened, understaffed, and overcrowded often with very high ratios of non-emergency patients to emergency patients. This creates huge wait times for patients and puts significant stress on medical staff.
Talk to your friends, family, coworkers, almost everyone has a bad story to share, whether about absurd wait times, wild costs, billing screw-ups, insurance debacles...
And talk to your doctors and nurses too, they are just as frustrated.
I never hear the Healthcare Insurance companies complaining. I guess they are too busy skimming off the top and weighing their profits.
We pay a far lesser portion of our GDP in Europe for health care and we have a longer life expectancy, higher chance of survival for the majority of cancer and cardiovascular diseases.
It’s not that hard to understand; you try to control market forces when you’re talking about inelastic demand because that kind of demand is an opportunity for serious abuse. Isn’t that the reason the US has its war on drugs? Yet it can’t see this more expensive and deadlier problem?
It’s not that hard to understand; you try to control market forces when you’re talking about inelastic demand because that kind of demand is an opportunity for serious abuse. Isn’t that the reason the US has its war on drugs? Yet it can’t see this more expensive and deadlier problem?
I always find it very odd that your average American puts up with the current system instead of revolting
as a kid growing up in the UK I remember watching (and not understanding at all) the episode of the Simpsons where Homer went to A&E, was told he needed a triple bypass urgently, couldn't afford it, and his condition got worse and worse
in my mind you went to the doctor/hospital when you were sick, and you came out well (or not at all), money didn't enter into it
I re-watched it again as an adult a few weeks ago, now with an understanding of HMOs, deductibles and previous condition waivers among other things, and found the episode to be really quite sad
as a kid growing up in the UK I remember watching (and not understanding at all) the episode of the Simpsons where Homer went to A&E, was told he needed a triple bypass urgently, couldn't afford it, and his condition got worse and worse
in my mind you went to the doctor/hospital when you were sick, and you came out well (or not at all), money didn't enter into it
I re-watched it again as an adult a few weeks ago, now with an understanding of HMOs, deductibles and previous condition waivers among other things, and found the episode to be really quite sad
Gasoline is an inelastic good but its price is relatively low and affordable because of the abundance of suppliers. In the US, local monopolies provide health care.
Gasoline is also affordable because individual needs tend to be fairly low and consistent.
Imagine what the gasoline market would look like if from time to time a person had to buy 100,000 gallons of gasoline or they would die.
Imagine what the gasoline market would look like if from time to time a person had to buy 100,000 gallons of gasoline or they would die.
Gas inelastic as a good, but gas vendors are easily substitutable with low friction. The vendor you get gas from one week doesn't need to be the same as the next. And that transaction, the purchase of gas is completely interchangeable and identical from one week to the next.
Medicare care in general does not have any of those characteristics (except for maybe annual checkups - but that's not where the bulk of medical costs are in our system). That has to do with the nature of the product and how it must be delivered, not necessarily with any monopoly effect. Even with a checkup, if you go to a different doctor every time that would reduce the effectiveness of the care.
Medicare care in general does not have any of those characteristics (except for maybe annual checkups - but that's not where the bulk of medical costs are in our system). That has to do with the nature of the product and how it must be delivered, not necessarily with any monopoly effect. Even with a checkup, if you go to a different doctor every time that would reduce the effectiveness of the care.
Gasoline is only inelastic compared to consumer goods. It's quite elastic compared to emergency medical care. The alternative to buying gas is to take a staycation or carpool to work. The alternative to treating emergencies is likely death.
How is that relevant?
In many European countries, gasoline taxes are quite high. Wikipedia's "Fuel tax" page says that in 2014 Germans paid US$6.14 per US gallon of gasoline.
Yet there is also an abundance of suppliers in Germany.
The hospitals in many European countries are publicly owned and operated. Quoting Wikipedia's "Healthcare in Denmark" page, "The central government plays a relatively limited role in health care in Denmark ... Hospital care is mainly provided by hospitals owned and run by the regions."
There are five such regions. Aren't there, using your argument, also five local monopolies in Denmark? But the situation in Denmark is nothing like the US.
In many European countries, gasoline taxes are quite high. Wikipedia's "Fuel tax" page says that in 2014 Germans paid US$6.14 per US gallon of gasoline.
Yet there is also an abundance of suppliers in Germany.
The hospitals in many European countries are publicly owned and operated. Quoting Wikipedia's "Healthcare in Denmark" page, "The central government plays a relatively limited role in health care in Denmark ... Hospital care is mainly provided by hospitals owned and run by the regions."
There are five such regions. Aren't there, using your argument, also five local monopolies in Denmark? But the situation in Denmark is nothing like the US.
I think you need to reread what I wrote and understand what I'm arguing.
The OP argued inelastic demand drives price gouging which isn't true in the case of gasoline. Price gouging in medicine isn't driven by inelasticity, its driven by a dearth of suppliers.
In Denmark, you have few suppliers but the suppliers you do have are owned and regulated by the government. It's not a relevant comparison. They are not a market-based supplier.
The OP argued inelastic demand drives price gouging which isn't true in the case of gasoline. Price gouging in medicine isn't driven by inelasticity, its driven by a dearth of suppliers.
In Denmark, you have few suppliers but the suppliers you do have are owned and regulated by the government. It's not a relevant comparison. They are not a market-based supplier.
It's not driven by the dearth of suppliers, it's driven by the impossibility of choosing the cheapest provider due to a combination of 1) the lack of transparency in hospital pricing; 2) not being able to anticipate your expenses; 3) the insurers being able to "cheat" by agreeing on lower prices with the providers; 4) insurers forming a cartel.
When there are so many forces pushing against the creation of a free market and a healthy balance between supply and demand, there is only one thing that the government can do: either socialize it (that's what happens with roads, for example), or regulate it like there's no tomorrow (that's what happens with utilities). However, in the US it is blasphemy to even suggest doing either thing to healthcare.
When there are so many forces pushing against the creation of a free market and a healthy balance between supply and demand, there is only one thing that the government can do: either socialize it (that's what happens with roads, for example), or regulate it like there's no tomorrow (that's what happens with utilities). However, in the US it is blasphemy to even suggest doing either thing to healthcare.
You're absolutely write to go after my "dearth of suppliers" point. It certainly is not the only reason for healthcare costs or even a large percentage. I even say so in a different comment.
1 and 2 are absolutely valid points and share responsibility for healthcare costs.
> However, in the US it is blasphemy to even suggest doing either thing to healthcare.
I wholeheartedly disagree with this. Healthcare is the most regulated industry in America.
1 and 2 are absolutely valid points and share responsibility for healthcare costs.
> However, in the US it is blasphemy to even suggest doing either thing to healthcare.
I wholeheartedly disagree with this. Healthcare is the most regulated industry in America.
I asked for clarification because I didn't understand what you are arguing. I don't think it helps to follow up by repeating that I need to understand.
I now understand your point, thank you.
I now understand your point, thank you.
I should apologize. I interpreted your question as rhetorical, rather than genuine, which is why I asked you to re-read my point. My mistake.
There are other ways to travel than by car, you can walk for example. Trains, light rails, bikes and electric cars don’t use gasoline and are options, if you make sacrifices.
There’s no alternative sacrifices you can make to solve your cancer problem, though; you need a doctor and the right treatment.
Gasoline is also a very bad example. They get loads of tax breaks from local, state and federal governments because they are too big to fail in terms of jobs, revenue and utility. They also get a lot of help when they have to clean up tgeir mess. That’s what I would call subsidy.
