How to Minimize Your Emergency Care Expenses

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CppCoder
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Re: How to Minimize Your Emergency Care Expenses

Post by CppCoder » Sat Jan 20, 2018 4:48 pm

jayk238 wrote:
Sat Jan 20, 2018 4:24 pm
I think your comment is absolutely out of touch with reality. First off, doctors can't unionize. At least in the traditional sense. We cant affect change to our income, working conditions, or other aspects despite being technically 'allowed' to join an union. Next, organizational structures do not lend themselves to billing. Its not because we think it is'someone elses department.' Thats your words. Physicians do not go through any training at any point from medical school through residency that prepares them for this. Not once in my training have I felt that somehow this would make me a better doctor. It wont. Id rather have spent the time like I did understanding how to intubate and place a central line and learn pharmacology which is relevant to my patient care than about billing which is not something that is life saving in medicine.

You mention that hospitals wont be there if we organized and stopped working. Again- we are prohibited. Not working is also against our ethics and not something I would do. The masses have access to some of the best healthcare in the world including treatment for some of the most difficult cancers out there, surgeries, and general chronic care. If you disagree know this- statistically the US has far better outcomes for conditions that are measured after the patient arrives to the hospital. Most studies publicized indicate patient deaths due to heart disease etc are better in Europe than here- but when they look at treatments and care that begins and ends at the hospital doors (and ignores choices, diet, lifestyle etc etc) the US is superior.
If you want to know what has happened to socialized care just look at the headlines at the NHS. They have patients waiting outside in the lobby who were already admitted to the ED because they are ovefilled. There will be no draconion laws dictating payments. Simply worse outcomes for patients comparable to that in Europe while the pay goes down.

I do sleep well at night and I will tell you why. Because I have the opportunity to see my patients do well. The one with the heart failure who I helped or the COPDer or the MI or the cancer patient. That far outweighs any of these negatives.
There is no reality here, only opinions and perceptions. Clearly, patient and physician perceptions differ. I think doctors would be better doctors if they studied at least one business course. When patients leave and then have massive stress and anxiety because they fear bankruptcy, doesn't it become a medical problem exacerbated by the system?

I didn't say unionize. I said organize. As one of the largest lobbying groups in the U.S. (according to Wikipedia, anyway), what exactly does the AMA do? I'm an engineer in oil and gas. I'm proud that I help power the world, provide electricity, and provide transportation. My job has a positive effect on humanity, just like yours. I don't think I'm ethically obligated to work, though. OK, maybe you do.

I didn't prescribe any kind of fix for the system. I don't have sufficient expertise to do so. My experience is that once things get bad enough, things tend to get "fixed," and that often doesn't lead to good results because the "fixers" do not necessarily have the expertise needed to fix something correctly. We just move from one mistake to the next. Essentially, you'd have lawyers attempting to fix medical problems. I also don't disagree that we don't have good medical outcomes. The problem seems to be affording those outcomes. I'm sure there are many that have terrible outcomes because they can't afford to get treatment. I don't know what the answer is to that problem.

I see how every doctor sleeps well knowing they helped, or at least tried to help patients. What about the patients who then go bankrupt? OK, well, we gave you a new heart. Enjoy the extra years eating dog food?

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Re: How to Minimize Your Emergency Care Expenses

Post by White Coat Investor » Sat Jan 20, 2018 4:57 pm

TheNightsToCome wrote:
Sat Jan 20, 2018 11:35 am
"When you first meet your doctor in the ED, make two things very clear to your doctor. First, that you would like to avoid doing anything today that can safely be done later as an outpatient or not at all. Second, that you understand that there is a great deal of uncertainty in what they're doing today and that you're not going to sue her if something isn't identified on this visit. Repeat this multiple times during your visit. Use words like "I'm willing to share this risk with you if it can save me substantial amounts of money" and "What would you do if it was your wife or child?" "Can this be done safely later if I'm not getting better?" What are the downsides of not doing that test or treatment today?" "What do you think the chances are that this is actually something serious? I'd rather not get a huge work-up today if you think the chances are less than 10%." "

I understand your intent here, but I'm not sure this (patient promising not to sue) is good advice. If a patient ever volunteered that he/she would not sue me, then I would immediately worry that the patient was looking for an opportunity to sue.
raddoc101 wrote:
Sat Jan 20, 2018 4:35 pm
"I'm willing to share this risk with you if it can save me substantial amounts of money"
Maybe I'm pessimistic, but if a patient said this to me, I wouldn't trust it.

The fear of litigation is a huge driver of medical costs. One of my ED friends told me they estimate 70% of their imaging orders are unnecessary. I couldn't believe it was so low. I thought it would be closer to 90%. It unfortunately shapes how we all practice. Sometimes being 99% sure isn't good enough. Not when you hear about multimillion dollar lawsuits over a missed pulmonary nodule. You wonder whether that vague density that you're almost certain is artifact could me blown up in court as evidence of a pulmonary nodule that turns into a lung cancer in 5 years. It sucks. You can't and don't of course recommend a CT on all of these patients, but if it's a 55 year old with a smoking history and no priors, that density even when you're almost certain may cause you to recommend a CT. But lung cancer is a big deal, so this example probably isn't the worst case. It's just one of too many.
It doesn't look like I explained myself very well in this regard. Let me try again.

In the ED, we do a lot of what we call "shared decision-making." The smarter and better educated the patient and the less likely to follow my instructions and not sue me, the more of this I do and the less "paternalistic medicine" (I make the decisions) and "veterinary medicine" (where I order more tests because I don't trust what the patient is telling me) I do.

For example, let's consider that I'm seeing my partner's spouse in the ED. I know for a fact that the patient and spouse are very medically intelligent, highly reliable, have plenty of resources, know how to navigate the medical system, and are extremely unlikely to sue me. I'm far less likely to order a questionably indicated CT scan on that patient than I am on a drunk, homeless, uninsured dude screaming about how he's going to sue me. Want to spend less? Act more like my partner's spouse.

Not all overtesting, probably not even most overtesting, is due to liability concerns. Much more of it is due to just not wanting to miss something and hurt somebody and not knowing if this will be the last chance to identify it before it is too late.

I hope that makes a little more sense. So maybe instead of saying, "I'm not going to sue you" just say something more like, "I understand it is difficult to know for sure what is going on in just one visit and that there is a lot of uncertainty in emergency medicine. In order to save costs, I would be willing to skip tests right now if you can tell me what I need to watch for and should come back immediately for and who I should follow-up with as an outpatient. I'd rather deal with a little uncertainty if it can save me a couple thousand dollars."
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Re: How to Minimize Your Emergency Care Expenses

Post by White Coat Investor » Sat Jan 20, 2018 5:00 pm

CppCoder wrote:
Sat Jan 20, 2018 4:48 pm
I see how every doctor sleeps well knowing they helped, or at least tried to help patients. What about the patients who then go bankrupt? OK, well, we gave you a new heart. Enjoy the extra years eating dog food?
I'm with you man. I think doctors not only have a hippocratic duty to their patient's health but also a fiduciary duty to their wallets.
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Re: How to Minimize Your Emergency Care Expenses

Post by White Coat Investor » Sat Jan 20, 2018 5:03 pm

nisiprius wrote:
Sat Jan 20, 2018 4:02 pm
This means that the common advice that, to avoid surprise bills, "get the procedure code and call the insurer," is basically non-actionable.
I agree that medicine is not currently a functioning market place any time there is a third-party payor involved. Now LASIK, cosmetic surgery etc, sure (and amazing how much those prices have dropped- you can get an augmentation for less than a CT in an ED) but not most stuff. Imagine if you had restaurant insurance and the menu had no prices on it.
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Re: How to Minimize Your Emergency Care Expenses

Post by White Coat Investor » Sat Jan 20, 2018 5:08 pm

simplesimon wrote:
Sat Jan 20, 2018 11:58 am
Why does this feel like more of a problem now? The advent of HDHP's?
We consume more health care than we used to. Part of that is that there is simply more health care to be consumed- more treatments, more medications, more tests etc. Sometimes the supply creates the demand. Nobody used to get MRIs because they hadn't been invented. Same with PPIs, statins, and atypical antipsychotics. There were no robot-assisted prostatectomies.

