How to Minimize Your Emergency Care Expenses

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White Coat Investor
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How to Minimize Your Emergency Care Expenses

Post by White Coat Investor » 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.]

First, a few comments about our health care system.
# 1 - It is screwed up, broken, and embarrassing to be a part of.
# 2 - Solutions are to either quit pretending it is a real market or to make it a real market. Depending on your political persuasion, you likely lean one way or the other on this.
# 3 - In order to have a functioning market, most/all of the market participants need to have skin in the game and there must be transparency of prices. Neither of those exists in our current health care "market." Especially transparency of prices.
# 4 - The health care system is unlikely to provide transparency of prices because it is so darn profitable not to have transparent prices. It is also an extremely difficult thing to do in any sort of exact manner, but it would be nice to see even in vague terms.
# 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.

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.

As an example, if you come in with severe shortness of breath due to your chest being full of fluid from a lung tumor, the hospital must drain the fluid before it can ask you to pay, but it does not need to provide you chemotherapy or surgery to cut out the tumor.

Once an emergent condition has been ruled out or stabilized, the hospital can then ask you to pay before proceeding with any further treatment. In practicality, by the time the emergent condition has been ruled out, the emergency doctor or OB/GYN has pretty much done all her work, so the whole "go charge the patient after the medical screening exam has been completed if they want to continue to get care" gets pretty silly.

In addition, "emergent medical condition" is a very gray area. What is emergent to one person might not be emergent to another. Plus, sometimes the complaint is emergent (such as chest pain) but the final diagnosis (GERD) is not. So it becomes an incredibly difficult law to navigate around. The easiest and most common thing to do for those working in the emergency department is to just take care of anyone who walks in the door as best you can, pretend everything is an emergency, and let the coders, billers, insurance companies, and patients sort it out later.

While the hospital and associated physicians are required to provide this care without first ascertaining ability to pay, they are not required to do it for free. They are allowed to bill the patient and/or their insurance company afterward. Many people that do not have insurance do not pay these bills. The typical reimbursement rate for uninsured patients is less than 10%. For some hospitals, the percentage of uninsured patients can be as high as 50%. In my particular practice, it is closer to 20%. Even in states that expanded Medicaid the number is still often close to 10% because people are either incapable or unwilling to sign-up for Medicaid or a PPACA plan. Many people who have good insurance do not pay their portion of the bill. Given the increasing use of high deductible health plans and health savings accounts, this is happening more and more often. Nevertheless, a bill is sent and if not paid, the account is eventually turned over to collections with the expected effects on the patient's credit score.

Third, hospital and physician billing is seriously screwed up by something called "Chargemaster Pricing." This is where the price on the initial bill is some astronomical amount. These are purposely set high in an effort to maximize profits. The idea is to have it so high that no payor is ever going to be willing to pay more than that. A typical health insurance company will negotiate much lower rates with hospitals and doctors. These negotiated rates are usually pretty fair rates for every one involved. Some payors just pay the chargemaster prices -- auto insurance or liability insurers for instance, since they aren't in the same business as a health insurance company. Some patients just pay the chargemaster price too, although not very many despite typically being offered a 20-25% discount from them for paying promptly (like within 30 days.) One of the best benefits of having an insurance policy, even if your deductible is so high you basically pay everything, is getting the benefit of the insurance company's negotiations with hospitals and doctors.

Fourth, when you go to the ED, you generally get multiple bills, although these are sometimes consolidated if the doctors involved are hospital employees.

Bill # 1 - From the hospital. This usually includes an emergency department charge which varies based on the complexity of your visit. These range from level 1 (perhaps a suture removal) to a level 2 (a wound check on sutures done the day before or an abscessed that was incised and drained 2 days ago) to a level 3 (a cold or back injury for which no medications were administered in the ED and no tests were done) to a level 4 (perhaps a UTI that was given IV antibiotics in the ED) to a level 5 (a work-up for chest pain, belly pain, shortness of breath, or altered mental status.) If you are really ill, there is an additional "critical care" charge. There are additional charges for procedures such as CPR, intubation, or suturing. This charge does not include the services of the doctor, but does include the IV tubing, placing the IV, drawing blood, nursing observations, respiratory therapists, monitors, housekeeping, linens, electricity, heating, crackers and juice, warm blankets, etc etc etc.

The typical amount for a level 4-5 visit that is freely negotiated between the hospital and a good insurance company is probably something around $2K.

The hospital bill also usually includes a charge for any x-rays, CT scans, ultrasounds, or MRIs, a charge for any labs done, and a charge for any medications given. This could easily be another $1-3K, more for an extensive evaluation like multiple CT scans. This does not include the services of a radiologist or pathologist if required.

