The care of ~11 million people in America has fallen to emergency rooms.
January 12, 2015 1:11 PM Subscribe
It's easy to break a patient like Rogelio—Mexican and poor and chronically ill—down to his potassium level and to make medical decisions according to a number. But that's only part of the story of how the undocumented ill are cared for here in Houston. Within this city's history—a history that includes segregation during the 1960s, a large immigrant population, strong economic growth over the past half century, not to mention the world's largest medical center—is the story of how Houston sought local solutions to provide compassionate care to its indigent and undocumented, the latter of which, some might say, have helped the city grow.Dr. Ricardo Nuila reports from the emergency room at Houston's Ben Taub Hospital, where Harris County's undocumented ill can avail themselves of some of the country's best health care: Taking Care of Our Own.
Read more about the Emergency Medical Treatment and Labor Act, a federal mandate that obligates all Medicare-participating hospitals to examine, stabilize, and/or appropriately transfer all incoming emergency care patients regardless of their immigration, citizenship, insurance, or financial status. Emergency care is the safety net of the nation's health care system, caring for everyone, regardless of ability to pay.
Don't know what Ben Taub's ER looks like these days, but back in 1970 I dislocated my shoulder in a biking accident and ended up there at 2am on a Sunday morning. Everyone there except me and my buddy who brought me there was Hispanic or black, 50% were drunk, and one guy was bleeding all over his chair from a knife would, but was so drunk he didn't really realize it. The staff were pretty indifferent to all the suffering, and it took 3 hours to get my shoulder xrayed and a pain prescription written. I felt sorry for the patients and for the staff.
posted by Mental Wimp at 1:24 PM on January 12, 2015
posted by Mental Wimp at 1:24 PM on January 12, 2015
This place actually sounds terrible. No, I don't think we should have the sort of system where everybody has to lie to get healthcare.
posted by roomthreeseventeen at 1:27 PM on January 12, 2015
posted by roomthreeseventeen at 1:27 PM on January 12, 2015
I don't provide healthcare directly, I now commission the training of healthcare providers. Believe it or not I don't worry about Hispanic, black, bleeding while drunk from Darwinian excesses, as all of those are just what I call BAU-business as usual. Maybe we're doing it wrong here in the UK......we have not yet applied a distinction between Spring Break Morons and uneducated/ignorant morons and the rest of the population. In the USA as far as I can make out physicians can make big bucks on the former.
posted by Wilder at 1:39 PM on January 12, 2015
posted by Wilder at 1:39 PM on January 12, 2015
Only 11 million? I thought I heard during the Obamacare debate that the number was somewhere between 15 and 20 million. Which would mean things are now 'better' but nowhere near 'good enough'. For as long as I can remember, 'medical economists' and such people have explained that the sky-high costs of hospitalization are partly caused by the 'overhead' of providing care to those unable to pay. But then, isn't this the inevitable result of the natural conflict between a system that makes health care a privilege, not a right, and the part of the Hippocratic Oath about "not denying care"?
And isn't this all related to the original premise of "St. Elsewhere" (Sent Elsewhere), which aired from 1982 to 1988? (Or am I still in Tommy Westphal's snow globe as I read this?)
posted by oneswellfoop at 1:43 PM on January 12, 2015 [2 favorites]
And isn't this all related to the original premise of "St. Elsewhere" (Sent Elsewhere), which aired from 1982 to 1988? (Or am I still in Tommy Westphal's snow globe as I read this?)
posted by oneswellfoop at 1:43 PM on January 12, 2015 [2 favorites]
How is it that this...this is the state we're in?
Profit.
There's really no other way to explain how a wealthy nation can hang-on so tightly to a system that penalizes the non-rich on every level of existence, including healthcare.
.....
I had to avail myself of the Marketplace this year for healthcare insurance. I noticed a lot of the policies offered to me had this really odd (to me) Emergency Room coverage where, essentially, if I go to the ER for something, but I'm not admitted to the hospital, I'm assessed an additional co-pay (on top of my initial copay and out-of-pocket expenses) to the tune of about $250.
Now, I've been to the ER a few times for some relatively serious things (like, almost cutting off my index finger) and have never been admitted. I've always been treated and sent home. This extra copay is a bit like the insurance company saying "Don't ever go to the ER unless you might otherwise die."
FWIW, the hospital in my county refers you to a loan company they work with, if you can't pay your bill.
posted by Thorzdad at 1:46 PM on January 12, 2015 [4 favorites]
Profit.
There's really no other way to explain how a wealthy nation can hang-on so tightly to a system that penalizes the non-rich on every level of existence, including healthcare.
.....
I had to avail myself of the Marketplace this year for healthcare insurance. I noticed a lot of the policies offered to me had this really odd (to me) Emergency Room coverage where, essentially, if I go to the ER for something, but I'm not admitted to the hospital, I'm assessed an additional co-pay (on top of my initial copay and out-of-pocket expenses) to the tune of about $250.
Now, I've been to the ER a few times for some relatively serious things (like, almost cutting off my index finger) and have never been admitted. I've always been treated and sent home. This extra copay is a bit like the insurance company saying "Don't ever go to the ER unless you might otherwise die."
FWIW, the hospital in my county refers you to a loan company they work with, if you can't pay your bill.
posted by Thorzdad at 1:46 PM on January 12, 2015 [4 favorites]
I had to avail myself of the Marketplace this year for healthcare insurance. I noticed a lot of the policies offered to me had this really odd (to me) Emergency Room coverage where, essentially, if I go to the ER for something, but I'm not admitted to the hospital, I'm assessed an additional co-pay (on top of my initial copay and out-of-pocket expenses) to the tune of about $250.
It's a financial incentive to get you to choose the much healthier, and much cheaper, option of seeing your primary care physician early rather than waiting until you are on death's door and rushing to the ER at the last minute.
posted by sideshow at 1:50 PM on January 12, 2015 [2 favorites]
It's a financial incentive to get you to choose the much healthier, and much cheaper, option of seeing your primary care physician early rather than waiting until you are on death's door and rushing to the ER at the last minute.
posted by sideshow at 1:50 PM on January 12, 2015 [2 favorites]
It's a financial incentive to get you to choose the much healthier, and much cheaper, option of seeing your primary care physician early rather than waiting until you are on death's door and rushing to the ER at the last minute.