Why do you think EDs advertise their wait times? If you're really having an emergency, do you care what the wait time is? Of course not. Not only are you going anyway, but you likely won't wait very long and you sure as heck aren't going to drive by the closest ED. The wait time advertising (and the silly "make an appointment in the ED" schemes) are trying to suck in people who aren't actually having a true emergency or who don't actually have skin in the game to come to the ED.
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Re: How to Minimize Your Emergency Care Expenses

Post by White Coat Investor » Sat Jan 20, 2018 5:10 pm

dodecahedron wrote:
Sat Jan 20, 2018 1:11 am
Thanks for this perspective, WCI. Out of curiosity, I wondered what fraction of patients you see in the ED really should have used some other provider setting (i.e., urgent care, their primary, the nurse phone line, etc.) In other words, how bad are random folks you encounter at discerning when the ED is really the appropriate solution? Is it half the patients? More than half?
"Should have" is in the eye of the beholder. Also, there is a huge difference between having an emergent complaint and having an emergent diagnosis.

But I assure you there are plenty of "random folks" who are terrible at discerning when the ED is appropriate.
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Re: How to Minimize Your Emergency Care Expenses

Post by White Coat Investor » Sat Jan 20, 2018 5:13 pm

Hug401k wrote:
Sat Jan 20, 2018 2:45 pm
One other thing I learned.. if you have a specialized issue like an eye and you are headed to the ER, call ahead. We were on our way, leaving the house, my husband called the ER to tell them he would need an eye specialist. The eye specialist called us back and directed us to his office instead, where he had all the proper equipment (and no ER rates). We were in and out in 45 minutes.
You were on your way to the ED, you called the ED, and an eye specialist called you back and told you to meet him at his office? Either you're on the medical staff or you live in Lake Wobegon. I hope nobody assumes from your comment that this is a service most EDs offer.

I agree that if you have an eye issue, you're usually better off being seeing seen in ophthalmology clinic than the ED if your eye issue occurs during banker's hours, if it can wait for banker's hours, or by some miracle you can get an ophthalmologist to meet you at the clinic after hours.
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Re: How to Minimize Your Emergency Care Expenses

Post by willthrill81 » Sat Jan 20, 2018 5:15 pm

Thanks Jim for excellent and thorough information!

I regularly tell my students that one of the primary reasons that healthcare costs are increasing is because consumers (and, in turn, employers) have little/no desire to reduce the cost of their care, especially if they have insurance. When I ask them whether they will ask how much a particular surgery they need will cost, they look at me like I'm a moron because we all know that they truly don't care; they will pay whatever they have to and expect their insurance company to do the same. And when demand is inelastic, prices will go up because there is little reason for them not to.

Unless/until we have a system where patients, as you say, have real "skin in the game," I don't see the cost of healthcare going anywhere but up.
Lee Saage wrote:
Fri Jan 19, 2018 7:15 pm
I think I knew most of this but it's useful, if depressing, to see it summarized in one place. Thanks for doing so. As an example of what not to do, I made use of a convenient hospital emergency room a few years ago for a bad scalp laceration that resulted from a trip and fall (stupid throw rug). As luck would have it, my insurance had just kicked over to a new fiscal year so my deductible was reset just in time for me to eat about $5K in ER charges for sutures and a tetanus shot. I wisely chose to visit a local urgent care facility to have the sutures removed. The urgent care PA said they could have done the sutures and shot for maybe $150. One learns. And relearns.

I have to say your summary certainly reinforces the truth of your #1 in the second paragraph of your post. Thanks, again, for the discourse.
We've been to urgent care facilities several times and have gotten excellent service for what I deem to be very reasonable prices, even with our mostly-employer-paid HDHP. Most of our visits have cost us $100-$300 out of pocket, with our insurance paying little/nothing but negotiating significantly lower prices. An exception was a visit to an urgent care clinic out of state (and out of network) for a sinus infection our daughter had that wouldn't clear up on its own. The visit itself was about $400, plus another $125 for prescription meds. I consider that to be a steal in today's environment.
White Coat Investor wrote:
Fri Jan 19, 2018 10:44 pm
stlrick wrote:
Fri Jan 19, 2018 9:04 pm
Thanks very much for this important and useful post.

I have a question about ambulance service. If I call 911 from my home, the responder will be the EMS service of my local fire department, not a private ambulance service. Will the fire department charges for transport to a local hospital be similar to what you have described for ambulances?
Yes, I would expect so.
Consumer Reports had a big piece last year that addressed the incredible cost of air ambulances and how seldom they are truly needed.
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Re: How to Minimize Your Emergency Care Expenses

Post by halfnine » Sat Jan 20, 2018 5:19 pm

Great Post WCI. Lots of great memories living in the US but the healthcare system is something I do not miss having to deal with at all. But this is great information I'll be sure to share with my family and friends still living there.

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Re: How to Minimize Your Emergency Care Expenses

Post by dodecahedron » Sat Jan 20, 2018 5:26 pm

ram wrote:
Sat Jan 20, 2018 4:44 pm
Hug401k wrote:
Sat Jan 20, 2018 2:45 pm
I wonder if hospitals start to see a rush towards the end of the financial year with so many high deductible plans.
Yes. I am a physician in a specialty where some treatments are "elective". Patients decide which year they want to get it done based on whether they have met the deductible or not. Our ability to take leave in December has decreased over the last few years.
This makes me wonder about whether C-sections and induced labor decisions for folks expecting babies around the New Year might also be affected by high deductible policies. There is already a body of evidence that tax incentives for births before midnight 12/31 may have small but clinically significant effects on birth timing.

http://www.nber.org/papers/w19283

https://sites.hks.harvard.edu/fs/achand ... g_1999.pdf

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Re: How to Minimize Your Emergency Care Expenses

Post by dm200 » Sat Jan 20, 2018 5:44 pm

dodecahedron wrote:
Sat Jan 20, 2018 3:02 pm
dm200 wrote:
Sat Jan 20, 2018 2:50 pm
2. Be informed about what is an "emergency" and what is not. For example, be aware of situations you might encounter.
3. Do NOT hesitate to use an ER when life threatened, such as severe heart attack, severe loss of blood, ruptured aorta, etc.
This is really hard to know in practice.
Heart attacks and strokes can be very hard to recognize sometimes.
I almost did not go to the ER when it turned out I had acute appendicitis. I just thought it was something I ate that disagreed with me. Fortunately I happened to be out of state visiting a family member with a very conservative doc we both know and trust who was able to see me quickly in his office. When he sent me to the ER, I knew I should go (because he is so conservative about interventions.) I am not sure if I would have gone without him telling me to go.
Yes - a challenge.

Two years ago, my wife had severe pain - and I took her to urgent care at 4 am on a Sunday. It was pancreatitis - and they sent her to be admitted to the hospital. With 20/20 hindsight - we think she had similar symptoms (but not severe and she got better) several times over the years.

What I like about our current urgent care facilities is that they can handle almost anything and the costs are very low to the patient.

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Re: How to Minimize Your Emergency Care Expenses

Post by dm200 » Sat Jan 20, 2018 5:45 pm

dodecahedron wrote:
Sat Jan 20, 2018 5:26 pm
ram wrote:
Sat Jan 20, 2018 4:44 pm
Hug401k wrote:
Sat Jan 20, 2018 2:45 pm
I wonder if hospitals start to see a rush towards the end of the financial year with so many high deductible plans.
Yes. I am a physician in a specialty where some treatments are "elective". Patients decide which year they want to get it done based on whether they have met the deductible or not. Our ability to take leave in December has decreased over the last few years.
This makes me wonder about whether C-sections and induced labor decisions for folks expecting babies around the New Year might also be affected by high deductible policies. There is already a body of evidence that tax incentives for births before midnight 12/31 may have small but clinically significant effects on birth timing.
http://www.nber.org/papers/w19283
https://sites.hks.harvard.edu/fs/achand ... g_1999.pdf
Never any personal experience, but there used to be stories that a ride in the old VW Beetles could accelerate labor.

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Re: How to Minimize Your Emergency Care Expenses

Post by CppCoder » Sat Jan 20, 2018 5:46 pm

dodecahedron wrote:
Sat Jan 20, 2018 5:26 pm

This makes me wonder about whether C-sections and induced labor decisions for folks expecting babies around the New Year might also be affected by high deductible policies. There is already a body of evidence that tax incentives for births before midnight 12/31 may have small but clinically significant effects on birth timing.

http://www.nber.org/papers/w19283

https://sites.hks.harvard.edu/fs/achand ... g_1999.pdf
My wife had her annual OB checkup scheduled for late December (convenient because I was home to watch the kids). Their office called two days ahead of time and canceled her appointment because the doctor would be in unplanned delivery all day. It was unclear to me how the office knew there would be all day "unplanned" deliveries. Either they don't understand the word unplanned or they've been in business long enough to predict statistically that the doctor would be in delivery per your above cited effect.