Emergency care is expensive to provide. There are a great deal of compliance and legal issues, highly trained staff, expensive equipment, consultants, and 24/7/365 availability of all that.

Bill # 2 - From the emergency physician. First there is an emergency visit charge using the same level 1-5 + critical care levels. This includes the doctor's history and physical, counseling, recommendations, prescriptions, work notes, charting, calling consultants, transferring you to other hospitals, talking to your primary doctor, reviewing old records calling an admitting physician etc. About 25% of the work I do for a given patient is visible to the patient so sometimes it feels like "all they did for me was give me a prescription for ibuprofen." If there was a billable procedure done (sutures, intubation, cardioversion, fracture reduction, abscess I&D, CPR, etc) there is an additional charge. Sometimes, the procedure charge is more than the visit charge. A typical level 5 physician bill might be $200-300 after insurance company negotiation. It's $175-200 for Medicare. Procedures are highly variable. Putting a breathing tube in to save your life is $146 when Medicare is paying. A little laceration on your scalp might be $100 when Medicare is paying.

Bill # 3 - From the radiologist. The hospital charges for the tech and machine. The radiologist charges for her expertise reading it. A typical fee to read a single CT might be $250 (Medicare) and up to twice that with a private insurance company.

Bill # 4 - If you were seen by another physician in the ED (a consultant) they will also send you a bill for their consultation and possibly any procedures they do.

As you can see, it doesn't take much to get the bill for a single ED visit into the $5K range for something where there wasn't even anything serious going on. Just like a single hospital admission, surgery, or delivery will hit the max out of pocket for the year on many insurance plans, so will a single emergency department visit. It's just really expensive stuff.

Fifth, nobody you interact with at the hospital at the time of your visit has any idea how much anything costs. Part of that is the whole price transparency thing. Those who know the price don't want the front line workers to know it. Part of it is the fact that there are so many moving parts. Medicine gets inappropriately compared to aviation a lot, but it really isn't a fair comparison. Every one getting on a flight is basically getting the same thing. Medicine is like an airline flight where every row has its own flight attendant, every one on the plane is going somewhere different, and they all get a different movie and meal hand delivered to them. Imagine how much that flight would cost? Finally, despite the fact that there are hundreds of different products and services being sold, everybody pays a different price for them. This is due to dozens of different insurance plans each of which has negotiated a different price for every product and service, co-insurance plans, government plans, and various different levels of deductibles and co-insurance and different amounts of previously consumed care already in the year.

Bottom line, don't expect to be able to "shop" while you're at the ED. It's impossible. We can't even tell you the chargemaster price, much less your price.

Now, let's get to the meat of this post- what you can do to minimize the costs of your emergency care.

# 1 Buy health insurance

When you go to the ED with a truly emergent condition, you're not going to be in any sort of position to negotiate prices. Far better to be associated with someone who has already done that for you and has far more pricing power than you do.

If you can't afford health insurance, apply for Medicaid. If you don't qualify, try to buy through a PPACA exchange. If you have a very low income, the subsidies are typically quite large and most of the middle class qualifies for a subsidy of some type. Even a family of 4 making $80K might be able to buy health insurance at a 50% discount after the tax subsidy.

If that still doesn't work for you, consider a health sharing plan. While these do not provide as comprehensive coverage as a PPACA plan, the "share" might be half as much as health insurance premiums.

Health insurance is expensive stuff because it gets used all the time and health care is expensive stuff. If you think you're only going to pay 2% of your household budget on health care while the nation as a whole spends nearly 20%, you need to reset your expectations. You're doing well if you're only spending 10% of your income on health insurance and health care.

Another option, assuming you can work, is to get a job where health insurance is offered as a benefit. If you can't afford health insurance, and your job doesn't offer it, you should continually be in the job market looking for a better job.

# 2 Expect to pay your maximum out of pocket costs

If your maximum out of pocket cost is $10,000, expect to pay that and be pleasantly surprised if it doesn't get that high. If that is too much for you to afford, buy an insurance policy with a lower deductible/out of pocket cost. The total cost of your ED visit is generally going to be a four figure amount, between $1,000 and $10,000.