Also to use urgent care clinics, not ERs, for non-life-threatening exigencies.
posted by Mental Wimp at 1:56 PM on January 12, 2015 [3 favorites]
Also to use urgent care clinics, not ERs, for non-life-threatening exigencies.
posted by Mental Wimp at 1:56 PM on January 12, 2015 [3 favorites]
Our last bill for a couple of days in the hospital is up to 5 figures and counting. Yet after the insurance company gets done with it, we'll "only" be on the hook for 4 figures or so.
Greatest healthcare system in the world, for an exceedingly narrow and stupid definition of "greatest."
posted by fifteen schnitzengruben is my limit at 1:58 PM on January 12, 2015 [4 favorites]
Greatest healthcare system in the world, for an exceedingly narrow and stupid definition of "greatest."
posted by fifteen schnitzengruben is my limit at 1:58 PM on January 12, 2015 [4 favorites]
Is this where the rest of the world gets to do a telethon for the health crisis in the USA?
posted by scruss at 2:01 PM on January 12, 2015 [4 favorites]
posted by scruss at 2:01 PM on January 12, 2015 [4 favorites]
Only 11 million? I thought I heard during the Obamacare debate that the number was somewhere between 15 and 20 million. Which would mean things are now 'better' but nowhere near 'good enough'.
11 million is an estimate [PDF] of the undocumented immigrant population in the U.S. circa 2011, down from an all-time high of 12.7 million in 2007. Relevant pull from the article:
posted by divined by radio at 2:02 PM on January 12, 2015
11 million is an estimate [PDF] of the undocumented immigrant population in the U.S. circa 2011, down from an all-time high of 12.7 million in 2007. Relevant pull from the article:
According to various studies, the undocumented use far less of our health-care resources than their documented counterparts, ESRD or not. Much of this is due to how expensive those services are. With the exception of Emergency Medicaid—which, depending on a state’s eligibility criteria, may cover the cost of emergency care—the use of federal health-program dollars to treat the undocumented is expressly forbidden. Legislation has reinforced this restriction time and again—the Personal Responsibility and Work Opportunity Reconciliation Act, the Illegal Immigration Reform and Immigrant Responsibility Act (both passed in 1996), and even the Affordable Care Act of 2010 have all made clear that the federal government does not intend to use tax dollars to help pay for the medical care of those who have entered this country without a visa. The majority of undocumented immigrants are Latino and poor, with jobs that rarely provide them with health insurance. Very few see primary-care doctors. When they seek nonurgent medical attention, they often do so through private doctors who see them for cash, some of whom take advantage of this arrangement by ordering excessive procedures—a complaint I’ve heard from many of my patients. While the Affordable Care Act prohibits the undocumented from purchasing insurance from state exchanges, no other legislation expressly forbids the purchase of health insurance otherwise. The majority of undocumented immigrants haven’t done so, however, because insurance is prohibitively expensive. The result is that the care of nearly 11 million people in America has fallen to emergency rooms across the country.The total number of uninsured citizens is 48 million, or ~15% of the American population.
posted by divined by radio at 2:02 PM on January 12, 2015
It's a financial incentive to get you to choose the much healthier, and much cheaper, option of seeing your primary care physician early rather than waiting until you are on death's door and rushing to the ER at the last minute.
Which is fine and dandy if "your primary care physician" is an actual primary care physician instead of an abstraction, and if there are lots of primary care physicians to go round.
Thing is, primary care physicians are still the weak link in what the US has instead of a healthcare system. They make relatively little money compared to specialists and ER doctors, which is problematic given the cost of a medical education; getting an appointment isn't always straightforward. This isn't helped by a consumerist bias in the US that leads people to believe that generalists are the ones who didn't do well enough to become specialists, nor is it helped by there being some shitty generalists, or by many generalists setting up boutique practices with membership fees or that only accept cash payments to reduce the costs of processing insurance claims.
Creating financial incentives for people to avoid the ER is relatively straightforward but also a blunt instrument. Creating financial incentives for a broad and decently-compensated primary care / general practice sector -- the basis of any proper healthcare system -- is a bit harder.
posted by holgate at 2:06 PM on January 12, 2015 [6 favorites]
Which is fine and dandy if "your primary care physician" is an actual primary care physician instead of an abstraction, and if there are lots of primary care physicians to go round.
Thing is, primary care physicians are still the weak link in what the US has instead of a healthcare system. They make relatively little money compared to specialists and ER doctors, which is problematic given the cost of a medical education; getting an appointment isn't always straightforward. This isn't helped by a consumerist bias in the US that leads people to believe that generalists are the ones who didn't do well enough to become specialists, nor is it helped by there being some shitty generalists, or by many generalists setting up boutique practices with membership fees or that only accept cash payments to reduce the costs of processing insurance claims.
Creating financial incentives for people to avoid the ER is relatively straightforward but also a blunt instrument. Creating financial incentives for a broad and decently-compensated primary care / general practice sector -- the basis of any proper healthcare system -- is a bit harder.
posted by holgate at 2:06 PM on January 12, 2015 [6 favorites]
Greatest healthcare system in the world, for an exceedingly narrow and stupid definition of "greatest."
Greatest if you are rich, which is all that matters to the rich.
posted by Steely-eyed Missile Man at 2:07 PM on January 12, 2015 [4 favorites]
Greatest if you are rich, which is all that matters to the rich.
posted by Steely-eyed Missile Man at 2:07 PM on January 12, 2015 [4 favorites]
The strangest part of all this is that Americans then go to Mexico in order to cross border shop/smuggle in pharmaceuticals.
Greatest if you are rich, which is all that matters to the rich.
Ironically, this isn't true for the mega-rich who are over-medicated and far more likely to suffer from iatrogenic illnesses as a result. Too much health care can kill you.
posted by srboisvert at 2:10 PM on January 12, 2015
Greatest if you are rich, which is all that matters to the rich.
