Obamacare is the law of the land

And then Iowa’s governor blamed the ACA, of course, not the administration who denied the requests.

Lowers the deficit by $3.8 billion.

Doesn’t alter the number of insured.

Which means it will never pass.

That certainly must be troubling for the House Republican conference, for sure.

Just christen it the “Make American Health Care Great Again Act” and pass that thing!

It should be amazing to see how they argue it’s bad to reduce the deficit while also preserving healthcare.

Ha I wish that’s what they’d need to argue. They’re just going to say CBO is fake news and it’ll cost the government trillions.

Easy peasy. I should be a Republican speech person/strategist.

The Republicans know this is their one chance in the foreseeable future to grab more money for the rich at the expense of actual healthcare. No way would they support this reasonable logical bipartisan bill.

Which is why they seem to be shifting towards “tax reform” lately. Stuff like the “average family saves $4000,” stuff.

Why is the service 10-100x as expensive in an ER? I mean, I can see a few reasons for additional overhead, but in my totally-not-a-doctor sense, it might be 1.5-3x as much.

Hey, since you’d be serving the interests of the Plutocracy, it would probably pay better than what you’re doing now, to boot! :-) There is that whole “living with yourself” problem, though…

I think I could manage…

Besides what ShivaX linked,which is entirely accurate, doctors in an ED setting are held to a different standard than those in primary care, as they should be. The rule for an ED doc is to not miss something that could kill the patient, at all costs, because that’s what the setting demands.

If an ED doc does miss something big - like mistaking a subarachnoid bleed for a migraine, or an epidural abscess for low back pain, then the lawyers and patients come calling with dollar signs in their eyes, and the medical board may take a look at their license to practice. So ED doctors will frequently order a lot more lab and imaging work to rule out those dangerous things than a primary doctor would. After all, an ED doc has access to a full hospital worth of equipment - CT scanners, MRIs, and ultrasound, and immediately delivered lab work - and they are expected to use as much of that as is required to rule out those life-threatening conditions. That costs a ton to be available immediately.

A PCP doesn’t have that access to labwork and imaging, so if they run into a situation where they are concerned about a patient having a dangerous condition, they’ll tell them to go to the ED for an immediate, and costly, workup. But a PCP will happily treat a suspected migraine as a migraine and not have to rule out that bleed to the same level that an ED doc must, because a PCP won’t see the same scrutiny from the medical board or likely from lawyers if they do miss a truly emergent condition that’s not obvious - after all, they’re PCPs not ER docs, and they aren’t trained to spot all of those emergent conditions.

And that’s why the bill for a migraine in the ED can cost 10-100x what it would at the PCP office, because the doctors have different capabilities and requirements for taking care of their patients.

The hospital system I work for is also the highest Trauma level in the area. This means we have to have staff in the building at all times for those very serious Trauma cases, whether they’re called or not. And sometimes when they’re called, as in they get ready, ready to perform and then they’re not needed for good and sometimes unfortunate reasons. Either way, that skillset and equipment, rooms even are shared costs on some level. Obviously very serious cases will cost more than minor ones but the Trauma team is there whether a Trauma case comes through the door or not, keeping in mind these high level trauma cases can actually be transfers from other hospitals, 24/7 accessible.

That’s not really accurate. A PCP is expected to be able to diagnose the same things as an ED doc, including a subarachnoid hemorrhage. In fact, until recently emergency rooms were staffed by the same PCPs who might see you in clinic later in the month. Before 1980, almost nobody trained exclusively in “Emergency Medicine”.

PCPs and ED docs have access to the same consultants, like radiologists, cardiologists, and surgeons, who will help them diagnose or treat a life-threatening illness. The difference is that a consultation ordered in the ER happens immediately, whereas the same consultation ordered in the PCP office will be scheduled for a time convenient for everyone. It’s obviously more expensive to have facilities constantly on call. The other big difference is that ED docs often have no medical history on their patients and must reach a diagnosis more quickly. That means they order repetitive and/or unnecessary tests more often. Haste makes waste.