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Re: How to Minimize Your Emergency Care Expenses

Post by GreenGrowTheDollars » Sat Jan 20, 2018 5:57 pm

Be careful that the place called "Urgent Care" is not actually a hospital ER in disguise.
https://khn.org/news/surprise-that-urge ... ke-the-er/

I found out that an Urgent Care I visited actually was operated by a hospital, and the bills were hospital rates.

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Re: How to Minimize Your Emergency Care Expenses

Post by CppCoder » Sat Jan 20, 2018 6:01 pm

Here in Texas, we have this "wonderful" problem of freestanding emergency rooms popping up on every corner. As best as I can tell, they are 24x7 urgent care clinics that charge you ER rates. Technically, they are not urgent care facilities. They do fall under different laws and are required to have different facilities, hours, etc. However, in practice, they treat the same things that the urgent care center treats and tell anyone with a truly emergent condition that they need to go to the hospital ER. Every google/yelp/etc review of these places say, "I went there for the flu, was there 15 minutes, they gave me an advil, and they charged me $1400!" Yes, people shouldn't go to these places, but if you don't live in Texas, you don't understand the marketing (maybe they have them where you live too?). They look like an urgent care center in a strip mall but have the letters ER on their signs. They tell people that it's like going to the emergency room but without the wait times. They outnumber urgent care centers, seemingly, 20:1. The vast majority of their business seems to be functioning as an urgent care but charging people crazy facility fees. I'm not sure who owns these places, but I really wish they'd be outlawed.

WCI, can you weigh in on these facilities? Are they ever worth going to? Is there really a middle ground between hospital ED and urgent care (ER lite?) or if you need emergency care, just go to the hospital?

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Re: How to Minimize Your Emergency Care Expenses

Post by CppCoder » Sat Jan 20, 2018 6:02 pm

GreenGrowTheDollars wrote:
Sat Jan 20, 2018 5:57 pm
Be careful that the place called "Urgent Care" is not actually a hospital ER in disguise.
https://khn.org/news/surprise-that-urge ... ke-the-er/

I found out that an Urgent Care I visited actually was operated by a hospital, and the bills were hospital rates.
Wow, clearly we were on exactly the same wavelength there...see my post right below yours.

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dm200
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Re: How to Minimize Your Emergency Care Expenses

Post by dm200 » Sat Jan 20, 2018 6:09 pm

Even when you (as a patient) try to do the right thing - it can be a huge challenge.

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Re: How to Minimize Your Emergency Care Expenses

Post by dodecahedron » Sat Jan 20, 2018 6:19 pm

CppCoder wrote:
Sat Jan 20, 2018 6:01 pm
Here in Texas, we have this "wonderful" problem of freestanding emergency rooms popping up on every corner. As best as I can tell, they are 24x7 urgent care clinics that charge you ER rates. Technically, they are not urgent care facilities. They do fall under different laws and are required to have different facilities, hours, etc. However, in practice, they treat the same things that the urgent care center treats and tell anyone with a truly emergent condition that they need to go to the hospital ER. Every google/yelp/etc review of these places say, "I went there for the flu, was there 15 minutes, they gave me an advil, and they charged me $1400!" Yes, people shouldn't go to these places, but if you don't live in Texas, you don't understand the marketing (maybe they have them where you live too?). They look like an urgent care center in a strip mall but have the letters ER on their signs.
Do these places accept insurance? I can't imagine that any insurance plan would stand for those egregiously inappropriate billing practices. (Arguably, the justification for high bill rates in a *real* emergency room in a hospital is that they have very high overhead for all the fancy equipment and specialists that are on standby in case it/they is needed.) But if an urgent care is masquerading as an ER and billing in the same over-the-top ER manner, I think your insurance company would either declare them out of network or bargain the rates down.

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Re: How to Minimize Your Emergency Care Expenses

Post by dm200 » Sat Jan 20, 2018 6:20 pm

The push seems to be expansion of expensive (to the patient and/or patient's insurance) care facilities. The large financial benefits of the providers seem to drive this.

It would seem, though, that these insurance companies (in large and dense areas like where I live) could drive the costs down by subsidizing or promoting or only covering places that have low costs. It is a real puzzle to me.

How does my provider, Kaiser, have 24x7 urgent care facilities - several able to keep patients (some very sick) up to 24 hours AND charge very low fees and copays? Several years ago, for example, my doctor got all excited that I might be having a heart attack (probably just a virus). I checked in, stayed all night, had blood tests, chest x-ray, heart monitor, next morning - stress test - and saw a cardiologist - who said I was OK. I paid less than $100 for all of this.

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Re: How to Minimize Your Emergency Care Expenses

Post by jayk238 » Sat Jan 20, 2018 6:26 pm

CppCoder wrote:
Sat Jan 20, 2018 6:01 pm
Here in Texas, we have this "wonderful" problem of freestanding emergency rooms popping up on every corner. As best as I can tell, they are 24x7 urgent care clinics that charge you ER rates. Technically, they are not urgent care facilities. They do fall under different laws and are required to have different facilities, hours, etc. However, in practice, they treat the same things that the urgent care center treats and tell anyone with a truly emergent condition that they need to go to the hospital ER. Every google/yelp/etc review of these places say, "I went there for the flu, was there 15 minutes, they gave me an advil, and they charged me $1400!" Yes, people shouldn't go to these places, but if you don't live in Texas, you don't understand the marketing (maybe they have them where you live too?). They look like an urgent care center in a strip mall but have the letters ER on their signs. They tell people that it's like going to the emergency room but without the wait times. They outnumber urgent care centers, seemingly, 20:1. The vast majority of their business seems to be functioning as an urgent care but charging people crazy facility fees. I'm not sure who owns these places, but I really wish they'd be outlawed.

WCI, can you weigh in on these facilities? Are they ever worth going to? Is there really a middle ground between hospital ED and urgent care (ER lite?) or if you need emergency care, just go to the hospital?
This is similar to what we call a micro-hospital. What you described may just be an ER- but they run a similar scam.

If you really care about healthcare write to your legislator to fight medicare from accepting these as actual hospital stays/ERs and allowing for the full visit. They basically want best of both worlds. They offer 'quick' and 'convenient' - code words for saying hey come here we will give you access at a high fee. Basically they have maybe 5 inpatient beds and keep maybe 1 or 2 beds open. They have an ER or urgent care place that pretends to see acute patients (since after all they can admit them to the hospital) - but really refer out 90% of all their patients- like an urgent care, and maybe keep 1 or 2 patients overnight.
Medicare won a case and claimed these were not true hospitals and could not charge full price but they've also acceded in other cases- its very touch and go right now.

Look up Embree group. They're a texas based real estate firm that runs this scam. Yes, real estate.

https://www.bdcnetwork.com/microhospita ... cess-point

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Re: How to Minimize Your Emergency Care Expenses

Post by White Coat Investor » Sat Jan 20, 2018 6:30 pm

dodecahedron wrote:
Sat Jan 20, 2018 5:26 pm
ram wrote:
Sat Jan 20, 2018 4:44 pm
Hug401k wrote:
Sat Jan 20, 2018 2:45 pm
I wonder if hospitals start to see a rush towards the end of the financial year with so many high deductible plans.
Yes. I am a physician in a specialty where some treatments are "elective". Patients decide which year they want to get it done based on whether they have met the deductible or not. Our ability to take leave in December has decreased over the last few years.
This makes me wonder about whether C-sections and induced labor decisions for folks expecting babies around the New Year might also be affected by high deductible policies. There is already a body of evidence that tax incentives for births before midnight 12/31 may have small but clinically significant effects on birth timing.

http://www.nber.org/papers/w19283

https://sites.hks.harvard.edu/fs/achand ... g_1999.pdf
"May have?" Give me a break. This is standard of care. Ask any OB. That "first birth of the new year" that is always celebrated is kind of like 2nd place- i.e. first loser!
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Re: How to Minimize Your Emergency Care Expenses

Post by White Coat Investor » Sat Jan 20, 2018 7:00 pm

CppCoder wrote:
Sat Jan 20, 2018 6:01 pm
Here in Texas, we have this "wonderful" problem of freestanding emergency rooms popping up on every corner. As best as I can tell, they are 24x7 urgent care clinics that charge you ER rates. Technically, they are not urgent care facilities. They do fall under different laws and are required to have different facilities, hours, etc. However, in practice, they treat the same things that the urgent care center treats and tell anyone with a truly emergent condition that they need to go to the hospital ER. Every google/yelp/etc review of these places say, "I went there for the flu, was there 15 minutes, they gave me an advil, and they charged me $1400!" Yes, people shouldn't go to these places, but if you don't live in Texas, you don't understand the marketing (maybe they have them where you live too?). They look like an urgent care center in a strip mall but have the letters ER on their signs. They tell people that it's like going to the emergency room but without the wait times. They outnumber urgent care centers, seemingly, 20:1. The vast majority of their business seems to be functioning as an urgent care but charging people crazy facility fees. I'm not sure who owns these places, but I really wish they'd be outlawed.