There’s no alternative sacrifices you can make to solve your cancer problem, though; you need a doctor and the right treatment.
Gasoline is also a very bad example. They get loads of tax breaks from local, state and federal governments because they are too big to fail in terms of jobs, revenue and utility. They also get a lot of help when they have to clean up tgeir mess. That’s what I would call subsidy.
You're missing the point. Gas is priced competitively in areas where there are no alternatives to its purchase. This is possible because there are lots of people who compete to supply gas. Basic econ 101.
With hospitals, you have one local monopoly to choose from. Therefore you get monopoly pricing.
Yes, if you're shot, you're not going to be too choosy about where the ambulance takes you. But most medical emergencies have some lead up to diagnosis and some wait time for the actual operation.
Even cancer is not treated immediately. You schedule an appointment to have it treated over a long period of time.
Now with all this time, you theoretically have the ability to compare suppliers. But in our world, there is one regional monopoly providing care.
THAT ISN'T THE ONLY REASON CARE IS EXPENSIVE. But it is a factor worth talking about and considering.
With hospitals, you have one local monopoly to choose from. Therefore you get monopoly pricing.
Yes, if you're shot, you're not going to be too choosy about where the ambulance takes you. But most medical emergencies have some lead up to diagnosis and some wait time for the actual operation.
Even cancer is not treated immediately. You schedule an appointment to have it treated over a long period of time.
Now with all this time, you theoretically have the ability to compare suppliers. But in our world, there is one regional monopoly providing care.
THAT ISN'T THE ONLY REASON CARE IS EXPENSIVE. But it is a factor worth talking about and considering.
You wrote: "But most medical emergencies have some lead up to diagnosis and some wait time for the actual operation. ... Now with all this time, you theoretically have the ability to compare suppliers. But in our world, there is one regional monopoly providing care."
Even when there is more than source of care and when there is plenty of time and the person is interesting in comparison shopping, in practice that is still difficult to do in the US.
Last year there was a piece by Johnny Harris at Vox titled "I tried to find out how much my son's birth would cost. No one would tell me." https://www.vox.com/2016/5/5/11591592/birth-cost-hospital-bi...
Childbirth is the #1 reason why people go to the hospital. If the price estimate isn't available for an average/low-risk birth, then it's not going to be available for other procedures.
And again, this includes areas where there are multiple hospitals which provide maternity services, so your explanation of "local monopoly" isn't enough. (Quoting https://www.womenshealthmag.com/mom/costs-of-giving-birth : "this charging system often results in "wildly inflated" costs, and they can vary from hospital to hospital—even if you're just looking at ones in the same neighborhood.")
Your "basic econ 101" quip doesn't go very far to explain why it is that the governmental organizations which regulate these hospitals aren't, you know, regulating them to prevent such "basic econ 101" problems.
What's the point of giving them a local monopoly if they are going to abuse it?
Even when there is more than source of care and when there is plenty of time and the person is interesting in comparison shopping, in practice that is still difficult to do in the US.
Last year there was a piece by Johnny Harris at Vox titled "I tried to find out how much my son's birth would cost. No one would tell me." https://www.vox.com/2016/5/5/11591592/birth-cost-hospital-bi...
Childbirth is the #1 reason why people go to the hospital. If the price estimate isn't available for an average/low-risk birth, then it's not going to be available for other procedures.
And again, this includes areas where there are multiple hospitals which provide maternity services, so your explanation of "local monopoly" isn't enough. (Quoting https://www.womenshealthmag.com/mom/costs-of-giving-birth : "this charging system often results in "wildly inflated" costs, and they can vary from hospital to hospital—even if you're just looking at ones in the same neighborhood.")
Your "basic econ 101" quip doesn't go very far to explain why it is that the governmental organizations which regulate these hospitals aren't, you know, regulating them to prevent such "basic econ 101" problems.
What's the point of giving them a local monopoly if they are going to abuse it?
> What's the point of giving them a local monopoly if they are going to abuse it?
Exactly. We need to be rid of it.
> Your "basic econ 101" quip doesn't go very far to explain why it is that the governmental organizations which regulate these hospitals aren't, you know, regulating them to prevent such "basic econ 101" problems.
My quip was directed at gas prices exclusively.
I don't have an explanation as to why the government does what is does. It seems to me it does everything in its power to make things worse. That's why I'd like to see less government in this industry.
> Even when there is more than source of care and when there is plenty of time and the person is interesting in comparison shopping, in practice that is still difficult to do in the US.
This is true for some cases and false for others.
In the cases its true, I believe its at least partially due to the fact that these hospitals have huge amounts of market power. Whether thats monopolistic or oligopolistic market power I leave to your judgement. But it undoubtedly plays a part. https://www.ftc.gov/system/files/documents/public_statements...
In the cases its false: wellness, vision, dental, ENT. Practices are very upfront about their costs. Even though these might entail shooting lasers into a person's eyes or putting a person under general anesthesia.
Why is it that I can call any dental office in America and immediately get a quote on a procedure but I can't call one of the two hospitals in my area and get a single price on anything at all?
I ask that genuinely. Why the difference? There are areas of the healthcare industry where its trivial and areas where its impossible to know.
Exactly. We need to be rid of it.
> Your "basic econ 101" quip doesn't go very far to explain why it is that the governmental organizations which regulate these hospitals aren't, you know, regulating them to prevent such "basic econ 101" problems.
My quip was directed at gas prices exclusively.
I don't have an explanation as to why the government does what is does. It seems to me it does everything in its power to make things worse. That's why I'd like to see less government in this industry.
> Even when there is more than source of care and when there is plenty of time and the person is interesting in comparison shopping, in practice that is still difficult to do in the US.
This is true for some cases and false for others.
In the cases its true, I believe its at least partially due to the fact that these hospitals have huge amounts of market power. Whether thats monopolistic or oligopolistic market power I leave to your judgement. But it undoubtedly plays a part. https://www.ftc.gov/system/files/documents/public_statements...
In the cases its false: wellness, vision, dental, ENT. Practices are very upfront about their costs. Even though these might entail shooting lasers into a person's eyes or putting a person under general anesthesia.
Why is it that I can call any dental office in America and immediately get a quote on a procedure but I can't call one of the two hospitals in my area and get a single price on anything at all?
I ask that genuinely. Why the difference? There are areas of the healthcare industry where its trivial and areas where its impossible to know.
Actually this is wrong. There is an abundance of retailers to buy your gas from. However in any given area they ALL get their gas from the same refinery. Any retailer that doesn't will have to to pay much higher shipping fees and thus cannot compete. That means the refinery has a monopoly even though you have a choice of names on the sign. (note that the station can choose additives so it isn't completely irrelevant)
During the golf war (first) I used to laugh at gas stations advertising that they sell gas made in the US. The refinery is in the US, but all the crude came from Canada. (This of course only applies the particular city I lived in at the time)
During the golf war (first) I used to laugh at gas stations advertising that they sell gas made in the US. The refinery is in the US, but all the crude came from Canada. (This of course only applies the particular city I lived in at the time)
The 5-year survival rate for cancers is much better in the US than Europe. It's what you'd expect for all the money spent, whether it is worth it is unclear.
https://www.ncbi.nlm.nih.gov/books/NBK62584/table/ch9.t1/?re...
For heart attack survival, the US isn't the best, but ranks somewhere in the top 4 depending on the data and criteria.
