Grifters, middlemen, and oligopolies are why healthcare is expensive in America. There is no reason we can't fund expensive R&D and also get cheap medicine.
> Yes, emergency rooms are a marvel of modern planning and materials.
Additionally, they're not good enough.
I've helped a friend go through a traumatic ER experience where she suffered 3 strokes and they released her from ER 3 times saying she was fine before she called me for help. We got her psych-eval'd so that they couldn't release her for 72 hours, so they had to run tests, and lo and behold, they did the CT that showed she had 3 strokes. This was at a world famous hospital.
Sadly, this isn't an exceptional story. Most folks don't believe it until they've experienced something like this personally. While I hope most people never have to experience this, we need more people to understand that this is a real problem.
Anytime you're in a hospital, make sure you or someone close to you (ideally w legal authority to make decisions on your behalf) can fight for your care.
Point is, yes they are amazing compared to an alternative of nothing. We have come far. But we can do better. They are by no means a paragon. Pick any part of healthcare, and there's room for improvement.
There have been some immensely interesting articles about price variations in chargemaster documents between hospitals.
https://www.pbs.org/newshour/health/new-report-shows-stagger...
In isolation, those prices are meaningless and can't be compared between two different hospital - even two different hospitals in the same network.
Hospitals make a marginal loss on patients who are on Medicare and Medicaid. They mark up the list prices of everything else to private insurers in order to make up the difference. The way that those markups are distributed doesn't really reveal anything, and even the aggregate size of the markup doesn't reveal anything other than a vague correlation with the proportion of their patient population that is on public insurance.
(That's even assuming that the private insurers pay the prices they are charged, which is never true - they negotiate for lower prices, although they are still required to pay more than Medicare does).
It is so great that we have an ER available to most people here at all times. But we can still do better with it. If you get in a car crash and they have to rush you to the nearest ER you don't get to shop around or choose, which is why it's a monopoly. They can charge you whatever price they want very specifically because your life literally depends on it. There's no market freedom in that. That's why healthcare shouldn't be left to just the free market. That's why so many countries have social healthcare. Sure the engineer you mentioned could handle it, an engineer can handle most financial burdens but not everyone is an engineer. One ER trip can make fixing your credit nearly impossible, and then you can't get a car(required in many areas of the USA due to how cities are planned) or a house, certain jobs, emergency loans, etc.
It's not "a little on the expensive side", it's "How much can we milk you for with your life on the line?"
In most of the developed world those fixed costs are amortized over everyone, in the form of government subsidies of one sort or another. It's like the police or the fire department; everyone chips in some, via taxes, to keep the service running whether they currently need it or not.
In America, however, we amortize them over everyone who comes into the ER. That's good for the guy who never needs medical attention: he gets all the peace of mind of having state of the art care a phone call away for free. It's good for the lady who rolls in at 3am with a gunshot wound: she gets her very elaborate lifesaving care for only a few percent over the marginal costs. It really sucks, though, for the guy with a dislocated thumb: he's forced to either massively cross-subsidize both the other patients or to forgo necessary but relatively simple care because of the huge expense. That guy doesn't need to believe the system should be free to have a valid complaint that he, personally, is getting screwed over by it.
https://data.worldbank.org/indicator/SH.XPD.TOTL.ZS?end=2014...
Come here in France and appreciate that you can go to the ER for ANYTHING (went 4 times last year for my kids because of bad cough and head injury), and not pay a dime. And they have the same kind of infrastructure to maintain here too, CT scanners, emergency rooms, surgeons and all.
You cannot tell people that the guy is hallucinating hidden costs. It is the health system that is hallucinating these costs. It is a race to the top of who is going to charge the most.
By world standards France is doing fine.
I'm not sure anyone is arguing that he should be paying the unit cost without anything going to overhead, but it seems reasonable that strep throat could be treated with antibiotics and be labelled a Category 1.
I had this same situation play out with my daughter where we were concerned with appendicitis and it turned out to be gas. Still was considered a Level 5 even though I protested. Nothing you can do about it. What are you going to do negotiate with the staff at 9pm while your daughter is hurting? What leverage does anyone have in that situation?! You going to risk being a social parriah and risk your family relationships to save money?
To use another example: You have a lump on your breast. It's either cancer or a benign cyst. Would you bill these differently for the diagnosis work on the doctor's part? Maybe I'm misunderstanding what happened in your situation, but if the same exact steps are taken in diagnosing appencitis vs gas, wouldn't you bill the same?