WCI, can you weigh in on these facilities? Are they ever worth going to? Is there really a middle ground between hospital ED and urgent care (ER lite?) or if you need emergency care, just go to the hospital?
Sure. This is a big topic in emergency medicine. I have mixed feelings about them.

A free-standing emergency department or emergency center is either owned by investors/doctors or owned by local hospitals (i.e. a Hospital Out Patient Department.) The first doesn't take Medicare or Medicaid at all. They're not allowed to, nor are they interested in doing so. The second does. That's the main difference. Unlike urgent cares, EMTALA applies to both of them. In addition, they generally must have a transfer agreement to a local hospital for patients that need to be admitted. Both of them charge "ER prices" so your bill looks just like it does when you go to the ED. Which is actually totally reasonable, since they offer ED-level care. They have a lab, an ultrasound, an x-ray, a CT scanner, and a board certified emergency rather than what you can get in an urgent care which is typically a P.A., an x-ray, rapid streps and flus, pregnancy tests, and a urine dip.

Here are the pros for both patients, hospitals and doctors.

1) Shorter wait times
2) Very personalized care, often "concierge-like." They generally see fewer patients per hour and so can see you faster, spend more time with you, and give you better care than what you might see in a crazy ED.
3) Relieves ED crowding by, well, having more ED beds in town.
4) A great source of referrals for hospital admissions since these patients are almost always insured with good insurance
5) The opportunity for the physician to see fewer patients per hour and have a more enjoyable practice
6) If physician-owned,the chance for the physician to actually own her job. No more risk of losing the contract with the hospital- the main business risk in emergency medicine.
7) If physician-owned, the chance for the physician to actually control how your care is delivered. In most EDs the techs, clerks, nurses, RTs, x-ray techs, lab techs etc are all employed by the hospital. The doc can't hire them, fire them, or tell them how to do their job. No control equals worse care and increased physician burnout.
8) If physician-owned, the chance for the physician to collect part of the facility fee. As noted in the OP, the facility fee is often 4-10 times what the physician professional fee is. If the physician can run the business well, she can dramatically boost her hourly pay. I almost invested in one of these once and reasonable projections showed a 100% yield on my investment in the first year and likely improving from there.
9) More EDs = shorter drive to the ED and potentially life-saving care.
10) Specialists like being on call for FSEDs because instead of getting a bunch of self-pay and Medicaid patients referred to them, they get the patients with money and insurance.

Here are the cons for patients, hospitals, and doctors.

1) No matter what you put on the sign or on the paperwork when you sign in, many people still won't be able to tell the difference between an urgent care and a free-standing ED. Then they'll get mad when they get an ER-level bill. And write their legislators. Who will get mad. This introduces serious legislative/regulatory risk to your business.
2) There is serious incentive for the FSED NOT to make it very obvious that this is an ED and not an UC, although that's really a very short-term mindset because eventually the community will figure it out and punish you for your business practices.
3) Free-standing EDs don't get built in the crummy areas of town. So in effect, they siphon off the well-insured patients from the hospital EDs. American capitalism at work. If it costs you the same, and you get better care at a FSED, you're going to go there. In fact, some studies show the time from presentation until you're in a hospital bed (or even the cath lab if you are having a big heart attack) is shorter if you go to a FSED and are transferred to the hospital than if you went to the hospital in the first place!)
4) More EDs creates some additional ED visits in a community (supply-induced demand), but mostly it just spreads the patients out among more EDs and emergency physicians. While a hospital (or a physician who owns the FSED) can make money on 10 patients per 24 hour period, physicians staffing a FSED need about 20 patients per day to start making money. So if a hospital builds a HOPD down the street and expects the physician group that staffs their main ED to staff it, the hospital may very well make money while the docs just had their hourly pay cut by 1/3.
5) Aside from the emergency physicians, more EDs dilutes resources and causes a lot of unnecessary duplication of resources. There are only so many ER nurses in town. It would be cheaper to have 2 CT scans in town that did 30 scans a day each than 6 CT scans in town that did 10 scans a day.
6) Hospitals accepting FSED transfers at the expense of their own ED patients may contribute to ED crowding in their own ED. The well-to-do slide in the back door getting excellent care while the poor folks spend the night on an ED gurney because there are no beds available.
7) FSEDs are generally much more aggressive with "medical screen outs" which is the practice of actually asking patients to pay just as soon as you know they don't have an emergency. Basically "emergency" may be defined a lot more rigidly for the uninsured who show up at a FSED.

Bottom line, as a physician entrepreneur I'm a huge fan of physician owned FSEDs. As a physician who works in hospital EDs, they are a major business threat, whether they are owned by someone else or owned by "my hospital" that then forces us to staff an unprofitable FSED at the risk of losing our main contract and because they pull patients from us. As a patient advocate, I have mixed feelings. Some things are better about them and some things are worse.

For the purposes of those reading this thread, the main thing is just to realize that they aren't urgent cares. Don't go there thinking it is an urgent care. It's an ED. It really is.
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Re: How to Minimize Your Emergency Care Expenses

Post by CppCoder » Sat Jan 20, 2018 7:46 pm

White Coat Investor wrote:
Sat Jan 20, 2018 7:00 pm
Sure. This is a big topic in emergency medicine. I have mixed feelings about them.
Thank you for taking the time to give such a well-thought out detailed analysis highlighting both sides of the FSED equation. They must be huge money makers for somebody. There are literally places in my, admittedly, well-to-do part of town that has these things across the street from each other. I think we have more of them (not exaggerating...I really think we do) than we have Starbucks. I went into one once when it first opened because they offered a free first aid kit if you brought in their advertisement. I walked to it from my house, got the first aid kit, and left. CppCoder 1, FSED 0! :D

Sadly (for humanity, I suppose), the moral I took from your analysis from the patient perspective is that FSEDs are a rich man's accelerated backdoor into hospital emergency care. Before now, I would have skipped these things in an emergency situation and tried to make it to the hospital. Now, if I'm having a heart attack, I'll just stumble to the FSED almost across the street (I won't, I'll call 911) and have them zip me to the hospital without the ER wait. $250 deductible and hospital co-pay either way...

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Re: How to Minimize Your Emergency Care Expenses

Post by CppCoder » Sat Jan 20, 2018 7:53 pm

dodecahedron wrote:
Sat Jan 20, 2018 6:19 pm
Do these places accept insurance? I can't imagine that any insurance plan would stand for those egregiously inappropriate billing practices. (Arguably, the justification for high bill rates in a *real* emergency room in a hospital is that they have very high overhead for all the fancy equipment and specialists that are on standby in case it/they is needed.) But if an urgent care is masquerading as an ER and billing in the same over-the-top ER manner, I think your insurance company would either declare them out of network or bargain the rates down.
To the best of my knowledge, yes, they take private insurance. I'm not sure if they have wide networks, though. My hunch is that they'd close down pretty quickly if they didn't take any insurance. I doubt they'd have a lot of repeat customers at full freight. Others more knowledgeable than me have responded about medicare and medicaid.

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Re: How to Minimize Your Emergency Care Expenses

Post by JBTX » Sat Jan 20, 2018 7:54 pm

jayk238 wrote:
Sat Jan 20, 2018 4:24 pm
CppCoder wrote:
Sat Jan 20, 2018 8:48 am
White Coat Investor wrote:
Fri Jan 19, 2018 6:41 pm
# 1 - It is screwed up, broken, and embarrassing to be a part of.
Thank you for being upfront and honest about this situation. As patients, we often wonder if the doctors even know this or care.
# 5 - Doctors and nurses generally aren't in control of what's on your bill(s) nor does most of the money paid toward your bill(s) go toward doctors and nurses, so no sense in taking it out on them.
I know the above is true, but honestly, the medical providers are the ones who make this industry work. Why don't doctors, nurses, etc. organize and fix the problem? If you don't, you're somewhat complicit. You are taking advantage of the system to receive high pay and abdicating responsibility for billing because "that's someone else's department." I assure you, most hospitals wouldn't be there if doctors organized and stopped working there. If nothing else, you'd think someone would want to do this for self-preservation reasons. Rightly or wrongly, eventually the masses can't take it anymore, and they come with tar, feathers, and pitchforks. In this case, I suspect that would be draconian laws dictating payment, not literal tar and feathering. Maybe this will never be the case because the really poor don't pay, the rich just pay and complain but it has no impact on them, and those stuck in the middle get squeezed but are too few and powerless to fix anything. Personally, I wouldn't be able to sleep at night working in an industry that yes, provides a needed and noble service, but also had a back office that worked like a loan shark. I can't imagine anyone going into medical school today doesn't realize this...they still go.

