The bizarre calculus of emergency room charges

[lakedaemonian]

Re: The bizarre calculus of emergency room charges

Perhaps one big difference between US costs and the rest of the world is related to the legal aspects. And I don't mean just the cost of paying lost lawsuits, or defending against them, but rather the indirect cost of AVOIDING lawsuits.

One big difference between the US and NZ is NZ has a comprehensive public insurance company called ACC.

It's function as I understand it is to make people physically whole in the event of an accident.....any accident.

Tied in with it is the lack of a "lawsuit lottery" mentality and opportunity.

It IS possible to sue a doctor for malpractice.....but to achieve a judgement in your favour and exemplary damages typically requires proving intent to harm.....accidents happen....doctors aren't perfect, hence the ACC.

It seems to work pretty well....ACC is funded with portions of car & motorcycle registrations(which are much higher than in the US), business fees(based on # of employees and industry risk). Problems of non-payment of ACC are sectors that do not contribute....such as farm quads, mountain bikes, and horses not being registered but having quite a few accidents...imperfect system...but seems to work well.

Current government is looking to open it up to competition from the private sector.....not sure how that will work.

[DSpencer]

Re: The bizarre calculus of emergency room charges

meanwhile service providers must make sure that their posted prices are high enough to capture whatever an insurer might offer: they don't want to only bill x when an insurer might be willing to pay x+y, so posted prices will always be above the highest rate offered by any insurer.

This is a very good point that is often missed. The whole system is a game.

We did take out insurance, but when we took out a claim the company found reason to deny it(claiming my family was permanently resident rather than visiting based on their visit length of just over 90 days).

Finding ways to deny and delay claims is how the insurance companies make profit. Nobody really knows the details of how their insurance works and what's covered. It probably isn't even possible.

The biggest issue we have is the complete lack of non-emergency options outside of bankers hours in the US.

This isn't totally true. We have "urgent care" that is typically used in this scenario. The hours for one right by me are:
M-F: 9:00am - 8:00pm
S-S: 9:00am - 5:00pm

Not 24/7 but it would have worked for you. It is very reasonable on prices as well. There are some that are 24/7 urgent cares out there.

Another consideration on this note though: Payment for services can be dependent on place of service. Often the same procedure performed in an ambulatory surgery center vs a hospital is reimbursed at a lesser rate. The same is probably true for urgent care vs emergency room. People start businesses to make money, not to lower costs for consumers by making less money themselves.

In my humble and biased opinion, this is another example of the problems created by the payers (CMS and private insurance) having too much control of pricing power.

[DSpencer]

Re: The bizarre calculus of emergency room charges

I had brain surgery in Victoria, British Columbia, Canada. The cost to me: not one-cent. Under socialized medicine, the government pays for everything, and you get the best surgery, the best equipment, the best medicines, and best doctors in the world.
.

Oh Canada, where the best healthcare in the world just falls from the sky for free...

the health money's chump change compared to the FIRE.

Non-sarcastic question: does health insurance not count as insurance for the purpose of this data?

i'm sure the health industry is small change compared to fire, overall. however, for pols on the right committees and subcommittees, i suspect they loom large. [e.g. the billy tauzin's of washington.]

For anyone who thinks the health insurance industry has not bought the appropriate legislative protections, try suing your health insurance company and see how far you get. I hope you don't have insurance provided by a private employer!

http://www.ehrlichfirm.com/legal-ser...a-appeals.html
http://www.consumerwatchdog.org/newsrelease/flipped-bird-you-can-sue-health-insurer-kills-loved-one-youre-out-luck-consumer-watchdog

That's like paying $60k for a Toyota Camry because your friend works for Toyota. Plus other mid-size cars are scary - what if they break down? You've never driven a Taurus. Better to pony up the $1,200 per month payment on the devil you know, you think...

When you think of it this way, what we do is almost the definition of irrational. Yet here we are. And if SCOTUS strikes the whole law down, the trend over the last couple of decades will definitely hold, because nothing will have changed.

I agree the system is screwed up. I might disagree on the causes though. I almost certainly disagree on the solution.