Edit: Oh I forgot to mention the main reason I commented. I have also heard that billing less (like level 4) even if you completed all the steps for level 5 but do not want to get flagged by the system for overbilling can in turn actually get you flagged for underbilling, and can be cause for an investigation/audit.
https://en.wikipedia.org/wiki/Healthcare_Common_Procedure_Co...
Edit: also note that CPT codes are part of the HCPCS
It'd be nice if patients didn't have to worry about these sorts of issues when receiving emergent care, but such is the country we live in.
The article touched on this, and I also discovered this through my own research when I attempted to dispute what in fact a Level 5 was. Add to the fact, that by entering into the hospital you are asked to enter into an arbitration agreement.
Compound this with the monopoly nature of an ER, and the only thing keep prices from spiraling out of control is the sheer benevolence of the hospital employees.
Additionally, insurance companies would be understandably upset if a hospital was charging them more than they should have been, so potential investigations that shed more light on this could help stabilize this part of the market. I appreciate your insight!
and willingness to push back against intense economic pressure from management.
It's not about how amazing ERs are and therefore expensive. It's about horrible allocation of resources across the entire system. If you don't have insurance, guess what, the ER becomes your clinic. If your child is screaming in pain at 2am with an ear ache, guess what, urgent care is closed, you have to go to the ER.
From personal experience, people will go to an ER knowing full well it's not life threatening and don't need the full services, knowing full well it's going to cost them a small fortune. But they just can't reasonably wait 6-12 hours to get treatment. Would you let your 3 year-old scream in agony until the next day because that's what time the Urgent care re-opens, so an MD cay say "Yup, that's an ear infection, here's your script, off you go"? It's a silly system that doesn't provide reasonable options to such common occurrences. People should dam well complain about it until there are better options.
It's not your only option. Chances are, it's not even your best option.
Urgent care clinics are much more appropriate for the bulk of things people are discussing in this thread. Not only are they cheaper for the patient, but they'll get treated faster, and they'll receive better care, because most of these things aren't what emergency physicians are actually trained to deal with.
Just because the hospital has a bunch of equipment and training doesn’t mean it’s efficient to charge everyone that goes in there for all of it. There is such a thing as marginal cost. The marginal cost of this guys visit was next to nothing, but they shook him down for all kinds of other crap, much of which has dubious health value.
I went to the hospital for a slipped disk. From cursory inspection the doctor could tell I had a slipped disk, but they gave me an x Ray. I said “does the x Ray show my slipped disk?” the doctor said “it doesn’t show that. I just gave you the x Ray to be on the safe side.” Then I had to get an MRI and they gave me a ton of opiates that I threw in the trash, after reading about them online. In the end, the physical therapy that got me back to health cost less than the ER visit.
On top of everything, what really gets me is the gall of the medical shake down industry to bring up “costs.” They use the government to make everything as expensive as possible: the absurd licensing and education requirements, the restrictions on foreign practitioners and nurses, the “certificate of need” BS, the lax anti trust treatment as hospitals consolidate into regional monopolies under the laughable excuse of “efficiency,” the use of regulation to restrict suppliers of even generic drugs, the abominable statistical malpractice and pharm rep industry and stupid commercials used to push useless and harmful drugs on everyone—many of them paid for by government in both research and point of sale. At every level the whole system is by design a shamanistic and monopolistic ritual that achieves very little. Look at the failure to replicate of all these stupid studies, the way doctors respond to reimbursements in their use of quack drugs and surgeries, the flatlining of real quality of life stats even as expenditures explode, the power of the various professional associations.
Not the people going to hospital thing - that happens all the time. It's just that nobody is ever charged thousands of dollars for it.
If there are cheaper ways of providing healthcare, what would have to change in the US to implement it?
For example, if there are three hospitals in a region, and they worked out an agreement among each other to not have overlap in specialized equipment (where hospital A sends all MRI patients to Hospital B just down the road), this is currently illegal (anti-collusion laws).
Another example -- a patient comes in with a headache. Well there could be a number of potentially fatal conditions that could be the cause, and due to liability reasons, they have to run tests to rule these out before giving the patient an aspirin (yes, this is an issue, in lower-income areas people go in for non-emergency issues that most likely doesn't need a doctor).
https://ourworldindata.org/the-link-between-life-expectancy-...
https://www.kff.org/health-costs/issue-brief/snapshots-healt...
https://www.pbs.org/newshour/health/health-costs-how-the-us-...