I think your comment is absolutely out of touch with reality. First off, doctors can't unionize. At least in the traditional sense. We cant affect change to our income, working conditions, or other aspects despite being technically 'allowed' to join an union. Next, organizational structures do not lend themselves to billing. Its not because we think it is'someone elses department.' Thats your words. Physicians do not go through any training at any point from medical school through residency that prepares them for this. Not once in my training have I felt that somehow this would make me a better doctor. It wont. Id rather have spent the time like I did understanding how to intubate and place a central line and learn pharmacology which is relevant to my patient care than about billing which is not something that is life saving in medicine.

You mention that hospitals wont be there if we organized and stopped working. Again- we are prohibited. Not working is also against our ethics and not something I would do. The masses have access to some of the best healthcare in the world including treatment for some of the most difficult cancers out there, surgeries, and general chronic care. If you disagree know this- statistically the US has far better outcomes for conditions that are measured after the patient arrives to the hospital. Most studies publicized indicate patient deaths due to heart disease etc are better in Europe than here- but when they look at treatments and care that begins and ends at the hospital doors (and ignores choices, diet, lifestyle etc etc) the US is superior.
If you want to know what has happened to socialized care just look at the headlines at the NHS. They have patients waiting outside in the lobby who were already admitted to the ED because they are ovefilled. There will be no draconion laws dictating payments. Simply worse outcomes for patients comparable to that in Europe while the pay goes down.

I do sleep well at night and I will tell you why. Because I have the opportunity to see my patients do well. The one with the heart failure who I helped or the COPDer or the MI or the cancer patient. That far outweighs any of these negatives.
I agree the notion to unionize is absurd and I don’t directly blame doctors for the situation. However given how the system is set up, the notion that doctors shouldn’t worry about the financial costs is naive. Some doctors seem to think they should only worry about the health care aspect and leave the financial side to somebody else. But the result is medicine gets more costly, which ultimately may lead to people avoiding needed care to save money.

I think the notion of evaluating and allocating care based upon financial impacts is completely against the way doctors are trained to practice. So we leave it to uneducated consumers or various administrative procedures and policies which are out of touch with the needs of the patient. Like it or not the doctor is in the best position to evaluate the cost and benefits of various procedures.

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Re: How to Minimize Your Emergency Care Expenses

Post by jayk238 » Sat Jan 20, 2018 7:59 pm

JBTX wrote:
Sat Jan 20, 2018 7:54 pm
jayk238 wrote:
Sat Jan 20, 2018 4:24 pm
CppCoder wrote:
Sat Jan 20, 2018 8:48 am
White Coat Investor wrote:
Fri Jan 19, 2018 6:41 pm
# 1 - It is screwed up, broken, and embarrassing to be a part of.
Thank you for being upfront and honest about this situation. As patients, we often wonder if the doctors even know this or care.
# 5 - Doctors and nurses generally aren't in control of what's on your bill(s) nor does most of the money paid toward your bill(s) go toward doctors and nurses, so no sense in taking it out on them.
I know the above is true, but honestly, the medical providers are the ones who make this industry work. Why don't doctors, nurses, etc. organize and fix the problem? If you don't, you're somewhat complicit. You are taking advantage of the system to receive high pay and abdicating responsibility for billing because "that's someone else's department." I assure you, most hospitals wouldn't be there if doctors organized and stopped working there. If nothing else, you'd think someone would want to do this for self-preservation reasons. Rightly or wrongly, eventually the masses can't take it anymore, and they come with tar, feathers, and pitchforks. In this case, I suspect that would be draconian laws dictating payment, not literal tar and feathering. Maybe this will never be the case because the really poor don't pay, the rich just pay and complain but it has no impact on them, and those stuck in the middle get squeezed but are too few and powerless to fix anything. Personally, I wouldn't be able to sleep at night working in an industry that yes, provides a needed and noble service, but also had a back office that worked like a loan shark. I can't imagine anyone going into medical school today doesn't realize this...they still go.

I think your comment is absolutely out of touch with reality. First off, doctors can't unionize. At least in the traditional sense. We cant affect change to our income, working conditions, or other aspects despite being technically 'allowed' to join an union. Next, organizational structures do not lend themselves to billing. Its not because we think it is'someone elses department.' Thats your words. Physicians do not go through any training at any point from medical school through residency that prepares them for this. Not once in my training have I felt that somehow this would make me a better doctor. It wont. Id rather have spent the time like I did understanding how to intubate and place a central line and learn pharmacology which is relevant to my patient care than about billing which is not something that is life saving in medicine.

You mention that hospitals wont be there if we organized and stopped working. Again- we are prohibited. Not working is also against our ethics and not something I would do. The masses have access to some of the best healthcare in the world including treatment for some of the most difficult cancers out there, surgeries, and general chronic care. If you disagree know this- statistically the US has far better outcomes for conditions that are measured after the patient arrives to the hospital. Most studies publicized indicate patient deaths due to heart disease etc are better in Europe than here- but when they look at treatments and care that begins and ends at the hospital doors (and ignores choices, diet, lifestyle etc etc) the US is superior.
If you want to know what has happened to socialized care just look at the headlines at the NHS. They have patients waiting outside in the lobby who were already admitted to the ED because they are ovefilled. There will be no draconion laws dictating payments. Simply worse outcomes for patients comparable to that in Europe while the pay goes down.

I do sleep well at night and I will tell you why. Because I have the opportunity to see my patients do well. The one with the heart failure who I helped or the COPDer or the MI or the cancer patient. That far outweighs any of these negatives.
I agree the notion to unionize is absurd and I don’t directly blame doctors for the situation. However given how the system is set up, the notion that doctors shouldn’t worry about the financial costs is naive. Some doctors seem to think they should only worry about the health care aspect and leave the financial side to somebody else. But the result is medicine gets more costly, which ultimately may lead to people avoiding needed care to save money.

I think the notion of evaluating and allocating care based upon financial impacts is completely against the way doctors are trained to practice. So we leave it to uneducated consumers or various administrative procedures and policies which are out of touch with the needs of the patient. Like it or not the doctor is in the best position to evaluate the cost and benefits of various procedures.
I agree. I think we need a new wave of physician-business men who are focused on their private practice but leading at an administrative organizational level. This is new -because the vast majority of MD/MBAs for a long time were focused on their own practice.
Maybe this will change but frankly its a challenge. How can someone convince me to 1. Take on more debt just when I started paying off my debt and 2. spend more time in education forgoing my income?

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Re: How to Minimize Your Emergency Care Expenses

Post by CppCoder » Sat Jan 20, 2018 8:19 pm

jayk238 wrote:
Sat Jan 20, 2018 7:59 pm
I agree. I think we need a new wave of physician-business men who are focused on their private practice but leading at an administrative organizational level. This is new -because the vast majority of MD/MBAs for a long time were focused on their own practice.
Maybe this will change but frankly its a challenge. How can someone convince me to 1. Take on more debt just when I started paying off my debt and 2. spend more time in education forgoing my income?
Do you think it would be completely inappropriate (maybe simply inadequate) to add a few business/entrepreneur classes to medical school? One might not need a full-fledged MBA. Maybe an accounting class and one other class would be sufficient for 90+% of the cases. My father had a physician friend who said it was a complete travesty that medical school had no business courses. He was expected to run his own practice (this was the 1970s or 1980s) but had absolutely no idea what he was doing in that space.

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Re: How to Minimize Your Emergency Care Expenses

Post by JBTX » Sat Jan 20, 2018 8:49 pm

WCI, I really enjoyed reading your post. I always like to hear from professionals who work within a field that can give a unique perspective to an issue.

Overall I think most of the post was an affirmation of what I thought was true and not necessarily new to me. I’m not in the medical field but have interacted with the health care system quite a bit due to family medical issues, including filing hundreds of out of network medical claims myself. Also what you have described is very much in line with articles I have read (the bitter bill in time magazine for example).

In terms of actionable items, i don’t think there is much new here for most Bogle heads, as much of it is common sense. However, it is good to see them reiterated from somebody who is highly knowledgeable in both medical and financial issues. It puts in context the occasional threads of posters who contemplate the idea of self funding their medical insurance.