There are a bunch of issues that adversely affect life expectancy in the US not directly related to the health care system. High violent crime rate, much greater dependence on driving cars, standard american diet, opioid crisis (maybe we can blame some of this on the health care system).
https://www.ncbi.nlm.nih.gov/books/NBK62584/table/ch9.t1/?re...
For heart attack survival, the US isn't the best, but ranks somewhere in the top 4 depending on the data and criteria.
There are a bunch of issues that adversely affect life expectancy in the US not directly related to the health care system. High violent crime rate, much greater dependence on driving cars, standard american diet, opioid crisis (maybe we can blame some of this on the health care system).
> The 5-year survival rate for cancers is much better in the US than Europe. It's what you'd expect for all the money spent, whether it is worth it is unclear.
Note that survival rate is measured from when the cancer is diagnosed. For many of those cancers the US screens for them more frequently than they do in the rest of the world.
If Alice and Bob both get cancer in 2015 which will kill them in 2021, and Alice lives in a place where they screen for it every year she will survive for 5 years after diagnoses. If Bob lives someplace where they only screen every 4 years and he was last screened in 2014 he will only survive 3 years after diagnoses. Same cancer, same outcome in the same number of years, but Alice counts as a 5 year survivor and Bob does not.
Another thing to watch out for when comparing health systems across countries is different definitions. For instance the US generally has a higher infant mortality rate than other western countries, but at least part of that is because of different definitions.
For example, a very premature baby with very low birth weight has essentially no chance of survival. In much of the world this would be counted as a stillbirth. In much of the US, however, if it was not actually dead at birth it will be counted as a live birth. Result: a few minutes or hours later, when it actually dies, it is infant mortality in the US statistics and not infant mortality elsewhere.
(These definitional differences are not enough to explain the higher infant mortality in the US, but they do close the gap a bit).
Note that survival rate is measured from when the cancer is diagnosed. For many of those cancers the US screens for them more frequently than they do in the rest of the world.
If Alice and Bob both get cancer in 2015 which will kill them in 2021, and Alice lives in a place where they screen for it every year she will survive for 5 years after diagnoses. If Bob lives someplace where they only screen every 4 years and he was last screened in 2014 he will only survive 3 years after diagnoses. Same cancer, same outcome in the same number of years, but Alice counts as a 5 year survivor and Bob does not.
Another thing to watch out for when comparing health systems across countries is different definitions. For instance the US generally has a higher infant mortality rate than other western countries, but at least part of that is because of different definitions.
For example, a very premature baby with very low birth weight has essentially no chance of survival. In much of the world this would be counted as a stillbirth. In much of the US, however, if it was not actually dead at birth it will be counted as a live birth. Result: a few minutes or hours later, when it actually dies, it is infant mortality in the US statistics and not infant mortality elsewhere.
(These definitional differences are not enough to explain the higher infant mortality in the US, but they do close the gap a bit).
Agree with all you've said, and your point about more screening in the US is another reason costs are higher. Both because more screenings cost more money, and the more stuff you find, the more costly interventions it leads to.
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It becomes much worse for the US when you frame it like this; ”if a given American gets diagnosed with a potentially fatal cancer, what is the chance for survival?” because then if the person can’t afford the therapy they need it looks very dire.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3699851/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3699851/
Interesting data, but it really doesn't look worse (vis a vis Europe). E.g., the 5 year cancer survival rates for uninsured americans who are diagnosed prostate cancer are still much higher than Europe, and breast cancer is about the same. And given the context of today, 91% of people have insurance. So for a given person in the US, high probability of better 5 year prognosis.
And in some cancer types the probability of death rises by 198% and becomes 97% without being insured. Prostate and breast cancer are common but they are not the majority of cases alone.
And in the context today, a very high proportion of Americans can’t afford parts or all of tgeir cancer treatment costs, in spite of being insured.
https://www.ncbi.nlm.nih.gov/m/pubmed/23442307/
And in the context today, a very high proportion of Americans can’t afford parts or all of tgeir cancer treatment costs, in spite of being insured.
https://www.ncbi.nlm.nih.gov/m/pubmed/23442307/
It's hard to get people to see this is an expensive and deadly problem when their paycheck depends on them not seeing it.
ERs are one of the few places where hospitals actually earn a profit. My partner fights on behalf of hospitals when insurance companies deny a claim. And over the past years, insurance companies have taken to denying valid claims just to get out of paying. An egregious example being a patient that needed heart surgery and the insurance company deemed it medically unnecessary because they claim he should have been observation only.
Claims denial departments are exploding, they used to be 4-8 person teams for a major hospital five years ago. Today my partner has 32 direct employees at a much smaller, regional hospital.
Hospitals have come to the realization that it's basically impossible for insurance companies to deny ER claims. After all, the patient came in with an "emergency."
Claims denial departments are exploding, they used to be 4-8 person teams for a major hospital five years ago. Today my partner has 32 direct employees at a much smaller, regional hospital.
Hospitals have come to the realization that it's basically impossible for insurance companies to deny ER claims. After all, the patient came in with an "emergency."
> An egregious example being a patient that needed heart surgery and the insurance company deemed it medically unnecessary because they claim he should have been observation only.
United Healthcare got in hot water for denying coverage for airlift EMS for MVA victims saying that the "trip wasn't preauthorized with the insurer"...
United Healthcare got in hot water for denying coverage for airlift EMS for MVA victims saying that the "trip wasn't preauthorized with the insurer"...
If you are interested in the various failures of the American health care system, I recommend reading Catastrophic Care by David Goldhill. It's a bit depressing, but eye-opening.
One of the ways consumers can push back on this is by becoming educated on health care practice. I would never have let a hospital give me a CT scan for a simple throat problem.
Then there are other issues that (supposedly) you have no control over. When I was hit on my bike, I refused the trip in the ambulance to a hospital. But when I got worse just an hour later, I ordered a taxi to go to an urgent care clinic. The clinic said I needed to be treated at a hospital, and then insisted that they would not let me leave except in an ambulance - which I then had to pay for.
Another thing that's stupid: apparently you have to pay for your ambulance ride in Pinellas County, Florida, but you never have to pay for your ride in Montgomery County, Maryland.
The reason you don't have to pay in Montgomery County? The state forced the county to shoulder tens of millions of dollars in teaching funds, and they had to come up with the money - so they made a law that county EMS could directly bill insurers, and this money goes directly to the county.
Then there are other issues that (supposedly) you have no control over. When I was hit on my bike, I refused the trip in the ambulance to a hospital. But when I got worse just an hour later, I ordered a taxi to go to an urgent care clinic. The clinic said I needed to be treated at a hospital, and then insisted that they would not let me leave except in an ambulance - which I then had to pay for.
Another thing that's stupid: apparently you have to pay for your ambulance ride in Pinellas County, Florida, but you never have to pay for your ride in Montgomery County, Maryland.
The reason you don't have to pay in Montgomery County? The state forced the county to shoulder tens of millions of dollars in teaching funds, and they had to come up with the money - so they made a law that county EMS could directly bill insurers, and this money goes directly to the county.
> and then insisted that they would not let me leave except in an ambulance - which I then had to pay for.
As an EMS provider, that is against the law. As long as you can show competence and comprehension, you are entitled (as you did with the ambulance in the first place) to refuse care, or any part of it ("You can dress my wounds, but not transport me"). They may wish to document your refusal AMA ("Against Medical Advice") for their liability / stave off abandonment claims, but "refusing to let you leave" is akin to kidnapping, no different to if anyone else had done it.