# 3 Don't go to the Emergency Department if you don't have to

Since emergency care is such expensive stuff, don't go there if you don't have to. This is a very expensive place for convenience care. If you're not having an emergency, exhaust all other options before turning to the ED. This includes nurse help lines, your cousin, your neighbor, your primary doctor, your cousin's primary doctor, telemedicine, and urgent cares. But if you're clearly having an emergency, for heaven's sake go to the ED. Far better to owe $10K than to lose life, limb, or eyesight. If you're not sure, do the best you can. Doctor's offices and urgent cares are good at quickly sending you to a higher level of care if needed.

# 4 Don't take the ambulance if you don't have to

An ambulance ride costs $1500-2000. An Uber costs $20. If you need the ambulance, for heaven's sake call it. But if not, call an Uber. This also applies to interhospital transfers. "Doc, I don't want to go by ambulance because it's so expensive. I know there is the liability thing, but I'd be willing to sign all that Against Medical Advice paperwork if you think the chances of something happening to me en route are less than 10%."

Just because the ambulance came to your house doesn't mean you have to ride with them to the hospital. Your taxes cover the trip to your house and the assessment by the medics. Your health insurance (and you) covers the trip from home to the hospital. Don't worry, you won't offend the medics. If they're really worried, they'll follow you there. That's a good sign that maybe you should have just gotten in the ambulance.

# 5 When you go to the ED, consume as little care as possible

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%."

If you don't want a $10 tylenol or a $100 morphine shot, don't take any medication while you're in the ED. If you're writhing in pain with a kidney stone, you'll be more than glad to pay $100. If the pain or nausea isn't too bad, just let the doc or nurse know that you'll tough it out and wait until you get prescriptions to go home with to treat those symptoms. "Do you think it would be safe to skip the IV dose here if I go to the pharmacy right away afterward and start taking the antibiotic prescription?" "Is there a cheaper medication you can prescribe that would work? I don't mind a few more side effects or having to take it three times a day if it is 1/10th the cost."

If you've got something serious enough to admit you to the hospital you're definitely going to hit your max out of pocket, so might as well just get what your doc thinks you need done.

By the way, it's important to understand that some admissions to the hospital are "observation admissions" and some are "inpatient admissions." Depending on your insurance, that may involve different amounts of co-pays or co-insurance from you. Medicare in particular is this way.

# 6 When the bills come, read them.

Take a look at the bills once they show up. After you get over the sticker shock, make sure they are reasonably accurate. Is there a pharmacy charge but you didn't get any medications while you were there? Is there lab charge but you didn't get labs? Bills are wrong all the time. Contest them if they are. Wait until it "runs through insurance." That first bill might be showing chargemaster prices, not the real prices.

If you've gone to an out of network hospital, you might be "balance billed." That means your insurance and the hospital or doctor don't have a negotiated agreement and your insurance company refuses to pay the whole bill. This becomes particularly problematic so many people, including legislators, are working on solutions to this. The problem is just outlawing balance billing gives the insurer enormous negotiating power over the hospital/doctors (why should we negotiate with you when we can just pay you whatever we want). But other solutions basically put government in the position to set prices for a private transaction. It's a tricky problem to solve and is best when the hospitals/doctors and insurance companies just make a good faith effort to negotiate a fair price/payment.

If you can't afford the bill, contact the hospital. They often have assistance programs that reduce the bill or allow you to pay interest-free over long periods of time.

If you really can't pay the bill, realize that there is nothing to repossess. Medical bills are like credit card bills. Sure, your credit goes to pot but after it does you can often negotiate to pay pennies on the dollar to the collection agency. Food, shelter, transportation, and utilities first.

If you're a Boglehead millionaire and hate paying $5K for your ED visit because there was nothing wrong with you anyway, but can easily afford it, pay your bill and realize that's why you saved up all that money in the first place. Problems that can be solved with money aren't problems when you have money. If you realize you screwed up and went to the ED when you shouldn't have, chalk it up to life experience and don't make that mistake again. Most of us (including me) have made that mistake.
1) Invest you must 2) Time is your friend 3) Impulse is your enemy | 4) Basic arithmetic works 5) Stick to simplicity 6) Stay the course

Suman
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Re: How to Minimize Your Emergency Care Expenses

Post by Suman » Fri Jan 19, 2018 7:07 pm

Excellent summary.

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Lee Saage
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Re: How to Minimize Your Emergency Care Expenses

Post by Lee Saage » 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.
Most of my money went to fast cars, fast living and good wine. The rest I just wasted.

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BogleFanGal
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Re: How to Minimize Your Emergency Care Expenses

Post by BogleFanGal » Fri Jan 19, 2018 7:50 pm

Incredibly helpful...thank you. Now if I could just be in the state of mind to remember a fraction of it when something happens, I'll consider myself very lucky.

noco-hawkeye
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Re: How to Minimize Your Emergency Care Expenses

Post by noco-hawkeye » Fri Jan 19, 2018 8:06 pm

Thank you so much for this post, White Coat Investor. It's a situation no one is really all that happy with, and this information is totally helpful!