What was a bit new, or at least interesting hearing it from someone such as yourself was to be very diligent and vocal during the whole process about avoiding unnecessary procedures or deferring them to later if they aren’t immediately urgent. This is good advice but it is a bit unnatural, because typically ER visits are stressful, and the mere thought of thinking about cost makes people feel guilty and gives the perception of caring about cost more than optimal health care outcome.

I agree with the other poster that said telling the provider you won’t sue them seems awkward and perhaps actually counter productive. But your advice of articulating you are willing to accept some risk if there is X percent chance of undesired outcome is probably an effective way of getting through.

I also agree with your assessment that we kind of have to go one way or other. The system is stuck in the middle trying to both a free market and quasi single payer-ish system and doing neither. While I am all for more price and cost visibility I struggle with the notion of consumers being able to pick and choose medical care a la cart from a price menu. As you do well articulate that just isn’t the way a health care transaction works. It is far more complicated.

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Re: How to Minimize Your Emergency Care Expenses

Post by jayk238 » Sat Jan 20, 2018 8:58 pm

CppCoder wrote:
Sat Jan 20, 2018 8:19 pm
jayk238 wrote:
Sat Jan 20, 2018 7:59 pm
I agree. I think we need a new wave of physician-business men who are focused on their private practice but leading at an administrative organizational level. This is new -because the vast majority of MD/MBAs for a long time were focused on their own practice.
Maybe this will change but frankly its a challenge. How can someone convince me to 1. Take on more debt just when I started paying off my debt and 2. spend more time in education forgoing my income?
Do you think it would be completely inappropriate (maybe simply inadequate) to add a few business/entrepreneur classes to medical school? One might not need a full-fledged MBA. Maybe an accounting class and one other class would be sufficient for 90+% of the cases. My father had a physician friend who said it was a complete travesty that medical school had no business courses. He was expected to run his own practice (this was the 1970s or 1980s) but had absolutely no idea what he was doing in that space.
No. I cant see any value to adding these classes. Most medical students are trying to match their residency and get an adequate education. If the class is not tested on boards then its not going to stick. If it is tested its going to take up valuable space from the large volume of information we already study and learn. Theres no way we have time for it. And having a class thats not tested is just more filler that takes up our time. I spent on average 60-80 hours a week studying to begin with.

I think a more useful remedy is for those in residency to have easy access to online course material that teaches us this stuff. If we are motivated, and if we have the downtime say in our last year then we can make the effort to learn about it.

Finally making it available for attendings in the form of actionable information may be of use. But frankly these next few years will be hard on me just from a medical knowledge/practice standpoint- despite having this much education the reality is that once an attending I will learn that much more as I progress- and again I dont think I will have time.

I suspect that I myself will become more vested in this process 10 year from now when I have enough money in the bank that I can risk branching out even if it leads to lower pay such as in administration/business.

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Re: How to Minimize Your Emergency Care Expenses

Post by dodecahedron » Sat Jan 20, 2018 9:06 pm

White Coat Investor wrote:
Sat Jan 20, 2018 7:00 pm
For the purposes of those reading this thread, the main thing is just to realize that they aren't urgent cares. Don't go there thinking it is an urgent care. It's an ED. It really is.
Wow, this is intriguing information. I don't believe we have any of these nearby, but I have to say it is awfully tricky for a patient to figure these things out, especially when they are under stress and trying to decide where to go.

Albany Medical Center, the major teaching hospital in our area, familiarly known as "Albany Med" owns about half a dozen freestanding facilities are branded with large signs advertising their name as "Albany Med EmUrgent Care. It is definitely an urgent care (my HMO's provider directory lists it as such) and people I know who have gone there have reported very modest bills for prompt, competent, and comprehensive treatment of whatever their issue was--broken bones, minor burns, etc. But the name on the signs definitely blurs the distinction.

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Re: How to Minimize Your Emergency Care Expenses

Post by HIinvestor » Sun Jan 21, 2018 12:12 am

I have been to the ER twice with my D when she was a baby/toddler in early 1990s, before ever hearing of urgent care. The first time she was ill and dehydrated but couldn’t keep fluids down and needed an IV. The second time she was very ill and needed to be admitted to the hospital.

We also have urgent care clinics in our state that so far appear to be just urgent care. They will X-ray on premises, read the X-ray and provide a soft boot, crutches, a cast or similar. They will also do wound care, treat infections, do physicals and more. I was billed my normal $15 copay and the person I saw was an ER doctor.

Our island also has orthopedic urgent care as well, open 7 days/week. I went there after I had been to the urgent care. They gave me a taller boot and said it appeared I had indeed fractured my fibula. They also had their PA or NP refer me to their orthopedic surgeon who specialized in ankles for follow up. Again I paid my normal $15 copay.

I learned about urgent care after referring a out-of-state friend to the ER after she fell off her horse. She complained that she had to wait MANY, MANY hours to be seen and then just got X-rays and some Rx for pain and finally sent home with mega-bill. Next time she went to urgent care and told me it was much faster and better and they got all they needed in under an hour with a much smaller bill.

On the other hand, another friend said her aunt died because the urgent care provider didn’t diagnose and promptly and aggressively treat her relative’s sepsis but just told them to provide symptomatic care for regular infection.

I guess from a lay perspective, urgent care is great for things like falls, possible orthopedic injuries but perhaps might not be as alert for more esoteric infections and problems. Is this accurate? Was the aunt just “unlucky”?

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Re: How to Minimize Your Emergency Care Expenses

Post by White Coat Investor » Sun Jan 21, 2018 12:40 am

HIinvestor wrote:
Sun Jan 21, 2018 12:12 am
I have been to the ER twice with my D when she was a baby/toddler in early 1990s, before ever hearing of urgent care. The first time she was ill and dehydrated but couldn’t keep fluids down and needed an IV. The second time she was very ill and needed to be admitted to the hospital.

We also have urgent care clinics in our state that so far appear to be just urgent care. They will X-ray on premises, read the X-ray and provide a soft boot, crutches, a cast or similar. They will also do wound care, treat infections, do physicals and more. I was billed my normal $15 copay and the person I saw was an ER doctor.

Our island also has orthopedic urgent care as well, open 7 days/week. I went there after I had been to the urgent care. They gave me a taller boot and said it appeared I had indeed fractured my fibula. They also had their PA or NP refer me to their orthopedic surgeon who specialized in ankles for follow up. Again I paid my normal $15 copay.

I learned about urgent care after referring a out-of-state friend to the ER after she fell off her horse. She complained that she had to wait MANY, MANY hours to be seen and then just got X-rays and some Rx for pain and finally sent home with mega-bill. Next time she went to urgent care and told me it was much faster and better and they got all they needed in under an hour with a much smaller bill.

On the other hand, another friend said her aunt died because the urgent care provider didn’t diagnose and promptly and aggressively treat her relative’s sepsis but just told them to provide symptomatic care for regular infection.

I guess from a lay perspective, urgent care is great for things like falls, possible orthopedic injuries but perhaps might not be as alert for more esoteric infections and problems. Is this accurate? Was the aunt just “unlucky”?
Minor suturing, minor orthopedic stuff, minor urinary symptoms, minor rashes, medication refills, stuff that doesn't actually need to be seen by anybody (colds, mild anxiety), fever in healthy people, low back pain, cough = urgent care

Chest pain, belly pain, shortness of breath, altered mental status/unconscious, trauma, elderly that just isn't right, weak and dizzy, suicidal, heavy vaginal or GI bleeding, pelvic pain in early pregnancy, loss of vision, focal weakness, difficulty speaking, amputations, difficult to control bleeding, fever in under 6 months, surgical complications, just about anything if you're on chemotherapy, severe acute pain, envenomations, hypothermia, heat stroke, near drowning, cardiac arrest, worst headache of your life, foreign bodies of all types (eye, ear, nose, throat, vagina, rectum, bladder, esophagus, stomach), inability to swallow liquids, G tube or shunt complications, severe allergic reactions, dislocations, hallucinations, severe delusions, abnormal vital signs, palpitations, passing out, severe, vomiting or diarrhea with dehydration, can't pee, can't poop, can't fart, anything else you're worried might be an emergency = emergency department
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Re: How to Minimize Your Emergency Care Expenses

Post by HIinvestor » Sun Jan 21, 2018 1:04 am

Thanks—very helpful perspective and lists distinguishing which symptoms merit what type of care. Our nonprofit serves folks who have underlying chronic lung condition, so shortness of breath is their main symptom.