Ironically, this isn't true for the mega-rich who are over-medicated and far more likely to suffer from iatrogenic illnesses as a result. Too much health care can kill you.
posted by srboisvert at 2:10 PM on January 12, 2015
It's not even greatest for the rich. It's only great for the rich and healthy. The rich and sick get to suffer like everyone else.
posted by elizilla at 2:12 PM on January 12, 2015
posted by elizilla at 2:12 PM on January 12, 2015
In the Daily Show interview with Steven Brill a week ago, John Stewart pointedly asked whether any cost savings had accrued within the healthcare system as a whole due to some people who otherwise would've gone to the ER gaining health insurance and hence using non-emergency services. Brill responded,
(spoiler alert: Brill's recommendation for cutting healthcare costs is to remove insurance companies from the healthcare system and heavily regulate the remaining elements of the system.)
posted by XMLicious at 2:13 PM on January 12, 2015 [1 favorite]
Well, what happens now is because because they have insurance, the hospitals can collect more money from them because they can collect it from the insurance companies.Seemed like it didn't answer the question about overall health care costs.
(spoiler alert: Brill's recommendation for cutting healthcare costs is to remove insurance companies from the healthcare system and heavily regulate the remaining elements of the system.)
posted by XMLicious at 2:13 PM on January 12, 2015 [1 favorite]
The numbers are so ridiculously unequivocal too; the US spends way more than everyone else, and gets way worse results.
posted by Sebmojo at 2:39 PM on January 12, 2015 [5 favorites]
posted by Sebmojo at 2:39 PM on January 12, 2015 [5 favorites]
In the Daily Show interview with Steven Brill a week ago
He got lots of airtime on 60 Minutes as well, which surely had no connection to the fact that Random House is owned by CBS. That 60 Minutes piece... meh. Don't we all know about bullshit billing bistromaths by now, and how it's there to permit bullshit "discounts" down to the margin hospitals want and insurers are willing to pay? Don't we all know about the contractual relationships between ER doctors and hospitals, or surgeons and their assistants, which ensure that whatever regulatory cost constraints might exist, there's always a shady way for some enterprising medic to lump patients with hefty out-of-network bills? Brill is a Big Name Writer, so he gets the billing and publicity, but TR Reid covered a lot of this ground a while ago.
posted by holgate at 2:51 PM on January 12, 2015
He got lots of airtime on 60 Minutes as well, which surely had no connection to the fact that Random House is owned by CBS. That 60 Minutes piece... meh. Don't we all know about bullshit billing bistromaths by now, and how it's there to permit bullshit "discounts" down to the margin hospitals want and insurers are willing to pay? Don't we all know about the contractual relationships between ER doctors and hospitals, or surgeons and their assistants, which ensure that whatever regulatory cost constraints might exist, there's always a shady way for some enterprising medic to lump patients with hefty out-of-network bills? Brill is a Big Name Writer, so he gets the billing and publicity, but TR Reid covered a lot of this ground a while ago.
posted by holgate at 2:51 PM on January 12, 2015
It's not even greatest for the rich. It's only great for the rich and healthy. The rich and sick get to suffer like everyone else.
Not really even great for the rich and healthy - they're still throwing away money picking up the inflated tab for the poor and sick having to wait and get emergency treatment instead of having proper healthcare and not getting as sick (among many other unnecessary costs produced by this system.)
It's not even great for the people employed to push all the endless paper, whose income and bread on the table rests upon the existence of the insurance-hospital bureaucracies, because most people gain greater job satisfaction from doing work that helps society in some way, while the for-profit system is purely parasitic; hindering healthcare delivery and quality, existing because of entrenchment and ideology and corrupt congress, rather than merit. Billions of society's productive work-hours squandered on making things worse instead of raising the quality of living.
It's only great for shareholders who profit from the profiteering, but most of those shareholders are subject to the same healthcare system being undermined, so it's kind of an own-goal even for the only people arguably getting anything out of this mess.
posted by anonymisc at 3:09 PM on January 12, 2015 [7 favorites]
Not really even great for the rich and healthy - they're still throwing away money picking up the inflated tab for the poor and sick having to wait and get emergency treatment instead of having proper healthcare and not getting as sick (among many other unnecessary costs produced by this system.)
It's not even great for the people employed to push all the endless paper, whose income and bread on the table rests upon the existence of the insurance-hospital bureaucracies, because most people gain greater job satisfaction from doing work that helps society in some way, while the for-profit system is purely parasitic; hindering healthcare delivery and quality, existing because of entrenchment and ideology and corrupt congress, rather than merit. Billions of society's productive work-hours squandered on making things worse instead of raising the quality of living.
It's only great for shareholders who profit from the profiteering, but most of those shareholders are subject to the same healthcare system being undermined, so it's kind of an own-goal even for the only people arguably getting anything out of this mess.
posted by anonymisc at 3:09 PM on January 12, 2015 [7 favorites]
I had to avail myself of the Marketplace this year for healthcare insurance. I noticed a lot of the policies offered to me had this really odd (to me) Emergency Room coverage where, essentially, if I go to the ER for something, but I'm not admitted to the hospital, I'm assessed an additional co-pay (on top of my initial copay and out-of-pocket expenses) to the tune of about $250.
sideshow: It's a financial incentive to get you to choose the much healthier, and much cheaper, option of seeing your primary care physician early rather than waiting until you are on death's door and rushing to the ER at the last minute.
Mental Wimp: Also to use urgent care clinics, not ERs, for non-life-threatening exigencies.
Except, of course, there are a very large class of emergency room events that are in fact emergencies but do not require admission. Of all the emergency room incidents that I have been party to in my family, all of them involved gushing blood, head injuries, or an ambulance trip, or some combination of the three. Of them, only one involved an admission to the hospital. These non-admissions included such events as:
-- tripped by child at school, cracked head on desk, entire side of head coated with blood
-- accidentally pushed arm through window, 8 inch gash on upper arm half way to bone
-- fell off bike and hit face on pavement, biting tongue, breaking nose and upper jaw on both sides, causing both parents and ambulance team to think child was about to die from massive head injury since they were leaking blood from both ears, nose, and mouth
In all cases, injuries were sewn up, bones were set, and the person went home without admission.
This also requires urgent care clinics to have a reliable standard of care; the only time I've visited one was when I fell during a hike and drove a stick into my calf to the bone. After a couple of days of fluid buildup and disturbing leakage, I went to one, where a doctor looked at the hole for a couple of minutes, did not probe it, clean it, or anything else, and then charged me a couple hundred dollars.
posted by tavella at 3:28 PM on January 12, 2015 [4 favorites]
sideshow: It's a financial incentive to get you to choose the much healthier, and much cheaper, option of seeing your primary care physician early rather than waiting until you are on death's door and rushing to the ER at the last minute.