This will never happen in the US, however, because the US is obsessed with concentrating power in private enterprise and refusing to fund social services. We have more than enough money to ensure the health and welfare of all of our citizens. We just don't actually care to do that, and would rather have rich companies and uneducated, sickly, indebted people.
http://www.ncsl.org/research/health/con-certificate-of-need-...
As a Canadian, I gladly fork over a few thousand a year to avoid tens to hundreds of thousands in one sitting should something horrible happen to mine/my family's health.
1. The US healthcare system is pretty good for some people in some places.
I broke a shoulder this week in a bad fall. All local urgent care had JUST closed so I went to a local ER, the only kind of place available with imaging, to confirm the nature on the injury.
ER trip was a little slow (I was triaged appropriately behind people with emergent issues) but within a few hours I got a sling, confirmation from X ray images that no immediate surgery was needed, and followup instructions.
When I left the ER I got a referral to the hospital's orthopedic group, and was able to get an appointment the next day with a PA & MD who specialize in sports medicine and broken shoulders. My GP confirms that this is a trustworthy referral.
So within 18 hrs of injury I got an expert to review the injury and they decided there was enough info from existing diagnostics to avoid additional tests (no more X ray views, no CT) and understand the pros/cons of further intervention.
I also scheduled a follow-up at T+36 from injury with my GP to make sure nothing ELSE was broken (mindful that shoulder experts will only look at the shoulder), and was reassured that nothing else is wrong and conservative management is ok.
So that's 3 healthcare visits within 36 hours of an injury, with almost immediate post-ER triage to (I am reliably told) a high-quality local expert.
This all felt really good and probably slightly faster than I would have been treated when I lived in the UK (with NHS London-area A&E as well as employer private insurance).
No complaints about the US system if you have employer provided insurance. I'm fully expecting to see a $4000 bill for these 3 trips and to pay significantly less than that because I carry a traditional high-premium low-coinsurance health plan. Overall it seemed pretty good, but only because I was fairly confident that paying for care wouldn't permanently ruin my finances.
Would have felt pretty painful to be uninsured. EMTALA keeps people alive but the medium term financial impact of the US's high quality of ER care is not to be taken lightly.
Also would have felt pretty painful if I had been in SF and been taken to SF General Hospital post injury as they are notorious for being extremely convenient to access but out-of-network to all insurance providers: https://www.quora.com/Why-does-San-Francisco-General-Hospita...
I do note that although US care is pretty great it can seem a little over the top sometimes:
2. This article gives an example of a patient with strep throat visiting an ER and being diagnosed using a CT scan … why? That seems like an odd choice.
I once visited an NHS urgent care clinic with a bad sore throat and I was told "you Americans come in for every sore throat, this is just a virus, go away." They didn't even run a strep test, just ruled it out from symptoms. No antibiotics or other treatment etc. Felt kinda harsh but was dirt cheap for the NHS and I think the outcome was the same as a similar US urgent-care visit.
(Actually, I visited an NHS urgent care clinic twice for that sore throat. The first time they told me that because I had an American passport they would charge me £60 to be seen. I was incredulous -- are you sure about that? I'm a UK taxpayer here on a work visa -- and got an apology from a service manager a week later.)
A random guy wakes up at 1am with a cramped muscle. Goes to facility that is equipped to deal with anything. On the spot surgeries, ability to break teeth safely to intubate and keep alive, drugs, cabinets with up to date equipment. Staffed with non-expired drugs that are regularly recycled. Staffed with people that can use all that round the clock, multiple backups. Staffed with people that keep the place reasonably sterile and safe. Staffed with all others to support an operation like that and expecting to get sued if it fails even a bit.
And then complains, he had to pitch in for all that. An engineer, most likely earning above 8k usd, had to give a weekly salary for something that he considered worth dragging his butt out of bed at 1 am.
The guy is delusional.
The US health care is, on the expensive side, and can be better, but nobody can argue it without taking into account all that goes into maintaining that, just so one can randomly walk inside with a spasm, or after a huge carcrash with 40 broken bones, and liters of blood lost, and probably stay alive.
I'm also amazed how most people here just ignore the reality of the scope of the overall operation, and claim that for a limited use case, it's too expensive.
I'm not even going to insert a car analogy here. If you can't see why health care by nature is socialized and a utilitarian model, I'm not going to argue with people from USA thinking that everything should be proportional to the service and their pocket.
Man up. You are not the center of the universe. This civilization was built for you, by people, and no matter if you like it or not, you will pay to maintain it for the people coming after you.
Humanity, is a social concept worth defending.