I encourage them to develop a written action plan with their healthcare provider as to what change in symptoms merits what level of escalating care, calling provider, 911, etc. Since they often have multiple health conditions most have seen the inside of more ERs and hospitals than I or they’d like.

There are studies which show that having a good written action plan with your provider when you have a chronic condition can help provide better, less expensive care.

I believe Telehealth may also have a role in helping patients make good choices about whether to go to Urgent Care, ER or call provider the next day.
Last edited by HIinvestor on Sun Jan 21, 2018 1:21 am, edited 1 time in total.

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Re: How to Minimize Your Emergency Care Expenses

Post by White Coat Investor » Sun Jan 21, 2018 1:09 am

HIinvestor wrote:
Sun Jan 21, 2018 1:04 am
Thanks—very helpful perspective and lists distinguishing which symptoms merit what type of care. Our nonprofit serves folks who have underlying chronic lung condition, so shortness of breath is their main symptom.

I encourage them to develop a written action plan with their healthcare provider as to what change in symptoms merits what level of escalating care, calling provider, 911, etc. Since they often have multiple health conditions most have seen the inside of more ERs and hospitals than I or they’d like.

There are studies which show that having a good written action plan with your provider when you have a chronic condition can help provide better, less expensive care.

I believe Telehealth nay also have a role in helping patients make good choices about whether to go to Urgent Care, ER or call provider the next day.
Yes, EDs and emergency physicians stink at most chronic conditions, particularly chronic pain. It doesn't mesh up well with our training. Chronic dyspnea is tricky...when IS it bad enough to come in? I also had a "frequent flyer" for years. Got dropped off a couple of mornings a week with chest pain. The problem was he had terrible heart disease. So he got a huge work-up twice a week. Half the time it was positive and half the time it wasn't. How do you tell someone like that to stop coming to the ED? Very nice, a bit of a language barrier and he eventually died...of heart disease.

Telehealth has more promise than results in my experience. The problem is very few nurses/docs are willing to say "no, that doesn't need to be seen" due to liability issues. They may cause more ED visits than they prevent.
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Re: How to Minimize Your Emergency Care Expenses

Post by HIinvestor » Sun Jan 21, 2018 1:30 am

Good point about liability issues RE Telehealth. One on my physician relatives was told by her medical malpractice carrier they'd drop any provider who participated in Telehealth — I’m guessing it was potential liability. It definitely turned my relative away from considering offering it.

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Re: How to Minimize Your Emergency Care Expenses

Post by marcopolo » Sun Jan 21, 2018 9:24 am

Various explanations of the crazy billing practices does not change the fact that it is simply absurd, and not limited to ER visit.

My wife recently had a Dexa scan done at a local hospital. The hospital charge was for $1468. They accepted $38 from the insurance company. I assume this was the negotiate rate. Other insurance companies probably have similar negotiated rates for this procedure. This must be profitable for the hospital at this rate. So, what is the point of charging $1468 for a procedure that costs less than $38? Who would be expected to pay that rate? Sure seems like price gouging of the unfortunate (those with out health insurance).
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Re: How to Minimize Your Emergency Care Expenses

Post by jayk238 » Sun Jan 21, 2018 9:59 am

marcopolo wrote:
Sun Jan 21, 2018 9:24 am
Various explanations of the crazy billing practices does not change the fact that it is simply absurd, and not limited to ER visit.

My wife recently had a Dexa scan done at a local hospital. The hospital charge was for $1468. They accepted $38 from the insurance company. I assume this was the negotiate rate. Other insurance companies probably have similar negotiated rates for this procedure. This must be profitable for the hospital at this rate. So, what is the point of charging $1468 for a procedure that costs less than $38? Who would be expected to pay that rate? Sure seems like price gouging of the unfortunate (those with out health insurance).
Why get a elective non-emergent scan at a hospital? DEXA are available in many many outpatient facilities with far cheaper costs.

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Re: How to Minimize Your Emergency Care Expenses

Post by marcopolo » Sun Jan 21, 2018 10:11 am

jayk238 wrote:
Sun Jan 21, 2018 9:59 am
marcopolo wrote:
Sun Jan 21, 2018 9:24 am
Various explanations of the crazy billing practices does not change the fact that it is simply absurd, and not limited to ER visit.

My wife recently had a Dexa scan done at a local hospital. The hospital charge was for $1468. They accepted $38 from the insurance company. I assume this was the negotiate rate. Other insurance companies probably have similar negotiated rates for this procedure. This must be profitable for the hospital at this rate. So, what is the point of charging $1468 for a procedure that costs less than $38? Who would be expected to pay that rate? Sure seems like price gouging of the unfortunate (those with out health insurance).
Why get a elective non-emergent scan at a hospital? DEXA are available in many many outpatient facilities with far cheaper costs.
"Far cheaper" than $38? That is my point. The $1468 is essentially a fictional number, unless you happen to be in the unfortunate situation of not having an insurance company to negotiate for you.
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Re: How to Minimize Your Emergency Care Expenses

Post by LadyGeek » Sun Jan 21, 2018 10:50 am

By member request, this thread is now a "sticky".

To our newer readers, White Coat Investor is Jim Dahle.

With regards to the first post:
White Coat Investor wrote:
Fri Jan 19, 2018 6:41 pm
About once a month or so we have someone start a thread about their recent visit to an emergency department. The post usually revolves around the bill being surprisingly high. They all kind of end up the same way. I get lots of PMs on the forum asking similar questions. Since this is a relatively common situation, I thought it might be useful to do a post for forum members about how to minimize their emergency care expenses [this is the actionable, non-medical advice reason for the post.]


Next, it is important to understand EMTALA- The Emergency Medical Treatment And Labor Act. This requires a hospital (particularly Labor and Delivery and the Emergency Department) and physicians working there to identify and stabilize any emergent medical conditions or labor without first ascertaining whether the patient can or will pay for it. The penalty to not do so is a personal penalty of $50,000. Malpractice insurance does not cover this penalty. A penalty can also be assessed to the hospital...
Please stay on-topic to discuss the financial aspects of your emergency care expenses.

Complaints about expense costs will derail this discussion. If you have a specific question, please start a new thread to discuss and state your concerns in a civil, factual manner.


===============
Some background info:

- Emergency Medical Treatment & Labor Act (EMTALA), from the Centers for Medicare & Medicaid Services
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Re: How to Minimize Your Emergency Care Expenses

Post by White Coat Investor » Sun Jan 21, 2018 11:32 am

marcopolo wrote:
Sun Jan 21, 2018 9:24 am
Various explanations of the crazy billing practices does not change the fact that it is simply absurd, and not limited to ER visit.
Yes, it's absurd (broken and embarrassing), but it doesn't appear likely to change significantly any time soon so this post is more about how to deal with the system currently in place.
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Re: How to Minimize Your Emergency Care Expenses

Post by UpsetRaptor » Sun Jan 21, 2018 11:51 pm

White Coast Investor,

I'm curious your thoughts on payments at time of service. I've had multiple occasions (e.g. during my wife's trips to her OB's office during pregnancy, during my son's visit to the ER a couple months ago, etc), where they request a direct payment at time of service because that's my expected out of pocket cost, or an initial payment towards it. I usually demur, and say please send it to my insurance company, I'll wait for the EOB to come back first, etc. Is my strategy there common and what one should normally do, or an atypical thing where you kindof come across as a jerk to your provider? If the former, why do they even ask?

For my son's ER visit, after I demurred and let it go through insurance, my final out of pocket cost ended up being significantly less than they had requested at the ER. I wondered to myself if it would've worked out that way (by reimbursement or whatever) if I had paid the requested amount at the ER.

Curious as to your thoughts here, and really appreciate your helpful advice on these boards. Thx in advance.

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Re: How to Minimize Your Emergency Care Expenses

Post by White Coat Investor » Mon Jan 22, 2018 12:34 am

johne417 wrote:
Sun Jan 21, 2018 11:51 pm
White Coast Investor,

I'm curious your thoughts on payments at time of service. I've had multiple occasions (e.g. during my wife's trips to her OB's office during pregnancy, during my son's visit to the ER a couple months ago, etc), where they request a direct payment at time of service because that's my expected out of pocket cost, or an initial payment towards it. I usually demur, and say please send it to my insurance company, I'll wait for the EOB to come back first, etc. Is my strategy there common and what one should normally do, or an atypical thing where you kindof come across as a jerk to your provider? If the former, why do they even ask?

For my son's ER visit, after I demurred and let it go through insurance, my final out of pocket cost ended up being significantly less than they had requested at the ER. I wondered to myself if it would've worked out that way (by reimbursement or whatever) if I had paid the requested amount at the ER.