I'd rather drive a $60k Camry than a car that is made by Congress, that costs $900 billion (oh wait, maybe $1.76 Trillion...for now) with a 900 page owners manual where the saleswoman tells me that I should buy it first and then see if/how it runs.

[mesyn191]

Re: The bizarre calculus of emergency room charges

Perhaps one big difference between US costs and the rest of the world is related to the legal aspects. And I don't mean just the cost of paying lost lawsuits, or defending against them, but rather the indirect cost of AVOIDING lawsuits. How many expensive steps do medical staff take just to avoid anything that might possibly get them sued? Regardless of how remote the chance?

There were 2 separate studies done in the early and later 2000's by the CBO and a private firm that both gave the same results: about 1-2% of medical costs are associated with legal and CYA expenses (aka "defensive medicine"). Here is a link to an article concerning the latter and the former is here.

[mesyn191]

Re: The bizarre calculus of emergency room charges

I'd rather drive a $60k Camry than a car that is made by Congress, that costs $900 billion (oh wait, maybe $1.76 Trillion...for now) with a 900 page owners manual where the saleswoman tells me that I should buy it first and then see if/how it runs.

That doesn't seem to be the case elsewhere a UHS has been implemented. If others are doing fine with a UHS and paying half the cost we do why shouldn't we?

[mesyn191]

Re: The bizarre calculus of emergency room charges

I'd love to hear from others in counties with socialized medicine. In the US, I've heard stories about Brits waiting years for non-urgent surgeries. Is this just propaganda?

LB

I live in the US but here is some worth while info. I've been able to scrounge up on the issue.

[lakedaemonian]

Re: The bizarre calculus of emergency room charges

This is a very good point that is often missed. The whole system is a game.



Finding ways to deny and delay claims is how the insurance companies make profit. Nobody really knows the details of how their insurance works and what's covered. It probably isn't even possible.



This isn't totally true. We have "urgent care" that is typically used in this scenario. The hours for one right by me are:
M-F: 9:00am - 8:00pm
S-S: 9:00am - 5:00pm

Not 24/7 but it would have worked for you. It is very reasonable on prices as well. There are some that are 24/7 urgent cares out there.

Another consideration on this note though: Payment for services can be dependent on place of service. Often the same procedure performed in an ambulatory surgery center vs a hospital is reimbursed at a lesser rate. The same is probably true for urgent care vs emergency room. People start businesses to make money, not to lower costs for consumers by making less money themselves.

In my humble and biased opinion, this is another example of the problems created by the payers (CMS and private insurance) having too much control of pricing power.

You're definitely right....I remember being stunned at the lack of options(we thought)....cheers for that!

I was in NZ at the time while my wife and kids were in the US riding out the earthquake mess we had down here......I think it was the lack of understanding of the US healthcare market/options and assuming we were safe with our insurance cover.....we were just looking at it last night and there were a number of options available for an ear infection that included WalGreens basic health care services in some of their stores up thru urgent care facilities as you mentioned that would have suited on the Sunday early afternoon besides the ER option chosen.

I think it was the lack of time and a clear head to investigate immediate options when the flair up occurred.....it's good to know there are options....it would truly be insane if there weren't any/many in such a large market.

Expensive lesson learned!

It doesn't change our feelings regarding insurance and insurance companies however......we are quite thankful for the ACC accident liability insurance scheme we have down here.

[lakedaemonian]

Re: The bizarre calculus of emergency room charges

I live in the US but here is some worth while info. I've been able to scrounge up on the issue.

Anecdotally, we've had a very good to excellent experience overall with the NZ healthcare system.

We've had two children who have received a high level of care, including an emergency C section that could have gone VERY wrong for Mum and bub.

Our 2nd child was born in a private hospital by scheduled C Section for less than $2500 total out of pocket and a 3 day stay in a private suite.

We've had multiple visits to the emergency room(no payment beyond our tax dollars) with immediate treatment for the serious injuries(multiple eye traumas)...immediate and long-term followup by ophthalmology in every instance...only requiring acceptable but long waiting room wait time.