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Re: How to Minimize Your Emergency Care Expenses

Post by runner3081 » Fri Jan 19, 2018 8:08 pm

Great post. Thanks for sharing. This should be pinned somewhere as a future reference.

I am also in healthcare, but on the admin side. The things I have seen over the years are crazy with billing, networks, etc.

Saving$
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Re: How to Minimize Your Emergency Care Expenses

Post by Saving$ » Fri Jan 19, 2018 8:15 pm

Thank you very much for taking the time to write this.
Much appreciated, and great information, as well as good reminders of how to keep this all in perspective.

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Mlm
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Re: How to Minimize Your Emergency Care Expenses

Post by Mlm » Fri Jan 19, 2018 8:30 pm

Great information. Thank you for taking the time to post this.

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Re: How to Minimize Your Emergency Care Expenses

Post by 2b2 » Fri Jan 19, 2018 8:44 pm

WCI,

Thank you!

2b2

stlrick
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Re: How to Minimize Your Emergency Care Expenses

Post by stlrick » 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?

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Re: How to Minimize Your Emergency Care Expenses

Post by Archimedes » Fri Jan 19, 2018 10:18 pm

stlrick wrote:
Fri Jan 19, 2018 9:04 pm

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?
Each ambulance company or service creates their own policies regarding billing. 20 years ago most municipal and volunteer ambulance services did not charge patients for their services. These days, however, most ambulance services do charge patients for their services, and this includes some of the volunteer ambulance services as well as some of the municipal 911 fire or police department based ambulance companies.

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Re: How to Minimize Your Emergency Care Expenses

Post by mrb09 » Fri Jan 19, 2018 10:26 pm

Bookmarked!

Thank you.

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White Coat Investor
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Re: How to Minimize Your Emergency Care Expenses

Post by White Coat Investor » 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.
1) Invest you must 2) Time is your friend 3) Impulse is your enemy | 4) Basic arithmetic works 5) Stick to simplicity 6) Stay the course

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Sandtrap
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Re: How to Minimize Your Emergency Care Expenses

Post by Sandtrap » Fri Jan 19, 2018 10:54 pm

Outstanding!
How about publishing a short book on this? Or an e-book?
I've forwarded the link to your post to all of my senior friends
thanks so much.
j :D

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Re: How to Minimize Your Emergency Care Expenses

Post by adamsapple19 » 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:

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Re: How to Minimize Your Emergency Care Expenses

Post by MrBeaver » Fri Jan 19, 2018 11:56 pm

Superb information, thank you.

If I may rant for a bit: There are two hospitals in our town, but I honestly don’t know which one to go to if we have an emergency. When I did my homework last year in preparation for labor and delivery, all four of the network lists provided by my insurance company said that hospital #1 was the only one covered for L&D. But hospital 1’s L&D department closed 2.5 years ago. Then I called several times, and finally got someone on the phone who said hospital #2 was covered for L&D based on their list. However, that wasn’t available in writing, so I had to trust a non-binding phone conversation. Luckily it worked out.

And at that same hospital, it just seemed like they were trying to keep us there unnecessarily long after delivery. Why do I know this? They advised us to stay, but our checkout papers had no non-standard waivers attached. Likewise when we went back for a gallbladder issue and it was not inflamed, they advised us to stay for observation and after much protest they let us leave without special papers. In general, I trust this hospital less as a result. Perhaps my insurance just pays too much so they want to provide me more services.


But for a real question:
Is there good guidance for which issues/symptoms to go to urgent care vs ED?

The comment that urgent care is good to send you to the ER if necessary is comforting…as long as they don’t load you into an unnecessary ambulance to get there. My gut says arterial or possible internal bleeding, or sudden internal pain in the chest cavity is an immediate ED trip, while other things, even broken bones could be handled by urgent care (assuming it’s after hours for our GP/pediatrician)?

This is particularly in my mind with two young children who will likely have ‘accidents’ at some point in the next 10 years.

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Re: How to Minimize Your Emergency Care Expenses

Post by daveydoo » Sat Jan 20, 2018 12:36 am

Excellent information!

#7 Pay someone to clean your gutters, limb the tree, patch the roof, etc.

Really.
"I mean, it's one banana, Michael...what could it cost? Ten dollars?"