(Psych holds and such in my area require Law Enforcement involvement, even on scene, as they are the only people authorized to actually 'enforce' the involuntary transport/hold laws, though it's with our recommendation).
As an EMS provider, that is against the law. As long as you can show competence and comprehension, you are entitled (as you did with the ambulance in the first place) to refuse care, or any part of it ("You can dress my wounds, but not transport me"). They may wish to document your refusal AMA ("Against Medical Advice") for their liability / stave off abandonment claims, but "refusing to let you leave" is akin to kidnapping, no different to if anyone else had done it.
(Psych holds and such in my area require Law Enforcement involvement, even on scene, as they are the only people authorized to actually 'enforce' the involuntary transport/hold laws, though it's with our recommendation).
> One of the ways consumers can push back on this is by becoming educated on health care practice. I would never have let a hospital give me a CT scan for a simple throat problem.
The average person doesn't have time to become enough of a medical expert to second guess their doctors about everything.
The average person doesn't have time to become enough of a medical expert to second guess their doctors about everything.
Anyone have any good data on the profitability of hospitals? I've always gotten the feeling that they are generally not making a whole lot of money, but I don't have much data to back it up. Is this kind of data even public?
You can construct a narrative for a bunch of different situations for Hospitals:
* High ER costs in order to offset the large number of people who just can't pay, but need to be treated anyways. * High costs in order to deal with all the regulatory requirements on Hospitals (it seems everything is regulated in a hospital, down to the kind of TP in the bathrooms). * High costs because hospitals have local monopolies and can screw patients. * etc.
I don't have enough data to figure out which one of these is the "right" version of the facts. Does anyone else?
You can construct a narrative for a bunch of different situations for Hospitals:
* High ER costs in order to offset the large number of people who just can't pay, but need to be treated anyways. * High costs in order to deal with all the regulatory requirements on Hospitals (it seems everything is regulated in a hospital, down to the kind of TP in the bathrooms). * High costs because hospitals have local monopolies and can screw patients. * etc.
I don't have enough data to figure out which one of these is the "right" version of the facts. Does anyone else?
Idea: yelp for hospitals. With list all prices and fees.
Not that this will solve the problem but it's better than finding out you owe $3k a week later.
Not that this will solve the problem but it's better than finding out you owe $3k a week later.
I like the concept in general but it's infeasible here in the US for a third party to survey prices and post results. Insurance plans renegotiate individual prices with providers, and each plan decides on coverage. The only way it could change would be if providers (and insurers) were to do it on their own, but they have no motivation to do so. I think only regulation or a seriously disruptive/innovative competitive force could do this.
Hospitals should be required to post price sheets. If they take a dozen insurance plans with negotiated prices, then they post a dozen price lists. There's no way this should be secret.
Check this out: https://www.oshpd.ca.gov/chargemaster/default.aspx
You can download chargemasters for many (most?) California hospitals, over the past 10 years, in Excel format. I downloaded one sample and it has a list of 3700 prices, some of which are as high as $84,000.
I'm really happy to discover this resource exists, but is anyone republishing the prices in a format consumers can work with? These sheets need UX design.
You can download chargemasters for many (most?) California hospitals, over the past 10 years, in Excel format. I downloaded one sample and it has a list of 3700 prices, some of which are as high as $84,000.
I'm really happy to discover this resource exists, but is anyone republishing the prices in a format consumers can work with? These sheets need UX design.
They already do, they are called chargemasters. However, they don't post the negotiated price lists since they have hundreds of contracts and thus hundreds of lists.
If you seriously require the services of an ER, you're not going to be in a position where you want to spend time comparison shopping.
Relevant: https://www.youtube.com/watch?v=Tct38KwROdw
The "existing legislation and regulation" section is pretty interesting for wikipedia: https://en.wikipedia.org/wiki/Chargemaster
The "existing legislation and regulation" section is pretty interesting for wikipedia: https://en.wikipedia.org/wiki/Chargemaster
That's really cool. I think of California as "legislation heavy" - sometimes that carries a negative connotation. But in this case, it's positive. The hospitals really do have to post their chargemasters online!
https://www.oshpd.ca.gov/Chargemaster/default.aspx
https://www.oshpd.ca.gov/Chargemaster/default.aspx
Better idea: single payer healthcare
I'm amazed at the stupidity permeating this thread ( and wiling to burn karma to defend against it).
A random guy wakes up at 1am with a cramped muscle. Goes to facility that is equipped to deal with anything. On the spot surgeries, ability to break teeth safely to intubate and keep alive, drugs, cabinets with up to date equipment. Staffed with non-expired drugs that are regularly recycled. Staffed with people that can use all that round the clock, multiple backups. Staffed with people that keep the place reasonably sterile and safe. Staffed with all others to support an operation like that and expecting to get sued if it fails even a bit.
And then complains, he had to pitch in for all that. An engineer, most likely earning above 8k usd, had to give a weekly salary for something that he considered worth dragging his butt out of bed at 1 am.
The guy is delusional.
The US health care is, on the expensive side, and can be better, but nobody can argue it without taking into account all that goes into maintaining that, just so one can randomly walk inside with a spasm, or after a huge carcrash with 40 broken bones, and liters of blood lost, and probably stay alive.
I'm also amazed how most people here just ignore the reality of the scope of the overall operation, and claim that for a limited use case, it's too expensive.
I'm not even going to insert a car analogy here. If you can't see why health care by nature is socialized and a utilitarian model, I'm not going to argue with people from USA thinking that everything should be proportional to the service and their pocket.
Man up. You are not the center of the universe. This civilization was built for you, by people, and no matter if you like it or not, you will pay to maintain it for the people coming after you.
Humanity, is a social concept worth defending.
A random guy wakes up at 1am with a cramped muscle. Goes to facility that is equipped to deal with anything. On the spot surgeries, ability to break teeth safely to intubate and keep alive, drugs, cabinets with up to date equipment. Staffed with non-expired drugs that are regularly recycled. Staffed with people that can use all that round the clock, multiple backups. Staffed with people that keep the place reasonably sterile and safe. Staffed with all others to support an operation like that and expecting to get sued if it fails even a bit.
And then complains, he had to pitch in for all that. An engineer, most likely earning above 8k usd, had to give a weekly salary for something that he considered worth dragging his butt out of bed at 1 am.
The guy is delusional.
The US health care is, on the expensive side, and can be better, but nobody can argue it without taking into account all that goes into maintaining that, just so one can randomly walk inside with a spasm, or after a huge carcrash with 40 broken bones, and liters of blood lost, and probably stay alive.
I'm also amazed how most people here just ignore the reality of the scope of the overall operation, and claim that for a limited use case, it's too expensive.
I'm not even going to insert a car analogy here. If you can't see why health care by nature is socialized and a utilitarian model, I'm not going to argue with people from USA thinking that everything should be proportional to the service and their pocket.
Man up. You are not the center of the universe. This civilization was built for you, by people, and no matter if you like it or not, you will pay to maintain it for the people coming after you.
Humanity, is a social concept worth defending.
False dichotomy. Yes, emergency rooms are a marvel of modern planning and materials. But just because they are impressive does not mean they need be expensive, or that such efficiency must be difficult to implement. The initial costs for the mediine is all front-loaded, in the R&D. The actual manufacturing of previously discovered medicine is cheap and trivial. The same is the case for many of the efforts of nurses and doctors (not to belittle their jobs), but they aren't doing R&D. They are following memorized checklists of knowledge, triaging based on information that was discovered elsewhere, then imported to their classrooms. All of this cost is also front-loaded.