Curious as to your thoughts here, and really appreciate your helpful advice on these boards. Thx in advance.
The doc probably doesn't know, so don't worry about offending her.

It depends on the policy, but our registration folks ask for money at the time of the initial visit, but you can get the 25% cash discount by paying up to 30 days later and we certainly can't deny taking care of you if you don't pay due to EMTALA, so we can't really force you. In your OB clinic they could. I've done this and had the clinic have to reimburse me when we overpaid on the initial visit.
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Re: How to Minimize Your Emergency Care Expenses

Post by inbox788 » Mon Jan 22, 2018 12:51 am

willthrill81 wrote:
Sat Jan 20, 2018 5:15 pm
Unless/until we have a system where patients, as you say, have real "skin in the game," I don't see the cost of healthcare going anywhere but up.
Copays was supposed to do that, but $5 wasn't enough skin, and $50+ became profit centers ("let's schedule another visit"). Now that some people have high deductibles, they'll tend to underutilize ED (potentially to the point of detriment) while only those that don't have skin in the game (where someone else is paying) will overutilize ED along with those that can afford it. I think there will still be enough of the latter for now to keep EDs busy. Hopefully some of the tips discussed here will help those with skin in the game to receive appropriate care in the right setting at the right time at minimum costs.
An exception was a visit to an urgent care clinic out of state (and out of network) for a sinus infection our daughter had that wouldn't clear up on its own. The visit itself was about $400, plus another $125 for prescription meds. I consider that to be a steal in today's environment.
I'm skeptical of the Walmart and CVS clinics that for relative low costs provide very basic services. I expect they'll discover that they're mainly treating people who normally wouldn't have gone to the doctor for conditions that really don't need a doctor, and will ultimately drive the cost of healthcare up as these for profit companies maximize their marketing and profit per square foot. I'm similarly skeptical of the phone based doctor on demand, amwell, teledoc, mdlive, etc. that give too quick access to doctors for a fee, again potentially driving health care costs up more than they reduce. But in your case, either of these choices might have been better than an urgent care center. I'm talking generalities here, not trying to get into specific medical issues. Finding that right medical treatment setting is not always simple, and the additional choices we now have can help in some situations and make it more difficult in others. You have more chances of picking the wrong one and needing a referral or wrongly choosing a more costly choice.

https://www.safesmartliving.com/amwell- ... healthtap/
Consumer Reports had a big piece last year that addressed the incredible cost of air ambulances and how seldom they are truly needed.
A couple of thoughts. If only you know apriori whether you truly needed the ambulance or air ride, you could make a better decision; what they say about hindsight being 20/20. And imagine if only those that truly need the service had to foot the bill for the ambulance service, the cost would likely be prohibitive. Those less needed rides help share the cost burden. In some ways, emergency rooms are like that too, that if they didn't have all the patients that weren't emergencies to share the costs of keeping the lights on, many would have to shut down.

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Re: How to Minimize Your Emergency Care Expenses

Post by HIinvestor » Mon Jan 22, 2018 3:12 am

In general, my insurer has a contract with providers that I am only supposed to pay the copay balance AFTER receiving EOB statement. As a practical matter, I will often offer to pay my regular fixed $15 copay for office visits to simplify things and reduce invoices sent to me.

When visit is to a provider at a medical center, there are sometimes additional costs like facilities charges of which insurer pays most of the contracted amount and I pay some reduced amount.

I have offered to prepay when I go to medical centers but they politely decline, explaining it would just make things more complicated in having them cut a check to reimburse me any overpayment.

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Re: How to Minimize Your Emergency Care Expenses

Post by dm200 » Mon Jan 22, 2018 9:14 am

HIinvestor wrote:
Mon Jan 22, 2018 3:12 am
In general, my insurer has a contract with providers that I am only supposed to pay the copay balance AFTER receiving EOB statement. As a practical matter, I will often offer to pay my regular fixed $15 copay for office visits to simplify things and reduce invoices sent to me.
When visit is to a provider at a medical center, there are sometimes additional costs like facilities charges of which insurer pays most of the contracted amount and I pay some reduced amount.
I have offered to prepay when I go to medical centers but they politely decline, explaining it would just make things more complicated in having them cut a check to reimburse me any overpayment.
When we had previous, employer insurance - for office visits it was common that the office staff of the various Physicians would often ask us, "Do you know what your copay should be" - after veifying that we had insurance. When that happened, we just said we did not know - please bill us.

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Re: How to Minimize Your Emergency Care Expenses

Post by Broken Man 1999 » Mon Jan 22, 2018 11:02 am

Interesting differences when copays are paid.

We have used HMOs, PPOs, EPNs over the years, and we have always paid the copay at time of the visit of PCD or specialist. In fact our copays are paid upon checking in with the receptionist, prior to seeing the doctor.

Currently my copay for PCD is $5.00, specialist visits are $20.00. My current coverage is a PPO, wife's coverage is an EPN.

I don't think I would want to put the burden on the practice to have the expense of billing me when I know what my copay is; the copay info is actually on my insurance ID card, I assume, perhaps incorrectly, copay info is on everyone's insurance card.

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Re: How to Minimize Your Emergency Care Expenses

Post by ResearchMed » Mon Jan 22, 2018 12:08 pm

Broken Man 1999 wrote:
Mon Jan 22, 2018 11:02 am
Interesting differences when copays are paid.

We have used HMOs, PPOs, EPNs over the years, and we have always paid the copay at time of the visit of PCD or specialist. In fact our copays are paid upon checking in with the receptionist, prior to seeing the doctor.

Currently my copay for PCD is $5.00, specialist visits are $20.00. My current coverage is a PPO, wife's coverage is an EPN.

I don't think I would want to put the burden on the practice to have the expense of billing me when I know what my copay is; the copay info is actually on my insurance ID card, I assume, perhaps incorrectly, copay info is on everyone's insurance card.

Broken Man 1999
If someone has reached the Out-Of-Pocket max, then it doesn't matter what the card says.
No further payments are to be made that year, and there would be no co-pay.
If the office insisted (never had that happen, when explaining the OOP was already reached), then the office would need to deal later with a refund.

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Re: How to Minimize Your Emergency Care Expenses

Post by HIinvestor » Mon Jan 22, 2018 12:18 pm

True—when I had approached or reached OOP max, I’d mention that and no copay would be sought or paid so I didn’t have to get a refund check. Some years we’d reach OOP max by mid-year. Sometimes we’d just get refund checks from insurer or providers if we paid copays after hitting OOP max. It worked out for us with our PPO plan over the years.

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Re: How to Minimize Your Emergency Care Expenses

Post by BogleMelon » Mon Jan 22, 2018 12:38 pm

adamsapple19 wrote:
Fri Jan 19, 2018 11:02 pm
mrb09 wrote:
Fri Jan 19, 2018 10:26 pm
Bookmarked!

Thank you.
+1

Thank you for this. Having this information consolidated into a single coherant post could seriously come in handy someday (though I hope not!) :wink:
+2
Posts like this are golden! Thank you WCI for your contribution!
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Re: How to Minimize Your Emergency Care Expenses

Post by telemark » Mon Jan 22, 2018 1:15 pm

CppCoder wrote:
Sat Jan 20, 2018 8:48 am
I know the above is true, but honestly, the medical providers are the ones who make this industry work. Why don't doctors, nurses, etc. organize and fix the problem? If you don't, you're somewhat complicit. You are taking advantage of the system to receive high pay and abdicating responsibility for billing because "that's someone else's department." I assure you, most hospitals wouldn't be there if doctors organized and stopped working there. If nothing else, you'd think someone would want to do this for self-preservation reasons. Rightly or wrongly, eventually the masses can't take it anymore, and they come with tar, feathers, and pitchforks. In this case, I suspect that would be draconian laws dictating payment, not literal tar and feathering. Maybe this will never be the case because the really poor don't pay, the rich just pay and complain but it has no impact on them, and those stuck in the middle get squeezed but are too few and powerless to fix anything. Personally, I wouldn't be able to sleep at night working in an industry that yes, provides a needed and noble service, but also had a back office that worked like a loan shark. I can't imagine anyone going into medical school today doesn't realize this...they still go.
The state of the computer industry can only be described as a disgrace. Look at the constant tracking and loss of privacy, the tendency toward democracy-threatening information bubbles, the constant hacking exacerbated by error-prone languages like C++, the whole "move fast and break things" ethos, etc. Why don't the programmers get together to stop this? They're the ones who make it
all work.

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