Mental Wimp: Also to use urgent care clinics, not ERs, for non-life-threatening exigencies.
Except, of course, there are a very large class of emergency room events that are in fact emergencies but do not require admission. Of all the emergency room incidents that I have been party to in my family, all of them involved gushing blood, head injuries, or an ambulance trip, or some combination of the three. Of them, only one involved an admission to the hospital. These non-admissions included such events as:
-- tripped by child at school, cracked head on desk, entire side of head coated with blood
-- accidentally pushed arm through window, 8 inch gash on upper arm half way to bone
-- fell off bike and hit face on pavement, biting tongue, breaking nose and upper jaw on both sides, causing both parents and ambulance team to think child was about to die from massive head injury since they were leaking blood from both ears, nose, and mouth
In all cases, injuries were sewn up, bones were set, and the person went home without admission.
This also requires urgent care clinics to have a reliable standard of care; the only time I've visited one was when I fell during a hike and drove a stick into my calf to the bone. After a couple of days of fluid buildup and disturbing leakage, I went to one, where a doctor looked at the hole for a couple of minutes, did not probe it, clean it, or anything else, and then charged me a couple hundred dollars.
posted by tavella at 3:28 PM on January 12, 2015 [4 favorites]
And good luck getting through the crowed of 11 million if you have an actual emergency that's slightly less than squirting blood on the ceiling!
posted by sammyo at 3:30 PM on January 12, 2015
posted by sammyo at 3:30 PM on January 12, 2015
Once again.
Follow the money.
It goes in a complete circle, and 99% of us are out of the loop
posted by any major dude at 3:37 PM on January 12, 2015 [4 favorites]
Follow the money.
It goes in a complete circle, and 99% of us are out of the loop
posted by any major dude at 3:37 PM on January 12, 2015 [4 favorites]
How is it that this...this is the state we're in? We're an enormously wealthy country with some of the best medical facilities in the world, but because people have to make money on the ill, we force them to make themselves even more ill just to be seen?
America seems to treat moral hazard (i.e., the idea that someone might get something for nothing and not get punished adequately to deter them from doing so) with the kind of dread our distant ancestors reserved for bears and wolves.
posted by acb at 3:59 PM on January 12, 2015 [14 favorites]
America seems to treat moral hazard (i.e., the idea that someone might get something for nothing and not get punished adequately to deter them from doing so) with the kind of dread our distant ancestors reserved for bears and wolves.
posted by acb at 3:59 PM on January 12, 2015 [14 favorites]
~It's a financial incentive to get you to choose the much healthier, and much cheaper, option of seeing your primary care physician early rather than waiting until you are on death's door and rushing to the ER at the last minute.
I'm not sure how that relates to almost cutting off a finger.
~Also to use urgent care clinics, not ERs, for non-life-threatening exigencies.
Sure. As long as you get injured during the urgent care clinic's business hours. And if they're in-network for your Marketplace plan. And, hopefully they will be able to do something for you. The urgent care places here pretty regularly tell people to go to the ER for things that, while not life threatening, are still bloody and severe.
posted by Thorzdad at 4:16 PM on January 12, 2015 [4 favorites]
I'm not sure how that relates to almost cutting off a finger.
~Also to use urgent care clinics, not ERs, for non-life-threatening exigencies.
Sure. As long as you get injured during the urgent care clinic's business hours. And if they're in-network for your Marketplace plan. And, hopefully they will be able to do something for you. The urgent care places here pretty regularly tell people to go to the ER for things that, while not life threatening, are still bloody and severe.
posted by Thorzdad at 4:16 PM on January 12, 2015 [4 favorites]
the use of federal health-program dollars to treat the undocumented is expressly forbidden.
In my moral universe, the tying of health care to citizenship would be expressly forbidden. Just thinking about it makes me livid.
Even with good insurance, we've found that ER visits have tended to run close to $1000 (and those are for treat-and-release visits; I've never been involved in one that resulted in needing to stay in the hospital and shudder to think what that might cost).
The Yakima Valley Farm Workers Clinic runs a network of comprehensive health care clinics (including dental services, mental health, etc) with sliding-scale fees throughout the northwest, and I've heard only good things about the care they provide. But compared to the level of need that is out there, they are a drop in the bucket, and the ERs are still the main support in most places.
posted by Dip Flash at 4:32 PM on January 12, 2015
In my moral universe, the tying of health care to citizenship would be expressly forbidden. Just thinking about it makes me livid.
Even with good insurance, we've found that ER visits have tended to run close to $1000 (and those are for treat-and-release visits; I've never been involved in one that resulted in needing to stay in the hospital and shudder to think what that might cost).
The Yakima Valley Farm Workers Clinic runs a network of comprehensive health care clinics (including dental services, mental health, etc) with sliding-scale fees throughout the northwest, and I've heard only good things about the care they provide. But compared to the level of need that is out there, they are a drop in the bucket, and the ERs are still the main support in most places.
posted by Dip Flash at 4:32 PM on January 12, 2015
The urgent care places here pretty regularly tell people to go to the ER for things that, while not life threatening, are still bloody and severe.
Yeah, urgent care as it actually exists in the US is better seen as a way for certain organisations to skim money off people who don't have a primary physician or can't get to see one, and those who are a little banged up and don't want to go to the ER. Not many proper healthcare systems have managed to get it right, so it's not simply a US thing; however, I have seen the threshold at which an urgent care clinic wants you to GTFO and go to the ER, and it's a combination of anything above their comfort zone and their domain of potential medical liability. It is 'urgent' mainly for speed of access, not the speed with which a condition needs to be treated. It's not "emergency-ish care".
posted by holgate at 4:38 PM on January 12, 2015
Yeah, urgent care as it actually exists in the US is better seen as a way for certain organisations to skim money off people who don't have a primary physician or can't get to see one, and those who are a little banged up and don't want to go to the ER. Not many proper healthcare systems have managed to get it right, so it's not simply a US thing; however, I have seen the threshold at which an urgent care clinic wants you to GTFO and go to the ER, and it's a combination of anything above their comfort zone and their domain of potential medical liability. It is 'urgent' mainly for speed of access, not the speed with which a condition needs to be treated. It's not "emergency-ish care".
posted by holgate at 4:38 PM on January 12, 2015
Even with good insurance, we've found that ER visits have tended to run close to $1000
This is such bullshit. The full cost of A&E treatment tops out at about £300 in England, and starts at under £100*. Although A&E units admit patients who'll need more than 4 hours worth of treatment, most patients are discharged within the 4 hours, problem solved.