Grifters, middlemen, and oligopolies are why healthcare is expensive in America. There is no reason we can't fund expensive R&D and also get cheap medicine.
Grifters, middlemen, and oligopolies are why healthcare is expensive in America. There is no reason we can't fund expensive R&D and also get cheap medicine.
I can't upvote this enough.
> Yes, emergency rooms are a marvel of modern planning and materials.
Additionally, they're not good enough.
I've helped a friend go through a traumatic ER experience where she suffered 3 strokes and they released her from ER 3 times saying she was fine before she called me for help. We got her psych-eval'd so that they couldn't release her for 72 hours, so they had to run tests, and lo and behold, they did the CT that showed she had 3 strokes. This was at a world famous hospital.
Sadly, this isn't an exceptional story. Most folks don't believe it until they've experienced something like this personally. While I hope most people never have to experience this, we need more people to understand that this is a real problem.
Anytime you're in a hospital, make sure you or someone close to you (ideally w legal authority to make decisions on your behalf) can fight for your care.
Point is, yes they are amazing compared to an alternative of nothing. We have come far. But we can do better. They are by no means a paragon. Pick any part of healthcare, and there's room for improvement.
> Yes, emergency rooms are a marvel of modern planning and materials.
Additionally, they're not good enough.
I've helped a friend go through a traumatic ER experience where she suffered 3 strokes and they released her from ER 3 times saying she was fine before she called me for help. We got her psych-eval'd so that they couldn't release her for 72 hours, so they had to run tests, and lo and behold, they did the CT that showed she had 3 strokes. This was at a world famous hospital.
Sadly, this isn't an exceptional story. Most folks don't believe it until they've experienced something like this personally. While I hope most people never have to experience this, we need more people to understand that this is a real problem.
Anytime you're in a hospital, make sure you or someone close to you (ideally w legal authority to make decisions on your behalf) can fight for your care.
Point is, yes they are amazing compared to an alternative of nothing. We have come far. But we can do better. They are by no means a paragon. Pick any part of healthcare, and there's room for improvement.
I think you are underestimating the amount of experience and intuition it takes to be an effective medical professional.
I think you are overestimating the portion of the cost that comes from the experience and intuition of doctors and underestimating the portion of the cost that comes from bureaucracy and simple exploitation.
There have been some immensely interesting articles about price variations in chargemaster documents between hospitals.
https://www.pbs.org/newshour/health/new-report-shows-stagger...
There have been some immensely interesting articles about price variations in chargemaster documents between hospitals.
https://www.pbs.org/newshour/health/new-report-shows-stagger...
> There have been some immensely interesting articles about price variations in chargemaster documents between hospitals.
In isolation, those prices are meaningless and can't be compared between two different hospital - even two different hospitals in the same network.
Hospitals make a marginal loss on patients who are on Medicare and Medicaid. They mark up the list prices of everything else to private insurers in order to make up the difference. The way that those markups are distributed doesn't really reveal anything, and even the aggregate size of the markup doesn't reveal anything other than a vague correlation with the proportion of their patient population that is on public insurance.
(That's even assuming that the private insurers pay the prices they are charged, which is never true - they negotiate for lower prices, although they are still required to pay more than Medicare does).
In isolation, those prices are meaningless and can't be compared between two different hospital - even two different hospitals in the same network.
Hospitals make a marginal loss on patients who are on Medicare and Medicaid. They mark up the list prices of everything else to private insurers in order to make up the difference. The way that those markups are distributed doesn't really reveal anything, and even the aggregate size of the markup doesn't reveal anything other than a vague correlation with the proportion of their patient population that is on public insurance.
(That's even assuming that the private insurers pay the prices they are charged, which is never true - they negotiate for lower prices, although they are still required to pay more than Medicare does).
Plenty of countries provide emergency and late night/weekend care without putting people into massive debt for it. Of course there are places where people are worse off than us, but there are places better off than us too. I'm not going to eat the exact same Tostino's pizza every night and say "That's good enough" just because in some countries people are dying of thirst and starvation. You don't stop improving things just because it's worse off elsewhere.
It is so great that we have an ER available to most people here at all times. But we can still do better with it. If you get in a car crash and they have to rush you to the nearest ER you don't get to shop around or choose, which is why it's a monopoly. They can charge you whatever price they want very specifically because your life literally depends on it. There's no market freedom in that. That's why healthcare shouldn't be left to just the free market. That's why so many countries have social healthcare. Sure the engineer you mentioned could handle it, an engineer can handle most financial burdens but not everyone is an engineer. One ER trip can make fixing your credit nearly impossible, and then you can't get a car(required in many areas of the USA due to how cities are planned) or a house, certain jobs, emergency loans, etc.
It's not "a little on the expensive side", it's "How much can we milk you for with your life on the line?"
It is so great that we have an ER available to most people here at all times. But we can still do better with it. If you get in a car crash and they have to rush you to the nearest ER you don't get to shop around or choose, which is why it's a monopoly. They can charge you whatever price they want very specifically because your life literally depends on it. There's no market freedom in that. That's why healthcare shouldn't be left to just the free market. That's why so many countries have social healthcare. Sure the engineer you mentioned could handle it, an engineer can handle most financial burdens but not everyone is an engineer. One ER trip can make fixing your credit nearly impossible, and then you can't get a car(required in many areas of the USA due to how cities are planned) or a house, certain jobs, emergency loans, etc.
It's not "a little on the expensive side", it's "How much can we milk you for with your life on the line?"
Yeah, you're totally right. Running an ER has huge fixed costs. Running an ER will inevitably have huge fixed costs because emergencies are, by definition, unexpected so they have to be ready for anything.
In most of the developed world those fixed costs are amortized over everyone, in the form of government subsidies of one sort or another. It's like the police or the fire department; everyone chips in some, via taxes, to keep the service running whether they currently need it or not.
In America, however, we amortize them over everyone who comes into the ER. That's good for the guy who never needs medical attention: he gets all the peace of mind of having state of the art care a phone call away for free. It's good for the lady who rolls in at 3am with a gunshot wound: she gets her very elaborate lifesaving care for only a few percent over the marginal costs. It really sucks, though, for the guy with a dislocated thumb: he's forced to either massively cross-subsidize both the other patients or to forgo necessary but relatively simple care because of the huge expense. That guy doesn't need to believe the system should be free to have a valid complaint that he, personally, is getting screwed over by it.
In most of the developed world those fixed costs are amortized over everyone, in the form of government subsidies of one sort or another. It's like the police or the fire department; everyone chips in some, via taxes, to keep the service running whether they currently need it or not.
In America, however, we amortize them over everyone who comes into the ER. That's good for the guy who never needs medical attention: he gets all the peace of mind of having state of the art care a phone call away for free. It's good for the lady who rolls in at 3am with a gunshot wound: she gets her very elaborate lifesaving care for only a few percent over the marginal costs. It really sucks, though, for the guy with a dislocated thumb: he's forced to either massively cross-subsidize both the other patients or to forgo necessary but relatively simple care because of the huge expense. That guy doesn't need to believe the system should be free to have a valid complaint that he, personally, is getting screwed over by it.
Please, US is spending more percentage of GDP than France on health.
https://data.worldbank.org/indicator/SH.XPD.TOTL.ZS?end=2014...