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dodecahedron
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Re: How to Minimize Your Emergency Care Expenses

Post by dodecahedron » 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?

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White Coat Investor
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Re: How to Minimize Your Emergency Care Expenses

Post by White Coat Investor » Sat Jan 20, 2018 2:31 am

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?
Are we judging them based on their education and the complaint or on the final outcome? If you base it on the final outcome, perhaps only 10% need to be there. If we judge based on the complaint, 90% need to be there. Most chest pain isn't a heart attack. Most dizziness isn't a stroke. Most shortness of breath is anxiety. All bleeding stops eventually. Like I tell people who call in on the phone, if you're worried you're having an emergency, come to the emergency department.

You'd be surprised at the percentage of our population that has a hard time interacting with the health care system. You might also be surprised at the percentage for whom an ED visit doesn't incur any significant expense. Medicaid co-payments are $3. I don't think Tricare has one, at least for active duty folks. If you've already hit your max OOP, no charge. If your employer pays 90% of your premiums and the plan has a $250 deductible you don't have much skin in the game. Most of the uninsured I meet simply can't figure out how to apply for a PPACA plan. Even applying for Medicaid is fairly complicated.
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Re: How to Minimize Your Emergency Care Expenses

Post by camillus » Sat Jan 20, 2018 3:05 am

Bedside RN here in an ICU environment. Thank you WCI.

It seems to me to be absolutely perverse that staff, like me, who interact with patients and families have little knowledge of how much things cost. I speak as a member of "the most trusted profession."

My wife recently gave birth to a son. She had no medication in the hospital other than ibuprofen (her desire). The ibuprofen, with pharmacy charges, cost $200-300.

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Re: How to Minimize Your Emergency Care Expenses

Post by StevieG72 » Sat Jan 20, 2018 6:53 am

Thanks for posting, great information.

I learned the hard way, will not make that mistake again.

Things have changed! An ER visit used to be a $50 or $100 copay. Nowadays everyone is on a high deductible plan so you will pay much more for that visit.

I now will try to see PCP first for any ailment that is not life threating. Urgent Care is the second choice, since these issues always arise on nights or weekends. ER is the last resort.

Side note, it seems that anytime and everytime I call the ask a nurse type service they direct me to go to the ER.
Fools think their own way is right, but the wise listen to others.

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DaftInvestor
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Re: How to Minimize Your Emergency Care Expenses

Post by DaftInvestor » Sat Jan 20, 2018 7:06 am

StevieG72 wrote:
Sat Jan 20, 2018 6:53 am

Side note, it seems that anytime and everytime I call the ask a nurse type service they direct me to go to the ER.
This is just a CYA thing - if they direct you to go to the ER you can't as easily hold them liable if something happens to you. Similar to getting in a minor accident - someone taps the back of my bumper, police show up and offer to call me an ambulance a dozen times even though I'm clearly not injured.

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Re: How to Minimize Your Emergency Care Expenses

Post by h82goslw » Sat Jan 20, 2018 7:52 am

Thanks for posting. I was just on the ER 3 weeks ago for something stupid but incredibly painful. Saw a GI doc in ER who ended up not being able to help, then a thoracic surgeon in the OR. Then was admitted to a room for another 12 hours.
Total in-hospital time: 19 hours
Total Bills so far: $15,000 and I’m sure there’s more coming.

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Re: How to Minimize Your Emergency Care Expenses

Post by Lynette » Sat Jan 20, 2018 8:31 am

Thank you so much WCI for taking the time to explain the system.

I'm fortunate to be in excellent health for a senior and I think that if some is really ill, one should seek the appropriate care. But to give a different perspective, I grew up in a country where there was virtually no malpractice. I've learnt to be highly suspicious of recommendations from doctors here as I think often they are simply trying to avoid malpractice. I know my own health and if necessary, I ignore recommendations for what I think is not necessary. I'm especially irritated by what I regard as excessive prescription of pain medication. Once I could not figure out why I was so tired when driving to work so I researched the medication I was taking. One prescription was Vicodin three times a day. I stopped this and I felt fine after that. Recently, I had a tooth implant and told the dentist I did not want any further pain medication. He was quite stunned and told me I was "tough". He relented and told me that about one in 25 people really had severe reaction to pain. So he prescribes the medication for everyone!

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Re: How to Minimize Your Emergency Care Expenses

Post by CppCoder » 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.

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Re: How to Minimize Your Emergency Care Expenses

Post by NorCalDad » Sat Jan 20, 2018 9:02 am

Great advice. The recommendations are very logical. WCI, any idea what percentage of patients in the ED should have gone to urgent care or outpatient instead? I know some friends and family who are quick to head to the ED. There are the uninsured who go there because they think they have no alternative. And then I know my wife and other medical professionals like you say to avoid it except when loss of limb or life is feared.