*although the only money that changes hands is a block payment based on the population within the catchment area.
posted by ambrosen at 5:01 PM on January 12, 2015 [1 favorite]
This is such bullshit. The full cost of A&E treatment tops out at about £300 in England, and starts at under £100*. Although A&E units admit patients who'll need more than 4 hours worth of treatment, most patients are discharged within the 4 hours, problem solved.
*although the only money that changes hands is a block payment based on the population within the catchment area.
posted by ambrosen at 5:01 PM on January 12, 2015 [1 favorite]
This also requires urgent care clinics to have a reliable standard of care
This. The closest urgent care clinic to me is just bad. I went their once with splitting head pain like none other I've ever had a couple weeks post-operative recovery. I vomited because of the pain and the doctor looked at me like I was some unwashed trash, because I had no where else to vomit but the sink. Then had the gall to tell me it was just a migraine as a migraine sufferer, I know the difference). When I told him it was nothing like any migraine I've had, he then told me it was an atypical migraine. Bloody brilliant, dude.
There is an urgent care facility about a half hour a way that was once a combined urgent care/emergency facility and they are able to operate at an almost emergency level. We go there now when possible/necessary. But that really requires trying out the different ones in a variety of situations that you don't want to find out their low quality.
Meanwhile, I've noticed an unpleasant trend- the majority of primary care facilities are tacking on urgent care to their services. And they're not adding new doctors, just stretching thin the already over-worked PCPs.
posted by [insert clever name here] at 5:08 PM on January 12, 2015 [2 favorites]
This. The closest urgent care clinic to me is just bad. I went their once with splitting head pain like none other I've ever had a couple weeks post-operative recovery. I vomited because of the pain and the doctor looked at me like I was some unwashed trash, because I had no where else to vomit but the sink. Then had the gall to tell me it was just a migraine as a migraine sufferer, I know the difference). When I told him it was nothing like any migraine I've had, he then told me it was an atypical migraine. Bloody brilliant, dude.
There is an urgent care facility about a half hour a way that was once a combined urgent care/emergency facility and they are able to operate at an almost emergency level. We go there now when possible/necessary. But that really requires trying out the different ones in a variety of situations that you don't want to find out their low quality.
Meanwhile, I've noticed an unpleasant trend- the majority of primary care facilities are tacking on urgent care to their services. And they're not adding new doctors, just stretching thin the already over-worked PCPs.
posted by [insert clever name here] at 5:08 PM on January 12, 2015 [2 favorites]
Yeah, it's unfortunate that the financial incentive hurts people who actually need to go the ER but not be admitted, but it's the easiest way to convince people to not use the ER as their doctor's office.
Even with good insurance, we've found that ER visits have tended to run close to $1000
This is such bullshit. The full cost of A&E treatment tops out at about £300 in England, and starts at under £100*. Although A&E units admit patients who'll need more than 4 hours worth of treatment, most patients are discharged within the 4 hours, problem solved.
I have decent insurance (Kaiser), and no matter how serious the visit to the ER, I'm only out $250. In fact, I might just have to only pay my regular co-pay ($20) if I get admitted overnight.
posted by sideshow at 5:42 PM on January 12, 2015
Even with good insurance, we've found that ER visits have tended to run close to $1000
This is such bullshit. The full cost of A&E treatment tops out at about £300 in England, and starts at under £100*. Although A&E units admit patients who'll need more than 4 hours worth of treatment, most patients are discharged within the 4 hours, problem solved.
I have decent insurance (Kaiser), and no matter how serious the visit to the ER, I'm only out $250. In fact, I might just have to only pay my regular co-pay ($20) if I get admitted overnight.
posted by sideshow at 5:42 PM on January 12, 2015
Meanwhile, I've noticed an unpleasant trend- the majority of primary care facilities are tacking on urgent care to their services.
Again, this is primary care facilities trying to tap into a source of income by being able to bill at urgent-care rates. It's only a whiff away from a general practice offering Deluxe Boutique Membership for a monthly fee in exchange for priorityboarding appointments and seat upgrades a direct line to their doctors.
How do you create the financial incentives to prevent that kind of bullshit? I suppose part of it is 'stuffing their mouths with gold', whether it's by writing off tuition debt or somehow making it more lucrative for general practitioners who want to do general practice instead of all kind of whiz-bang income-generating schemes.
posted by holgate at 6:11 PM on January 12, 2015
Again, this is primary care facilities trying to tap into a source of income by being able to bill at urgent-care rates. It's only a whiff away from a general practice offering Deluxe Boutique Membership for a monthly fee in exchange for priority
How do you create the financial incentives to prevent that kind of bullshit? I suppose part of it is 'stuffing their mouths with gold', whether it's by writing off tuition debt or somehow making it more lucrative for general practitioners who want to do general practice instead of all kind of whiz-bang income-generating schemes.
posted by holgate at 6:11 PM on January 12, 2015
Even with good insurance, we've found that ER visits have tended to run close to $1000
This is such bullshit. The full cost of A&E treatment tops out at about £300 in England, and starts at under £100
That's all bullshit. Total cost in Ontario of an ER visit: $0. (They will charge you for an ambulance though, which is wtf on many levels, given that the times I've had to use one were 1) recommended by the provincially-funded Telehealth service, which you call to get medical advice from RNs, because I had all the symptoms of a stroke, and 2) called for me last year when it seemed like a good move to eat my entire medicine cabinet.)
posted by feckless fecal fear mongering at 6:13 PM on January 12, 2015 [1 favorite]
This is such bullshit. The full cost of A&E treatment tops out at about £300 in England, and starts at under £100
That's all bullshit. Total cost in Ontario of an ER visit: $0. (They will charge you for an ambulance though, which is wtf on many levels, given that the times I've had to use one were 1) recommended by the provincially-funded Telehealth service, which you call to get medical advice from RNs, because I had all the symptoms of a stroke, and 2) called for me last year when it seemed like a good move to eat my entire medicine cabinet.)
posted by feckless fecal fear mongering at 6:13 PM on January 12, 2015 [1 favorite]
That's all bullshit.