Come here in France and appreciate that you can go to the ER for ANYTHING (went 4 times last year for my kids because of bad cough and head injury), and not pay a dime. And they have the same kind of infrastructure to maintain here too, CT scanners, emergency rooms, surgeons and all.
You cannot tell people that the guy is hallucinating hidden costs. It is the health system that is hallucinating these costs. It is a race to the top of who is going to charge the most.
https://data.worldbank.org/indicator/SH.XPD.TOTL.ZS?end=2014...
Come here in France and appreciate that you can go to the ER for ANYTHING (went 4 times last year for my kids because of bad cough and head injury), and not pay a dime. And they have the same kind of infrastructure to maintain here too, CT scanners, emergency rooms, surgeons and all.
You cannot tell people that the guy is hallucinating hidden costs. It is the health system that is hallucinating these costs. It is a race to the top of who is going to charge the most.
Is that an appropriate comparison?
If I pay my insurer $X in premiums, and they pay $X for health care, is that 2*$X GDP , vs if the government collects taxes (not GDP) and then pays $X for my healthcare?
Okay, but France is not known for its stellar economy or the prosperity of its people. Over here, at least, France is known for its stifling amount of government control when it comes to anything economic. It’s possible these things are related. (Just sayin’!)
Stellar compared to what? Anomalies like the US? Petrostates like Norway or Saudi Arabia?
By world standards France is doing fine.
By world standards France is doing fine.
The comment was a criticism of the US as compared to France. So you can’t write off the US as an anomaly because that comparison was the whole point!
The US is a large political entity and comparing it to France isn't fair. A better comparison is to the entire EU, both in terms of population and ecomomy. Where there's France there's states like Georgia which are neither the best nor the worst.
I'm not entirely sure you read the article. The article discusses that there are 5 categories of care and that step throat is billed equally as a gun shot wound due to market failure and lack of competition.
I'm not sure anyone is arguing that he should be paying the unit cost without anything going to overhead, but it seems reasonable that strep throat could be treated with antibiotics and be labelled a Category 1.
I had this same situation play out with my daughter where we were concerned with appendicitis and it turned out to be gas. Still was considered a Level 5 even though I protested. Nothing you can do about it. What are you going to do negotiate with the staff at 9pm while your daughter is hurting? What leverage does anyone have in that situation?! You going to risk being a social parriah and risk your family relationships to save money?
I'm not sure anyone is arguing that he should be paying the unit cost without anything going to overhead, but it seems reasonable that strep throat could be treated with antibiotics and be labelled a Category 1.
I had this same situation play out with my daughter where we were concerned with appendicitis and it turned out to be gas. Still was considered a Level 5 even though I protested. Nothing you can do about it. What are you going to do negotiate with the staff at 9pm while your daughter is hurting? What leverage does anyone have in that situation?! You going to risk being a social parriah and risk your family relationships to save money?
Isn't level 5 billing just noting that the diagnostic decision making was complex and complete enough to warrant billing that much? It requires that one perform a complete history, a complete physical exam, and warrant "high complexity medical decision making".
To use another example: You have a lump on your breast. It's either cancer or a benign cyst. Would you bill these differently for the diagnosis work on the doctor's part? Maybe I'm misunderstanding what happened in your situation, but if the same exact steps are taken in diagnosing appencitis vs gas, wouldn't you bill the same?
Edit: Oh I forgot to mention the main reason I commented. I have also heard that billing less (like level 4) even if you completed all the steps for level 5 but do not want to get flagged by the system for overbilling can in turn actually get you flagged for underbilling, and can be cause for an investigation/audit.
To use another example: You have a lump on your breast. It's either cancer or a benign cyst. Would you bill these differently for the diagnosis work on the doctor's part? Maybe I'm misunderstanding what happened in your situation, but if the same exact steps are taken in diagnosing appencitis vs gas, wouldn't you bill the same?
Edit: Oh I forgot to mention the main reason I commented. I have also heard that billing less (like level 4) even if you completed all the steps for level 5 but do not want to get flagged by the system for overbilling can in turn actually get you flagged for underbilling, and can be cause for an investigation/audit.
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There is no way of knowing. No standards exist between 1-5. You walk into the ER and hope it doesnt result in bankruptcy.
I believe that standards do indeed exist, and they are called HCPCS codes. I had written a whole comment to your previous comment that got deleted, but please read the below wiki article to start. Note that the levels described in this article are not the same as your "levels 1-5". Those are CPT codes. For example, a level 5 billing for an emergency room visit is CPT code 99285.
https://en.wikipedia.org/wiki/Healthcare_Common_Procedure_Co...
Edit: also note that CPT codes are part of the HCPCS
https://en.wikipedia.org/wiki/Healthcare_Common_Procedure_Co...
Edit: also note that CPT codes are part of the HCPCS
I'm going to reply to my own comment here as I think something needs to be said regarding my own opinion on this. I think that it's very obscure to patients as to what they might end up having to pay when they enter an ER. These codes are super complicated to me, and I think it takes quite a long time for medical coders to get proficient at their job.
It'd be nice if patients didn't have to worry about these sorts of issues when receiving emergent care, but such is the country we live in.
It'd be nice if patients didn't have to worry about these sorts of issues when receiving emergent care, but such is the country we live in.
There isn't a standard between what is a 1 and what is 5. There is a standard that they in fact exist in the first place and charged accordingly. But what one hospital considers a Level 5 and another considers a level 5, is based on the amount of competition the ER has, because there isn't another externality keeping it in check.
The article touched on this, and I also discovered this through my own research when I attempted to dispute what in fact a Level 5 was. Add to the fact, that by entering into the hospital you are asked to enter into an arbitration agreement.
Compound this with the monopoly nature of an ER, and the only thing keep prices from spiraling out of control is the sheer benevolence of the hospital employees.
The article touched on this, and I also discovered this through my own research when I attempted to dispute what in fact a Level 5 was. Add to the fact, that by entering into the hospital you are asked to enter into an arbitration agreement.
Compound this with the monopoly nature of an ER, and the only thing keep prices from spiraling out of control is the sheer benevolence of the hospital employees.
I think I understand what you are saying now, thank you. The only thing I have to offer is that regulatory bodies such as CMS and DHHS may have the authority to investigate these variations in level breakdowns, besides the sheer benevolence of hospital employees.
Additionally, insurance companies would be understandably upset if a hospital was charging them more than they should have been, so potential investigations that shed more light on this could help stabilize this part of the market. I appreciate your insight!
Additionally, insurance companies would be understandably upset if a hospital was charging them more than they should have been, so potential investigations that shed more light on this could help stabilize this part of the market. I appreciate your insight!
> sheer benevolence of the hospital employees.
and willingness to push back against intense economic pressure from management.
and willingness to push back against intense economic pressure from management.
The problem is that at 1am, with whatever horrible pain prompts you to drag yourself, or your child, to seek out medical care, your ONLY option is often an ER.
It's not about how amazing ERs are and therefore expensive. It's about horrible allocation of resources across the entire system. If you don't have insurance, guess what, the ER becomes your clinic. If your child is screaming in pain at 2am with an ear ache, guess what, urgent care is closed, you have to go to the ER.
From personal experience, people will go to an ER knowing full well it's not life threatening and don't need the full services, knowing full well it's going to cost them a small fortune. But they just can't reasonably wait 6-12 hours to get treatment. Would you let your 3 year-old scream in agony until the next day because that's what time the Urgent care re-opens, so an MD cay say "Yup, that's an ear infection, here's your script, off you go"? It's a silly system that doesn't provide reasonable options to such common occurrences. People should dam well complain about it until there are better options.