Hearing/speech support for our oldest due to traumatic birth was quite good as well....only requiring scheduled visits...and acceptable but long waiting room wait time.

My wife received cosmetic surgery related to her emergency C Section that couldn't be completely rectified with the birth of our 2nd child, but that was covered and the job was exceptional.

The only personal complaint with our health system is the "inflation through inferior quality" problem we've had.

Our "baby birthing business" has been dominated by midwives in recent decades....all public births without complications are handled by midwives now.

Our first child and my wife could have died due to complications and an unwillingness of our midwife to seek assistance(which is readily available depending on volume of work in all public hospitals) soon enough.....which seems to be a recurring pattern of behavior in the profession and has cost some lives unnecessarily.

Pharmaceuticals(on the approved list of the government pharm purchasing body) are typically quite inexpensive compared to the US.......but god forbid you need an obscure and expensive drug...you may be out of pocket to a staggering degree.....pharm purchasing seems focused on providing the most bang to the most people for the buck...if you're an outlier...you may be completely out of luck......which is understandable, unless you're that unlucky person/family.

Private insurance is an option in NZ, but competition is low, I'm only aware of 1 major health insurance market player.....not sure of their cost/value(supplemental) as we have not explored it.

That's been our experience.....overall quite good bar one serious event that ended well for our family......but it is imperfect...we hope it can be affordably sustained.

[c1ue]

Re: The bizarre calculus of emergency room charges

re telemedicine: there are already u.s. licensed radiologists in india reading xray images sent over the internet. it's especially valuable as a way to arbitrage time zones, not just fees.

Are these radiologists working under their own name tag, or as contracted by large health insurance companies or hospital systems? The latter I would not be surprised by since these corporations are more than large enough to fight the AMA if necessary.

While I think you make some good points and bring forward serious/legitimate concerns.....I think the expansion of the relationship that already exists between physician assistants/nurse practitioners under PMD/Medical Control of a Physician is likely when you combine the dramatic improvements in telecommunications/sensing technology, the falling cost of telecom/computing power, the perpetual ratcheting up of healthcare costs, and the common examples of cost being controlled thru reduced(or masked) quality/quantity in a high inflation environment.

If we see a bar of chocolate maintain price, but shrink the quantity/quality of the content(and multiply that example in cars, clothes, etc.).....isn't it reasonable to believe the same could/would happen with healthcare where price inflation is quite high?

The problem with the 'extension' system you are speaking of is not in the delivery of directed capabilities. Directed capabilities in my understanding is when a diagnosis is made and a course of treatment is prescribed. Monkey see/monkey do works fine in this context.

However, medicine doesn't work this way. First of all many initial diagnoses are wrong or inconclusive. In such a situation, the lack of a capable doctor is going to cause severe problems. Secondly such 'extensions' as you speak of are often not capable of handling emergencies that might arise. There are many other situations where an 'extension' cannot provide the capability a doctor can.

You also didn't speak to the legal/insurance aspects of the situation - a rather important issue given what I've noted previously.

[lakedaemonian]

Re: The bizarre calculus of emergency room charges

Are these radiologists working under their own name tag, or as contracted by large health insurance companies or hospital systems? The latter I would not be surprised by since these corporations are more than large enough to fight the AMA if necessary.



The problem with the 'extension' system you are speaking of is not in the delivery of directed capabilities. Directed capabilities in my understanding is when a diagnosis is made and a course of treatment is prescribed. Monkey see/monkey do works fine in this context.

However, medicine doesn't work this way. First of all many initial diagnoses are wrong or inconclusive. In such a situation, the lack of a capable doctor is going to cause severe problems. Secondly such 'extensions' as you speak of are often not capable of handling emergencies that might arise. There are many other situations where an 'extension' cannot provide the capability a doctor can.

You also didn't speak to the legal/insurance aspects of the situation - a rather important issue given what I've noted previously.

My program focus is on remote medicine that includes a significant telemedical component under Physician control with some latitude for "in extremis" situations.