To spell out ambrosen's comment, the nominal price of an A&E visit in England is solely for the purposes of NHS accounting: patients aren't chased around for a credit card once the blood has been mopped up. I'm sure that provincial Medicaid has a similar reimbursement formula behind the scenes with Canadian hospitals, especially given that many of them are privately operated.
But that forces the question of whether the supposed disincentive of charging premium rates for emergency treatment is just crude market mythology, and not reflected in behaviour. The disincentive that most Canadians and British people still recognise is the collective understanding that emergency services are for everyone when they need it, and that there's a relatively strong and broad primary care system when the need is not so great.
posted by holgate at 6:23 PM on January 12, 2015
To spell out ambrosen's comment, the nominal price of an A&E visit in England is solely for the purposes of NHS accounting: patients aren't chased around for a credit card once the blood has been mopped up. I'm sure that provincial Medicaid has a similar reimbursement formula behind the scenes with Canadian hospitals, especially given that many of them are privately operated.
But that forces the question of whether the supposed disincentive of charging premium rates for emergency treatment is just crude market mythology, and not reflected in behaviour. The disincentive that most Canadians and British people still recognise is the collective understanding that emergency services are for everyone when they need it, and that there's a relatively strong and broad primary care system when the need is not so great.
posted by holgate at 6:23 PM on January 12, 2015
Total cost in Ontario of an ER visit: $0.
Unless you need something not covered by OHIP. So not always $0, but way better than the equivalent in the U.S.
posted by one more dead town's last parade at 6:31 PM on January 12, 2015
Unless you need something not covered by OHIP. So not always $0, but way better than the equivalent in the U.S.
posted by one more dead town's last parade at 6:31 PM on January 12, 2015
In which case the cost would be the same whether you're in the ER or at your GP or a walk-in clinic.
Generally speaking the only things OHIP doesn't cover are optical and dental, physiotherapy, psychotherapy, and elective surgeries. I would be kind of astonished by someone going to the ER for something that isn't medically necessary.
posted by feckless fecal fear mongering at 6:40 PM on January 12, 2015
Generally speaking the only things OHIP doesn't cover are optical and dental, physiotherapy, psychotherapy, and elective surgeries. I would be kind of astonished by someone going to the ER for something that isn't medically necessary.
posted by feckless fecal fear mongering at 6:40 PM on January 12, 2015
Oh you people...
I'm assured by my government that all this price signal stuff is like magic for healthcare. Of course, it seems my government also believes in actual magic - so perhaps draw your own conclusions...
posted by pompomtom at 6:45 PM on January 12, 2015 [1 favorite]
I'm assured by my government that all this price signal stuff is like magic for healthcare. Of course, it seems my government also believes in actual magic - so perhaps draw your own conclusions...
posted by pompomtom at 6:45 PM on January 12, 2015 [1 favorite]
OHIP doesn't cover prescriptions or some medical supplies (slings, crutches, and some types of casts, for instance). Again, the price-gouging you see in the U.S. is pretty much absent here, but I was still surprised when I had to get out my wallet at the hospital.
And the fact that OHIP considers vision not medically necessary is hilariously infuriating for someone like me.
posted by one more dead town's last parade at 6:51 PM on January 12, 2015
And the fact that OHIP considers vision not medically necessary is hilariously infuriating for someone like me.
posted by one more dead town's last parade at 6:51 PM on January 12, 2015
it's unfortunate (that the financial incentive hurts people)
This always seems to be the phrase deployed to sweep the suffering of other people under the rug when the speaker knows they won't encounter the same thing. So unfortunate.
posted by Steely-eyed Missile Man at 8:21 PM on January 12, 2015 [1 favorite]
This always seems to be the phrase deployed to sweep the suffering of other people under the rug when the speaker knows they won't encounter the same thing. So unfortunate.
posted by Steely-eyed Missile Man at 8:21 PM on January 12, 2015 [1 favorite]
My son's company provides insurance, which means he's ineligible for Obamacare, even though the insurance is pathetic. He pays about $200 a month, has a $5K deductible, and the insurance pays for only three diagnostic tests per year, period. That means that after the yearly routine blood panel, he's down to two. If he breaks something and has an x-ray, that leaves one, and if he requires a CBC to see if he lost too much blood, that's it for the year.
Last summer he was holding a dog leash in his hand when the dog spotted a cat and took off after it - yes, I know, and so does he - naughty mongrel. The leash cut his hand across the palm and over two fingers. He said it hurt like nothing he'd ever imagined. After an hour or so of pacing and cussing and icing it, he went to the store and bought antibiotic ointment and gauze bandages and spray-on Bactine and whatever else he could find. He cleaned it with hydrogen peroxide (while screaming, he said, just from getting it wet). The wound wasn't particularly deep, just angry. So he cleaned it all up nicely, used antibacterial stuff on it, kept after it faithfully for a week, and it was healing well - no pus, no signs of infection.
Then one day at work he felt sick, sick enough he had to go home, which he never does. He was freezing (it was HOT outside) and he went to bed, got up and put on a coat and got blankets and went to bed and just got sicker and sicker. Eventually he knew he had to get to a doctor and so (the idiot, said with love) drove himself to Urgent Care. They took one look at him and made him get a friend to come drive him to the ER - they wouldn't allow him to drive the three blocks or so to the hospital. The ER admitted him with sepsis and he was in the hospital for three or four days - I don't remember which. He was nearly put in the ICU, but escaped that because the ICU was nearly full. So - he came out fine. He likely never would have had the sepsis if he'd had oral antibiotics to take when the injury first occurred, and if he felt he could afford to see a doctor about the injury he would have, but he knew it would kill him financially.
He was billed $17,000 after his insurance paid its portion, plus a lab bill of several hundred dollars.
