Obamacare is the law of the land


#2975

It’s a thorny problem, the current ER laws. An ER has to provide a screening exam, and at that point, if the problem isn’t emergent, they are legally allowed to discharge the patient. However, the optics and potential liability if something goes wrong is high enough that most (read: all) hospital systems go ahead and treat the patients for their non-emergent issue at that time.

That sounds ok, all in all, cause you don’t want to miss an emergency. Unfortunately, a whole lot of people go to the ED for common primary care reasons, and they are seen, then undergo expensive testing to rule out emergencies, and then get their common issue treated. They then often don’t pay for that very expensive (likely 10-100 times the cost of the same evaluation in a PCP office) service, leading the hospital to file it to charity. People know that they will get treated at the ED, and will not have to pay for that treatment, so they go there for all of their care.

So the question is where do you draw the line? It’s not easy to figure out where, but all attempts to draw it anywhere but getting full treatment in the ED have led to significant lawsuits with big payouts and lots of gun shy hospital systems. Thorny indeed, but there is an issue there, not necessarily just evil politicians wanting people to die already.


#2976

This may be true at some of the religious non-profit hospitals but my understanding is the for-profit hospitals (which are a majority) send out bills. They may well write off those bills later, after the patients declare bankruptcy.

If health care in the US did not cost double for the same procedures as it does in other countries, and if we had coverage for everybody this issue wouldn’t happen. Rather than blaming the indigent who are often desperate and also lack the knowledge to tell an emergent from non-emergent condition, we should be looking at systemic change to avoid this problem altogether.


#2977

I’m not blaming anyone, or giving advice on how to fix it. It is a legitimately difficult problem without a clear answer. I agree that wholesale change, like single payer, is the likeliest way to solve the problem, but the devil will be in the details.


#2978

You can’t just provide Financial Assistance willie nillie. The non-profits will also send a bill, but whichever department is responsible for Financial Assistance is going to try and qualify them for FA. They might even encourage them to sign-up for a Medicaid process. The point is, it is not automagic, and the systems often pay third parties for things like credit reports and what not because gain, it can’t just be opinion that qualifies you or that is, you guessed it, another lawsuit potential.

It is cheaper to see the PCP for these common problems, but they will make you pay before they see you. Urgent care, also cheaper, again requires payment.

There are a efforts, mentioned above in an article, to shift non-emergent to express type services, sometimes run by a nurse but I believe there are legal issues to have someone go to the ER/ED and not be seen by a physician so there is a physician review in there somewhere.

So sending people away from the ED who need care would just wind up with deaths, PR nightmares and providers horrified that someone was hurt or killed as result.


#2979

http://www.npr.org/sections/health-shots/2017/10/24/559843562/administration-denies-more-states-plans-to-customize-insurance-markets

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


#2980

Lowers the deficit by $3.8 billion.

Doesn’t alter the number of insured.


#2981

Which means it will never pass.


#2982

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


#2983

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


#2984

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


#2985

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.


#2986

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.


#2987

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


#2988

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.


#2989

#2990

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…


#2991

I think I could manage…


#2992

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.


#2993

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.


#2994

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.