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Re: How to Minimize Your Emergency Care Expenses

Post by White Coat Investor » Sat Jan 20, 2018 11:09 am

NorCalDad wrote:
Sat Jan 20, 2018 9:02 am
Great advice. The recommendations are very logical. WCI, any idea what percentage of patients in the ED should have gone to urgent care or outpatient instead? I know some friends and family who are quick to head to the ED. There are the uninsured who go there because they think they have no alternative. And then I know my wife and other medical professionals like you say to avoid it except when loss of limb or life is feared.
As discussed above, depends on whether you're looking at the chief complaint (usually emergent) or the final diagnosis (usually not emergent.)
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Re: How to Minimize Your Emergency Care Expenses

Post by White Coat Investor » Sat Jan 20, 2018 11:13 am

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."
Yes.
CppCoder wrote:
Sat Jan 20, 2018 8:48 am
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 don't know, stay up long enough taking care of drunks and people that lie to you and assault you and might be able to get a little shuteye before the pager goes off again.
CppCoder wrote:
Sat Jan 20, 2018 8:48 am
I can't imagine anyone going into medical school today doesn't realize this...they still go.
Totally disagree with that. I would argue almost no medical student realizes this and many attending physicians have not yet realized it. There is no training into the business of medicine in medical school. If you have no interest in financial stuff, you could go your entire career, especially as an employee, and not realize what's going on back there. You actually have to seek out the information I posted in the OP, even if you work in a hospital.
1) Invest you must 2) Time is your friend 3) Impulse is your enemy | 4) Basic arithmetic works 5) Stick to simplicity 6) Stay the course

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Re: How to Minimize Your Emergency Care Expenses

Post by SocalLiving » Sat Jan 20, 2018 11:25 am

Thank you so much for taking the time to post this.

I would like to emphasise that a lot of thought should go into step #1 (Buy Health Insurance). This is where so much headache and stress can be avoided. Know what your plan covers and does not cover.

We are self-employed and have to shop for a new Individual and family plan every year because of the ever shifting landscape. I know many people who sign up for plans based on premiums alone. Many do not know how much a "medical event" will cost them until they are in the ER. That is not the time to be stressing about costs. I find that it's the not knowing that is sometimes more stressful than paying the actual costs.

When I sign up for health insurance I evaluate a plan based on how much it will cost my family for a minor, major, and life threatening medical situation. For 2018 I was deciding between two plans. One was $95/month cheaper for premiums. But, the cheaper plan had no ER coverage until out of pocket maximum was met ($6,300), 40% co-insurance for urgent care and out-patient surgery until out of pocket maximum. For the more expensive plan, ER visits were $350, Urgent Care was $35 copay, outpatient-surgery was 20% co-insurance. Doctors visits and specialist visits were co-pay on the more expensive plan, and co-insurance on the cheaper plan.

For my family it made sense to choose the more expensive plan. But, if I had gone with lower premiums, I would be aware that an ER visit would probably cost me my out of pocket maximum (#2 in OP). If I had gone with the cheaper plan, I would know that a specialist visit is NOT going to be a small co-pay, but a more expensive co-insurance.

When you sign up for health insurance, anticipate a medical emergency, and evaluate the plan to make sure you are satisfied with the coverage your plan will provide. Many people can't afford the premiums for the expensive plans, or choose to self-insure some of the costs. But, it is still important to KNOW what is covered and not covered by the plan you are on.

My husband just faced an unexpected medical emergency in the first week of January. Knowing exactly how much the bill would be on our brand new plan was a huge relief while going through the process.

Thank you again to White Coat Investor for taking the time to make this post.

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Re: How to Minimize Your Emergency Care Expenses

Post by simplesimon » Sat Jan 20, 2018 11:26 am

How did it get this way? What was it like 30 years ago?

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Re: How to Minimize Your Emergency Care Expenses

Post by TheNightsToCome » 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.

On the other hand, it is reasonable to point out that you (as patient) would like to avoid doing things in the ER if they can be done safely elsewhere and later.

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Re: How to Minimize Your Emergency Care Expenses

Post by ResearchMed » Sat Jan 20, 2018 11:42 am

simplesimon wrote:
Sat Jan 20, 2018 11:26 am
How did it get this way? What was it like 30 years ago?
30 years ago (also more recently), if you did not have employer-provided health insurance and had any notable pre-existing condition... there was NO health insurance for you. (Or perhaps there was some medically underwritten policy that would be too expensive anyway.)