It's not about how amazing ERs are and therefore expensive. It's about horrible allocation of resources across the entire system. If you don't have insurance, guess what, the ER becomes your clinic. If your child is screaming in pain at 2am with an ear ache, guess what, urgent care is closed, you have to go to the ER.
From personal experience, people will go to an ER knowing full well it's not life threatening and don't need the full services, knowing full well it's going to cost them a small fortune. But they just can't reasonably wait 6-12 hours to get treatment. Would you let your 3 year-old scream in agony until the next day because that's what time the Urgent care re-opens, so an MD cay say "Yup, that's an ear infection, here's your script, off you go"? It's a silly system that doesn't provide reasonable options to such common occurrences. People should dam well complain about it until there are better options.
> The problem is that at 1am, with whatever horrible pain prompts you to drag yourself, or your child, to seek out medical care, your ONLY option is often an ER.
It's not your only option. Chances are, it's not even your best option.
Urgent care clinics are much more appropriate for the bulk of things people are discussing in this thread. Not only are they cheaper for the patient, but they'll get treated faster, and they'll receive better care, because most of these things aren't what emergency physicians are actually trained to deal with.
It's not your only option. Chances are, it's not even your best option.
Urgent care clinics are much more appropriate for the bulk of things people are discussing in this thread. Not only are they cheaper for the patient, but they'll get treated faster, and they'll receive better care, because most of these things aren't what emergency physicians are actually trained to deal with.
It's likely the only option unless you live in a large metropolitan area or can drive a couple hours. I guess there aren't enough clients to support both so we get the one that can do everything.
I mentioned urgent cares. There are none open 24/7 near me, and that seems to be pretty common. I don't live in some remote area.
The hospital gets to choose whether the ER visit complexity is from 1 to 5. How is dispensing a muscle relaxant a 4? What would be an example of a 1?
Ahh, you misunderstand. The 'scale' is meaningless and only there to present a perception of judgement. They only have one to make you think that there is some decision to be made at all. It's like Uber ratings, anything less than a 5 star is a 0 star, or like TickeMaster pricing where there really was never a ticket on sale for 30$.
This is absurd. Look at the cost escalations over time. Were ER’s not well equipped ten years ago? No they have just ratcheted up the cost because they can. Consider that, given their bargaining position, wouldn’t it be a surprise if they didn’t take advantage of it? What’s holding them back from shaking everybody down for as much as they can? Morals? Lol.
Just because the hospital has a bunch of equipment and training doesn’t mean it’s efficient to charge everyone that goes in there for all of it. There is such a thing as marginal cost. The marginal cost of this guys visit was next to nothing, but they shook him down for all kinds of other crap, much of which has dubious health value.
I went to the hospital for a slipped disk. From cursory inspection the doctor could tell I had a slipped disk, but they gave me an x Ray. I said “does the x Ray show my slipped disk?” the doctor said “it doesn’t show that. I just gave you the x Ray to be on the safe side.” Then I had to get an MRI and they gave me a ton of opiates that I threw in the trash, after reading about them online. In the end, the physical therapy that got me back to health cost less than the ER visit.
On top of everything, what really gets me is the gall of the medical shake down industry to bring up “costs.” They use the government to make everything as expensive as possible: the absurd licensing and education requirements, the restrictions on foreign practitioners and nurses, the “certificate of need” BS, the lax anti trust treatment as hospitals consolidate into regional monopolies under the laughable excuse of “efficiency,” the use of regulation to restrict suppliers of even generic drugs, the abominable statistical malpractice and pharm rep industry and stupid commercials used to push useless and harmful drugs on everyone—many of them paid for by government in both research and point of sale. At every level the whole system is by design a shamanistic and monopolistic ritual that achieves very little. Look at the failure to replicate of all these stupid studies, the way doctors respond to reimbursements in their use of quack drugs and surgeries, the flatlining of real quality of life stats even as expenditures explode, the power of the various professional associations.
Just because the hospital has a bunch of equipment and training doesn’t mean it’s efficient to charge everyone that goes in there for all of it. There is such a thing as marginal cost. The marginal cost of this guys visit was next to nothing, but they shook him down for all kinds of other crap, much of which has dubious health value.
I went to the hospital for a slipped disk. From cursory inspection the doctor could tell I had a slipped disk, but they gave me an x Ray. I said “does the x Ray show my slipped disk?” the doctor said “it doesn’t show that. I just gave you the x Ray to be on the safe side.” Then I had to get an MRI and they gave me a ton of opiates that I threw in the trash, after reading about them online. In the end, the physical therapy that got me back to health cost less than the ER visit.
On top of everything, what really gets me is the gall of the medical shake down industry to bring up “costs.” They use the government to make everything as expensive as possible: the absurd licensing and education requirements, the restrictions on foreign practitioners and nurses, the “certificate of need” BS, the lax anti trust treatment as hospitals consolidate into regional monopolies under the laughable excuse of “efficiency,” the use of regulation to restrict suppliers of even generic drugs, the abominable statistical malpractice and pharm rep industry and stupid commercials used to push useless and harmful drugs on everyone—many of them paid for by government in both research and point of sale. At every level the whole system is by design a shamanistic and monopolistic ritual that achieves very little. Look at the failure to replicate of all these stupid studies, the way doctors respond to reimbursements in their use of quack drugs and surgeries, the flatlining of real quality of life stats even as expenditures explode, the power of the various professional associations.
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Not addressed in the article is the collections part of the equation - as ERs can’t turn people away, they often end up treating many people that are uninsured and/or can’t pay for their care - causing ER’s to try make up the difference on patients that can pay...
Did you know that in the rest of the developed world, what you described is considered absolutely insane, and never happens?
Not the people going to hospital thing - that happens all the time. It's just that nobody is ever charged thousands of dollars for it.
Not the people going to hospital thing - that happens all the time. It's just that nobody is ever charged thousands of dollars for it.
Do the other countries have a lower cost method of maintaining service, or is the patient charged the same, just not all at once (i.e., spread out over a lifetime of higher taxes)?
If there are cheaper ways of providing healthcare, what would have to change in the US to implement it?
For example, if there are three hospitals in a region, and they worked out an agreement among each other to not have overlap in specialized equipment (where hospital A sends all MRI patients to Hospital B just down the road), this is currently illegal (anti-collusion laws).
Another example -- a patient comes in with a headache. Well there could be a number of potentially fatal conditions that could be the cause, and due to liability reasons, they have to run tests to rule these out before giving the patient an aspirin (yes, this is an issue, in lower-income areas people go in for non-emergency issues that most likely doesn't need a doctor).
If there are cheaper ways of providing healthcare, what would have to change in the US to implement it?
For example, if there are three hospitals in a region, and they worked out an agreement among each other to not have overlap in specialized equipment (where hospital A sends all MRI patients to Hospital B just down the road), this is currently illegal (anti-collusion laws).
Another example -- a patient comes in with a headache. Well there could be a number of potentially fatal conditions that could be the cause, and due to liability reasons, they have to run tests to rule these out before giving the patient an aspirin (yes, this is an issue, in lower-income areas people go in for non-emergency issues that most likely doesn't need a doctor).