One thing that has changed the whole ER/PCP/Urgent Care dynamic that I know of is that hospitals have all joined chains. Our Sacred Heart Medical Center is part of a nationwide chain of Catholic hospitals and boy, how things have changed since I worked there when it was run by a bunch of Catholic nuns. It was the biggest hospital in the area then and still is, but even when run as it was then it had its own heart center (where they even did transplants) and their care was state of the art. But those who worked there years ago and still do will tell about the changes - and they're not pretty, from a patient's point of view. All doctors have to be part of groups, groups that are part of bigger groups, groups that are really just businesses, which is what the hospitals are now also - the "healing" idea has faded so it's hardly even noticable anymore - it's just business. How long do you get with a doc in your doctor's office? Do you even see a doc? Or, more likely, a PA? What meds do you think need changing? Apparently every patient sees something on TV they want to try??? Don't know - I don't have a TV. They've decided there's too much testing, so no tests anymore unless you've turned orange or blue. If you're old, Medicare will pay, but only a portion of what the clinics/docs want to charge. If you're not old, God help you.
I have no complaints for myself - I'm old, I'm on my way to going back to dust, and I have Medicare - but I have a kazillion complaints about what this country's lack of affordable and quality medical care is doing to our children and grandchildren. And I have issues with anyone paying for the quality of insurance that allows him to walk out of a hospital without having had surgery or ICU or heart conversion or something like that with a bill of $17,000 after insurance. That's nearly what he has left on student loans.
Like everyone else, I guess, I'm sick of it.
posted by aryma at 8:38 PM on January 12, 2015 [3 favorites]
Last summer he was holding a dog leash in his hand when the dog spotted a cat and took off after it - yes, I know, and so does he - naughty mongrel. The leash cut his hand across the palm and over two fingers. He said it hurt like nothing he'd ever imagined. After an hour or so of pacing and cussing and icing it, he went to the store and bought antibiotic ointment and gauze bandages and spray-on Bactine and whatever else he could find. He cleaned it with hydrogen peroxide (while screaming, he said, just from getting it wet). The wound wasn't particularly deep, just angry. So he cleaned it all up nicely, used antibacterial stuff on it, kept after it faithfully for a week, and it was healing well - no pus, no signs of infection.
Then one day at work he felt sick, sick enough he had to go home, which he never does. He was freezing (it was HOT outside) and he went to bed, got up and put on a coat and got blankets and went to bed and just got sicker and sicker. Eventually he knew he had to get to a doctor and so (the idiot, said with love) drove himself to Urgent Care. They took one look at him and made him get a friend to come drive him to the ER - they wouldn't allow him to drive the three blocks or so to the hospital. The ER admitted him with sepsis and he was in the hospital for three or four days - I don't remember which. He was nearly put in the ICU, but escaped that because the ICU was nearly full. So - he came out fine. He likely never would have had the sepsis if he'd had oral antibiotics to take when the injury first occurred, and if he felt he could afford to see a doctor about the injury he would have, but he knew it would kill him financially.
He was billed $17,000 after his insurance paid its portion, plus a lab bill of several hundred dollars.
One thing that has changed the whole ER/PCP/Urgent Care dynamic that I know of is that hospitals have all joined chains. Our Sacred Heart Medical Center is part of a nationwide chain of Catholic hospitals and boy, how things have changed since I worked there when it was run by a bunch of Catholic nuns. It was the biggest hospital in the area then and still is, but even when run as it was then it had its own heart center (where they even did transplants) and their care was state of the art. But those who worked there years ago and still do will tell about the changes - and they're not pretty, from a patient's point of view. All doctors have to be part of groups, groups that are part of bigger groups, groups that are really just businesses, which is what the hospitals are now also - the "healing" idea has faded so it's hardly even noticable anymore - it's just business. How long do you get with a doc in your doctor's office? Do you even see a doc? Or, more likely, a PA? What meds do you think need changing? Apparently every patient sees something on TV they want to try??? Don't know - I don't have a TV. They've decided there's too much testing, so no tests anymore unless you've turned orange or blue. If you're old, Medicare will pay, but only a portion of what the clinics/docs want to charge. If you're not old, God help you.
I have no complaints for myself - I'm old, I'm on my way to going back to dust, and I have Medicare - but I have a kazillion complaints about what this country's lack of affordable and quality medical care is doing to our children and grandchildren. And I have issues with anyone paying for the quality of insurance that allows him to walk out of a hospital without having had surgery or ICU or heart conversion or something like that with a bill of $17,000 after insurance. That's nearly what he has left on student loans.
Like everyone else, I guess, I'm sick of it.
posted by aryma at 8:38 PM on January 12, 2015 [3 favorites]
"Don't ever go to the ER unless you might otherwise die."
In theory, those $250 copays are doing two things: subsidizing ER visits for people who aren't lucky enough to have insurance at all, with a $250 ER copay at all, and encouraging you, the discriminating educated Healthcare consumer, to get yourself in your car (everybody has one of those right) and drive yourself to an urgent care facility, where your copay is probably $50-100.
Naturally most folks don't know what urgent care is for until they get a $400 ER bill after the $200+ copay and go crying to HR, because you are using benefits of gainful employment (right?).
Urgent care facilities are great even when they kind of suck, as a parent I've managed to never go to the ER, but I am lucky, urgent care facilities are closer to me than the hospital, and I happened to have the $600 on hand when I got the fateful bill for a drunken sprained ankle in my mid 20s, when I followed Internet advice to use an ER when I couldn't walk.
posted by aydeejones at 4:51 AM on January 13, 2015
In theory, those $250 copays are doing two things: subsidizing ER visits for people who aren't lucky enough to have insurance at all, with a $250 ER copay at all, and encouraging you, the discriminating educated Healthcare consumer, to get yourself in your car (everybody has one of those right) and drive yourself to an urgent care facility, where your copay is probably $50-100.
Naturally most folks don't know what urgent care is for until they get a $400 ER bill after the $200+ copay and go crying to HR, because you are using benefits of gainful employment (right?).
Urgent care facilities are great even when they kind of suck, as a parent I've managed to never go to the ER, but I am lucky, urgent care facilities are closer to me than the hospital, and I happened to have the $600 on hand when I got the fateful bill for a drunken sprained ankle in my mid 20s, when I followed Internet advice to use an ER when I couldn't walk.
posted by aydeejones at 4:51 AM on January 13, 2015
Naturally it's only a matter of time before a shitload of people die of heart attacks in an urgent care facility when trying to save money, because the other privilege you must exert when deciding whether it's emergent or urgent is somehow knowing the difference between the two types of facilities. Never go to urgent care with chest pain unless a hospital is out of reach. But how out of reach?
posted by aydeejones at 4:56 AM on January 13, 2015
posted by aydeejones at 4:56 AM on January 13, 2015
Also, I believe $100-150 of my ER bill (after copay) was for "durable medical equipment," one of the greater ripoffs in healthcare. We're taking a plastic inflatable "air cast" that was happy meal toy quality. A total piece of shit. And crutches that I would use for a week, because I had the choice in the hospital of either paying through the nose, or getting my friend to also drive me to a grocery store so I could literally crawl on the floor to the customer service desk and rent some crutches. They wouldn't just let him pick them up, as I recall.