It’s true that a PCP dealing with an emergency will send the patient to the ER. Not usually because they want the ER to diagnose it, but simply because they want the workup to be done quickly. It is very common for a patient to be sent to the ER with a complete set of instructions by the PCP, eg "I think you might have a subarachnoid bleed, so go to the ER where I will arrange for X,Y, and Z tests to be done and then I will instruct the ER whether to admit you.

The main place where trained ER docs excel is not so much in diagnosis, nor in treatment, but in keeping patients alive and stable in the short time between diagnosis and treatment.

If you think a primary care doctor wouldn’t get the ever-loving crap sued out of them for missing something like a subarachnoid hemorrhage, I suspect you are mistaken. There are probably other conditions that would be better examples of your point, but a primary care doctor that whiffs on that or a stroke or a heart attack is going to be in for some pain, I’d think.

A PCP who misses any obvious emergency does open themselves to lawsuits, but not all emergencies present in the usual obvious ways. The point I was making is less about ED vs PCP lawsuits and more about costs, and the lawsuits do impact costs. ED care is expensive because it has to be, both because it’s an ED where the whole point is to find emergencies and stabilize patients while getting them to the care they need, and because of the very real possibility of malpractice if an ED doc does miss something. All of that, and the points Nesrie brought up about 24/7 availability of specialists, nurses, radiologists, techs, etc, add into the overall cost of an ED visit.

And magnet, things have changed a whole lot since PCPs staffed EDs in the 70s. The ED specialty had barely gotten recognized at that point. No acute ED uses PCPs now if they can avoid it - their training is not sufficient for what is expected of an ED doctor who is seeing the full spectrum of emergent care now. Some rural EDs that don’t see much trauma do still use PCPs, so it’s not completely gone, but no level 1, 2, or even 3 trauma center is likely to use a PCP now. And I’ve never seen a patient sent from the PCP with a list or orders for testing to be done, not that it can’t happen, just that I’ve never experienced that.

To further elaborate on the headache example, I would hope most PCPs would recognize the symptoms of an acute subarachnoid - thunderclap headache, brief loss of consciousness, and the worst headache of a person’s life are taught to every medical student - and send them to the ED for workup. But a more subtle presentation is possible, perhaps only some neck pain or a lateralizing symptom that only a thorough neuro exam would detect. I feel certain that a PCP would be much less likely to be sued than an ED doc who misses that, assuming that good PCP-patient relationship.

I didn’t discuss stroke or heart attacks, because of course every PCP knows the classic symptoms and will send patients to the ED if they are having them. However, an epidural abscess hiding in a sea of low back pain is easy to miss as a PCP. Nausea can be the only presenting symptom of a heart attack, especially in the elderly, and especially for females, and a posterior stroke may only have dizziness as a presenting symptom. Nausea and dizziness are very common causes to see a PCP, so I can easily see both a stroke and a heart attack being missed by a PCP in the 15 minutes they have to assess and treat a patient. And still, the PCP would be much less likely to be sued if they did.

Why do I keep saying that the PCP would be less likely to be sued than the ED doc? Because good studies have shown that the number one reason people sue their doctor is that they didn’t feel cared for. People know that doctors make mistakes, but they are far more likely to give their PCP (that they know, like, and feel good about) the benefit of the doubt than some random ED doc who likely didn’t spend the amount of time listening to them that would have made them feel cared for. It’s about feelings more than it is about poor outcomes. I consider the PCP-patient relationship as the most important part of a PCP’s job, and all bets are off if a PCP hasn’t fostered that relationship - they are doing their patients and themselves a disservice.

I wasn’t sure exactly where you were going/what you had in mind. It’s pretty funny…at least when I was in medical school, the clinical presentations they describe to you are, 99% of the time, the classic symptoms that no one would miss. That’s what I was envisioning. As you say, real life (and real practice) isn’t always so obvious. No harm, no foul. Carry on.