US healthcare costs are completely out of control compared to other modern nations. We pay 2-3x the cost of other nations for our care per capita. Primarily I would attribute that to other nations applying a universal healthcare principle, and in some form or other placing government controls on the prices of medical procedures and drugs. We pay more, and our life expectancy is shorter.
https://ourworldindata.org/the-link-between-life-expectancy-...
https://www.kff.org/health-costs/issue-brief/snapshots-healt...
https://www.pbs.org/newshour/health/health-costs-how-the-us-...
https://ourworldindata.org/the-link-between-life-expectancy-...
https://www.kff.org/health-costs/issue-brief/snapshots-healt...
https://www.pbs.org/newshour/health/health-costs-how-the-us-...
Other countries develop custom funding models based on a universal healthcare initiative. Basically, they find a way to pay for it, and they just do it.
This will never happen in the US, however, because the US is obsessed with concentrating power in private enterprise and refusing to fund social services. We have more than enough money to ensure the health and welfare of all of our citizens. We just don't actually care to do that, and would rather have rich companies and uneducated, sickly, indebted people.
This will never happen in the US, however, because the US is obsessed with concentrating power in private enterprise and refusing to fund social services. We have more than enough money to ensure the health and welfare of all of our citizens. We just don't actually care to do that, and would rather have rich companies and uneducated, sickly, indebted people.
Limitations on specialized equipment are enforced by many states:
http://www.ncsl.org/research/health/con-certificate-of-need-...
http://www.ncsl.org/research/health/con-certificate-of-need-...
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Sure they pay for it. It is called taxes, and it does come to thousands of dollars.
Yeah, instead US residents pay taxes so corporations can avoid them.
In America, instead of paying taxes for socialized healthcare, people pay 2 - 3 times more to corporations because it's the American way.
As a Canadian, I gladly fork over a few thousand a year to avoid tens to hundreds of thousands in one sitting should something horrible happen to mine/my family's health.
As a Canadian, I gladly fork over a few thousand a year to avoid tens to hundreds of thousands in one sitting should something horrible happen to mine/my family's health.
Also man up, woman making minimum wage with no savings and children to support?
so what you're saying is, as long as there's consumer surplus in healthcare, we should suck it up and deal with the high costs?
Yeah so:
1. The US healthcare system is pretty good for some people in some places.
I broke a shoulder this week in a bad fall. All local urgent care had JUST closed so I went to a local ER, the only kind of place available with imaging, to confirm the nature on the injury.
ER trip was a little slow (I was triaged appropriately behind people with emergent issues) but within a few hours I got a sling, confirmation from X ray images that no immediate surgery was needed, and followup instructions.
When I left the ER I got a referral to the hospital's orthopedic group, and was able to get an appointment the next day with a PA & MD who specialize in sports medicine and broken shoulders. My GP confirms that this is a trustworthy referral.
So within 18 hrs of injury I got an expert to review the injury and they decided there was enough info from existing diagnostics to avoid additional tests (no more X ray views, no CT) and understand the pros/cons of further intervention.
I also scheduled a follow-up at T+36 from injury with my GP to make sure nothing ELSE was broken (mindful that shoulder experts will only look at the shoulder), and was reassured that nothing else is wrong and conservative management is ok.
So that's 3 healthcare visits within 36 hours of an injury, with almost immediate post-ER triage to (I am reliably told) a high-quality local expert.
This all felt really good and probably slightly faster than I would have been treated when I lived in the UK (with NHS London-area A&E as well as employer private insurance).
No complaints about the US system if you have employer provided insurance. I'm fully expecting to see a $4000 bill for these 3 trips and to pay significantly less than that because I carry a traditional high-premium low-coinsurance health plan. Overall it seemed pretty good, but only because I was fairly confident that paying for care wouldn't permanently ruin my finances.
Would have felt pretty painful to be uninsured. EMTALA keeps people alive but the medium term financial impact of the US's high quality of ER care is not to be taken lightly.
Also would have felt pretty painful if I had been in SF and been taken to SF General Hospital post injury as they are notorious for being extremely convenient to access but out-of-network to all insurance providers: https://www.quora.com/Why-does-San-Francisco-General-Hospita...
I do note that although US care is pretty great it can seem a little over the top sometimes:
2. This article gives an example of a patient with strep throat visiting an ER and being diagnosed using a CT scan … why? That seems like an odd choice.
I once visited an NHS urgent care clinic with a bad sore throat and I was told "you Americans come in for every sore throat, this is just a virus, go away." They didn't even run a strep test, just ruled it out from symptoms. No antibiotics or other treatment etc. Felt kinda harsh but was dirt cheap for the NHS and I think the outcome was the same as a similar US urgent-care visit.
(Actually, I visited an NHS urgent care clinic twice for that sore throat. The first time they told me that because I had an American passport they would charge me £60 to be seen. I was incredulous -- are you sure about that? I'm a UK taxpayer here on a work visa -- and got an apology from a service manager a week later.)
1. The US healthcare system is pretty good for some people in some places.
I broke a shoulder this week in a bad fall. All local urgent care had JUST closed so I went to a local ER, the only kind of place available with imaging, to confirm the nature on the injury.
ER trip was a little slow (I was triaged appropriately behind people with emergent issues) but within a few hours I got a sling, confirmation from X ray images that no immediate surgery was needed, and followup instructions.
When I left the ER I got a referral to the hospital's orthopedic group, and was able to get an appointment the next day with a PA & MD who specialize in sports medicine and broken shoulders. My GP confirms that this is a trustworthy referral.
So within 18 hrs of injury I got an expert to review the injury and they decided there was enough info from existing diagnostics to avoid additional tests (no more X ray views, no CT) and understand the pros/cons of further intervention.
I also scheduled a follow-up at T+36 from injury with my GP to make sure nothing ELSE was broken (mindful that shoulder experts will only look at the shoulder), and was reassured that nothing else is wrong and conservative management is ok.
So that's 3 healthcare visits within 36 hours of an injury, with almost immediate post-ER triage to (I am reliably told) a high-quality local expert.
This all felt really good and probably slightly faster than I would have been treated when I lived in the UK (with NHS London-area A&E as well as employer private insurance).
No complaints about the US system if you have employer provided insurance. I'm fully expecting to see a $4000 bill for these 3 trips and to pay significantly less than that because I carry a traditional high-premium low-coinsurance health plan. Overall it seemed pretty good, but only because I was fairly confident that paying for care wouldn't permanently ruin my finances.
Would have felt pretty painful to be uninsured. EMTALA keeps people alive but the medium term financial impact of the US's high quality of ER care is not to be taken lightly.
Also would have felt pretty painful if I had been in SF and been taken to SF General Hospital post injury as they are notorious for being extremely convenient to access but out-of-network to all insurance providers: https://www.quora.com/Why-does-San-Francisco-General-Hospita...
I do note that although US care is pretty great it can seem a little over the top sometimes:
2. This article gives an example of a patient with strep throat visiting an ER and being diagnosed using a CT scan … why? That seems like an odd choice.
I once visited an NHS urgent care clinic with a bad sore throat and I was told "you Americans come in for every sore throat, this is just a virus, go away." They didn't even run a strep test, just ruled it out from symptoms. No antibiotics or other treatment etc. Felt kinda harsh but was dirt cheap for the NHS and I think the outcome was the same as a similar US urgent-care visit.
(Actually, I visited an NHS urgent care clinic twice for that sore throat. The first time they told me that because I had an American passport they would charge me £60 to be seen. I was incredulous -- are you sure about that? I'm a UK taxpayer here on a work visa -- and got an apology from a service manager a week later.)
Today's instalment of how America's healthcare is a trainwreck.
0. https://en.wikipedia.org/wiki/Certificate_of_need