The air cast was really a stabilizer brace and it sucked. I worked for an orthopedic clinic. The supply guy confirmed that they sucked and happened to have a velcro Hely Weber brace that has been used and couldn't be sold to anyone. It was amazing. And velcro. It was like something from an Arnold Schwarzenegger movie. I still use it, but I briefly lost it and paid like $8 at Walgreens for a weaker alternative that still lorded over the shitty air cast.
posted by aydeejones at 5:11 AM on January 13, 2015 [1 favorite]
The air cast was really a stabilizer brace and it sucked. I worked for an orthopedic clinic. The supply guy confirmed that they sucked and happened to have a velcro Hely Weber brace that has been used and couldn't be sold to anyone. It was amazing. And velcro. It was like something from an Arnold Schwarzenegger movie. I still use it, but I briefly lost it and paid like $8 at Walgreens for a weaker alternative that still lorded over the shitty air cast.
posted by aydeejones at 5:11 AM on January 13, 2015 [1 favorite]
OHIP doesn't cover prescriptions or some medical supplies (slings, crutches, and some types of casts, for instance)
From experience, if you're in the ER and can't afford a scrip, they'll send you home with the meds you need. Ditto slings/crutches/canes.
posted by feckless fecal fear mongering at 9:48 AM on January 13, 2015
From experience, if you're in the ER and can't afford a scrip, they'll send you home with the meds you need. Ditto slings/crutches/canes.
posted by feckless fecal fear mongering at 9:48 AM on January 13, 2015
Jesus, America. Stories about your health system make me so angry. It's like a precisely tooled machine for manufacturing misery.
posted by Sebmojo at 12:54 PM on January 13, 2015 [9 favorites]
posted by Sebmojo at 12:54 PM on January 13, 2015 [9 favorites]
This article is a sterling tribute to what compassionate conservatism can accomplish when implemented properly.
If all of the illegal-immigrant heavy states had the capability and the foresight to keep the ailing illegals just healthy enough to work backbreaking jobs for a pittance it would be like an end run against the amendment that prohibits slavery and a major economic boon.
USA, USA, USA!
posted by Renoroc at 1:08 PM on January 13, 2015 [1 favorite]
If all of the illegal-immigrant heavy states had the capability and the foresight to keep the ailing illegals just healthy enough to work backbreaking jobs for a pittance it would be like an end run against the amendment that prohibits slavery and a major economic boon.
USA, USA, USA!
posted by Renoroc at 1:08 PM on January 13, 2015 [1 favorite]
Please don't refer to human beings as 'illegals.'
posted by feckless fecal fear mongering at 1:16 PM on January 13, 2015 [3 favorites]
posted by feckless fecal fear mongering at 1:16 PM on January 13, 2015 [3 favorites]
Ben Taub is just down the way. It's where you want to go when you've got a gunshot wound or other trauma because they're the best in the city at treating that. There's a sometimes unstated corollary which talks about what they're not the best in the city at treating.
It's great to hear more positive stories about Ben Taub. And yes, I'd say that despite the negative points (Rogelio), this is ultimately something of a positive story about using local taxpayer dollars to treat the undocumented (sin documentos) who would otherwise not be provided effective treatment (Angel of Silence) thanks to screwy federal laws. It's also a very Texas story.
Do I want taxpayer-funded medical care for everyone, right now, regardless of immigration status? Cómo no. Will I take a more-compassionate-than-expected local hospital district? Por supuesto.
posted by librarylis at 5:51 PM on January 13, 2015
It's great to hear more positive stories about Ben Taub. And yes, I'd say that despite the negative points (Rogelio), this is ultimately something of a positive story about using local taxpayer dollars to treat the undocumented (sin documentos) who would otherwise not be provided effective treatment (Angel of Silence) thanks to screwy federal laws. It's also a very Texas story.
Do I want taxpayer-funded medical care for everyone, right now, regardless of immigration status? Cómo no. Will I take a more-compassionate-than-expected local hospital district? Por supuesto.
posted by librarylis at 5:51 PM on January 13, 2015
Steely-eyed Missile Man: This always seems to be the phrase deployed to sweep the suffering of other people under the rug when the speaker knows they won't encounter the same thing. So unfortunate.
Indeed. It's not actual connected to abuse of an emergency room, since there are many incidents that require emergency room care but not inpatient care. It likely terrifies some of the working poor out of going to the emergency room when they need to. It's is supposed to "encourage" an option that is not even available to many people due to location or hours. But it lets people post smugly about how *healthier* it will encourage people to be, and how people (not like us) are abusing the system because they weren't actually about to die from that shattered leg or slashed hand.
posted by tavella at 10:30 AM on January 14, 2015 [1 favorite]
Indeed. It's not actual connected to abuse of an emergency room, since there are many incidents that require emergency room care but not inpatient care. It likely terrifies some of the working poor out of going to the emergency room when they need to. It's is supposed to "encourage" an option that is not even available to many people due to location or hours. But it lets people post smugly about how *healthier* it will encourage people to be, and how people (not like us) are abusing the system because they weren't actually about to die from that shattered leg or slashed hand.
posted by tavella at 10:30 AM on January 14, 2015 [1 favorite]
Please don't refer to human beings as 'illegals.'
Yes. 'People of Illegality' is the currently preferred term.
posted by Sebmojo at 11:53 AM on January 14, 2015 [1 favorite]
Yes. 'People of Illegality' is the currently preferred term.
posted by Sebmojo at 11:53 AM on January 14, 2015 [1 favorite]
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This thread has been archived and is closed to new comments
How is it that this...this is the state we're in? We're an enormously wealthy country with some of the best medical facilities in the world, but because people have to make money on the ill, we force them to make themselves even more ill just to be seen?
It's disgraceful.
posted by xingcat at 1:24 PM on January 12, 2015 [27 favorites]