And if you weren't poverty stricken, there was just about no $$ help anywhere... unless health care costs caused one to become poverty stricken.

That meant paying what I'm guessing is now those "chargemaster" rates the WCI mentions, including at pharmacies, where "self-pay" could be 10x (or more) what someone would pay out of pocket prior to getting to out of pocket limits.

There were several paths to this disaster...

RM
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Re: How to Minimize Your Emergency Care Expenses

Post by SocalLiving » Sat Jan 20, 2018 11:57 am

ResearchMed wrote:
Sat Jan 20, 2018 11:42 am
30 years ago (also more recently), if you did not have employer-provided health insurance and had any notable pre-existing condition... there was NO health insurance for you. (Or perhaps there was some medically underwritten policy that would be too expensive anyway.)
+1
For our family, the new reality is infinitely preferable to the old reality (less than 10 years ago). Trying to get decent health insurance for a young healthy family (self-employed) was incredibly difficult. At least we are no longer one medical event from bankruptcy.
I try to focus on the aspects I can control and anticipate, all the while hoping that it will get less complex and cheaper.

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Re: How to Minimize Your Emergency Care Expenses

Post by simplesimon » Sat Jan 20, 2018 11:58 am

ResearchMed wrote:
Sat Jan 20, 2018 11:42 am
simplesimon wrote:
Sat Jan 20, 2018 11:26 am
How did it get this way? What was it like 30 years ago?
30 years ago (also more recently), if you did not have employer-provided health insurance and had any notable pre-existing condition... there was NO health insurance for you. (Or perhaps there was some medically underwritten policy that would be too expensive anyway.)

And if you weren't poverty stricken, there was just about no $$ help anywhere... unless health care costs caused one to become poverty stricken.

That meant paying what I'm guessing is now those "chargemaster" rates the WCI mentions, including at pharmacies, where "self-pay" could be 10x (or more) what someone would pay out of pocket prior to getting to out of pocket limits.

There were several paths to this disaster...

RM
Why does this feel like more of a problem now? The advent of HDHP's?

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Re: How to Minimize Your Emergency Care Expenses

Post by ResearchMed » Sat Jan 20, 2018 12:05 pm

simplesimon wrote:
Sat Jan 20, 2018 11:58 am
ResearchMed wrote:
Sat Jan 20, 2018 11:42 am
simplesimon wrote:
Sat Jan 20, 2018 11:26 am
How did it get this way? What was it like 30 years ago?
30 years ago (also more recently), if you did not have employer-provided health insurance and had any notable pre-existing condition... there was NO health insurance for you. (Or perhaps there was some medically underwritten policy that would be too expensive anyway.)

And if you weren't poverty stricken, there was just about no $$ help anywhere... unless health care costs caused one to become poverty stricken.

That meant paying what I'm guessing is now those "chargemaster" rates the WCI mentions, including at pharmacies, where "self-pay" could be 10x (or more) what someone would pay out of pocket prior to getting to out of pocket limits.

There were several paths to this disaster...

RM
Why does this feel like more of a problem now? The advent of HDHP's?
Not really the same at all, although it might feel that way if one isn't facing true catastrophic medical costs.

That HIGH deductible? Once you pay that, and any other co-pays/etc., there *IS* a "cap", even if it "feels" like a lot.

Without insurance? NO CAP. None.

Well, okay. There is a cap = all of your money. :shock:
Or almost so...
Once you are destitute, then there would be medicaid/etc.

RM
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Re: How to Minimize Your Emergency Care Expenses

Post by simplesimon » Sat Jan 20, 2018 1:48 pm

ResearchMed wrote:
Sat Jan 20, 2018 12:05 pm
simplesimon wrote:
Sat Jan 20, 2018 11:58 am
ResearchMed wrote:
Sat Jan 20, 2018 11:42 am
simplesimon wrote:
Sat Jan 20, 2018 11:26 am
How did it get this way? What was it like 30 years ago?
30 years ago (also more recently), if you did not have employer-provided health insurance and had any notable pre-existing condition... there was NO health insurance for you. (Or perhaps there was some medically underwritten policy that would be too expensive anyway.)

And if you weren't poverty stricken, there was just about no $$ help anywhere... unless health care costs caused one to become poverty stricken.

That meant paying what I'm guessing is now those "chargemaster" rates the WCI mentions, including at pharmacies, where "self-pay" could be 10x (or more) what someone would pay out of pocket prior to getting to out of pocket limits.