It's focus is support of military/expeditionary/humanitarian-catastrophe/remote emergency and long-term sustainment of life and basic primary care. Which would be an extension beyond say a traditional paramedic in terms of longer-term life sustainment, and BASIC primary care.

Sometime over the next few weeks I'm presenting to our defense health school where I'm hoping to get a better sense of where folks far more qualified than me think we are going in this realm both in terms of military and domestic civilian health care.

You may wish to reconsider or refine your opinion on "extensions" often not capable of handling emergencies. I guess is depends on how you define an emergency. If it's an immediate life sustaining emergency you may be surprised to learn that the more one-dimensional healthcare technicians such as EMTs and especially paramedics would be better placed in many instances than most physicians and other high level physician specialists(bar ER/trauma specialists and the like) who haven't been near an emergency in quite some time.

Education in emergency medical rotations during physician clinical training is excellent, but how useful is a radiologist in an emergency 10 years out of med school?

But if we are talking about general practice non-emergency emergencies that are more quality of life rather than immediate sustainment of life issues or specialist intervention emergencies, I would completely agree. An "extender" isn't going to be as good as a physician general practitioner.

While I completely agree that there are considerable hurdles to conquer and that the suggestion/vision I offered is admittedly far from perfect, living in a socialized medicine environment and having seen the clear examples of medical service price inflation through inferior quality I'm convinced that if medical service price inflation continues society will have to weigh whether it wants higher taxes, longer wait times, higher hurdles for care approval, and/or inferior quality of care. It comes down to the definition of good enough.

Midwives are good enough, when OB/GYNs were the previous good enough.

Physician Assistants and Nurse Practitioners are good enough, when Physician GPs were the previously good enough.

The trend already exists, I simply see inflation/technology helping to push it along further.

I guess in as simple terms as possible is I reckon the possibility exists for a shift towards proportionally more blue collar than white collar front line health care workers.

I did cover legal/insurance aspects in post #46.

The legal/insurance system regarding healthcare in NZ is different and in my opinion superior to the US in being a consumer of both systems. But I do not believe it would be possible to just cookie cut the same or closely aligned system in the US. Apples and oranges.

I believe in order to see significant and broad improvement in the US healthcare system it will require comprehensive legal/insurance reform, but also fundamental political reform by mitigating or preferably eliminating excessive special interest influence and control.

[c1ue]

Re: The bizarre calculus of emergency room charges

You may wish to reconsider or refine your opinion on "extensions" often not capable of handling emergencies. I guess is depends on how you define an emergency. If it's an immediate life sustaining emergency you may be surprised to learn that the more one-dimensional healthcare technicians such as EMTs and especially paramedics would be better placed in many instances than most physicians and other high level physician specialists(bar ER/trauma specialists and the like) who haven't been near an emergency in quite some time.

Your paramedic examples above aren't directly relevant because the ER people are specifically trained to handle most common emergency situations, whereas a neurosurgeon generally works after extensive prep.

Equally so nurses also are trained for common emergencies.

The situations I speak of are more like: a famous neurosurgeon is teledirecting a regular surgeon when operating on a brain tumor, and something unexpected happens. Or something else is going on which the regular surgeon doesn't see because they're simply less experienced. Or a specialist misses a diagnosis because the GP actually on site doesn't notice the patient has this or that other symptom.

Sure, I could probably do an appendectomy with a spoon because I know where the appendix is, and have a modicum of medical basics, but I wouldn't want someone else like me doing the appendectomy on myself.

It comes down to the definition of good enough.

Midwives are good enough, when OB/GYNs were the previous good enough.

Physician Assistants and Nurse Practitioners are good enough, when Physician GPs were the previously good enough.

As was noted elsewhere in this thread, one consequence of 'good enough' is more people die.

That might be perfectly acceptable to some, but not to many others.

I did cover legal/insurance aspects in post #46.

So your solution is to put all malpractice under the auspices of the government.

I am unclear on why this is feasible when national health care isn't.

Equally unclear is how a relatively limited damages and well defined coverage area like auto insurance translates into malpractice insurance. Is cosmetic surgery covered? Cosmetic dentistry? What about experimental procedures/medicines? High risk operations like heart transplants?