There were several paths to this disaster...

RM
Why does this feel like more of a problem now? The advent of HDHP's?
Not really the same at all, although it might feel that way if one isn't facing true catastrophic medical costs.

That HIGH deductible? Once you pay that, and any other co-pays/etc., there *IS* a "cap", even if it "feels" like a lot.

Without insurance? NO CAP. None.

Well, okay. There is a cap = all of your money. :shock:
Or almost so...
Once you are destitute, then there would be medicaid/etc.

RM
I see, so we're talking about people that don't have insurance...not that the cost structure of healthcare changed. I was wondering why it seems like people/Bogleheads are more concerned about ER costs now than before.

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Re: How to Minimize Your Emergency Care Expenses

Post by TN_Boy » Sat Jan 20, 2018 2:19 pm

simplesimon wrote:
Sat Jan 20, 2018 1:48 pm
ResearchMed wrote:
Sat Jan 20, 2018 12:05 pm
simplesimon wrote:
Sat Jan 20, 2018 11:58 am
ResearchMed wrote:
Sat Jan 20, 2018 11:42 am
simplesimon wrote:
Sat Jan 20, 2018 11:26 am
How did it get this way? What was it like 30 years ago?
30 years ago (also more recently), if you did not have employer-provided health insurance and had any notable pre-existing condition... there was NO health insurance for you. (Or perhaps there was some medically underwritten policy that would be too expensive anyway.)

And if you weren't poverty stricken, there was just about no $$ help anywhere... unless health care costs caused one to become poverty stricken.

That meant paying what I'm guessing is now those "chargemaster" rates the WCI mentions, including at pharmacies, where "self-pay" could be 10x (or more) what someone would pay out of pocket prior to getting to out of pocket limits.

There were several paths to this disaster...

RM
Why does this feel like more of a problem now? The advent of HDHP's?
Not really the same at all, although it might feel that way if one isn't facing true catastrophic medical costs.

That HIGH deductible? Once you pay that, and any other co-pays/etc., there *IS* a "cap", even if it "feels" like a lot.

Without insurance? NO CAP. None.

Well, okay. There is a cap = all of your money. :shock:
Or almost so...
Once you are destitute, then there would be medicaid/etc.

RM
I see, so we're talking about people that don't have insurance...not that the cost structure of healthcare changed. I was wondering why it seems like people/Bogleheads are more concerned about ER costs now than before.
The cost of medical care has risen quite a bit more than overall inflation over the last 30 years. And high(er) deductible plans are more common.

That, at least, is my non-medical professional opinion. Medical care is a lot more expensive.

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Re: How to Minimize Your Emergency Care Expenses

Post by CppCoder » Sat Jan 20, 2018 2:35 pm

White Coat Investor wrote:
Sat Jan 20, 2018 11:13 am
CppCoder wrote:
Sat Jan 20, 2018 8:48 am
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 don't know, stay up long enough taking care of drunks and people that lie to you and assault you and might be able to get a little shuteye before the pager goes off again.
OK, fair enough...I have no doubt you come home exhausted. No one denies the work is hard and hard on you. I think you know II did, of course, mean metaphorically.
CppCoder wrote:
Sat Jan 20, 2018 8:48 am
I can't imagine anyone going into medical school today doesn't realize this...they still go.
Totally disagree with that. I would argue almost no medical student realizes this and many attending physicians have not yet realized it. There is no training into the business of medicine in medical school. If you have no interest in financial stuff, you could go your entire career, especially as an employee, and not realize what's going on back there. You actually have to seek out the information I posted in the OP, even if you work in a hospital.
That surprises me only because by the time one gets to medical school age, I would assume that one has been a patient or had relatives/friends who have been patients and seen the horrors of balance billing. They may not understand the details, but certainly, they must see it's broken. That said, you're definitely in a position to know the reality of your industry better than I am. It's unfortunate that you're in the minority, but thankfully, you're there, and there must at least be some others like you.

I'm sure you'll hate this next part: Calling all Bogleheads! Jim Dahle to replace Orrin Hatch for Utah Senate in 2018! :twisted: (Moderators: It's not politics--it's just a joke...but seriously, do it :)).

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Re: How to Minimize Your Emergency Care Expenses

Post by Hug401k » Sat Jan 20, 2018 2:45 pm

I also maintain a list of health care items I plan to attend to after I hit my out of pocket. Nothing urgent, but a few aches and pains I'll only get taken care of once we see if we hit the deductible. I wonder if hospitals start to see a rush towards the end of the financial year with so many high deductible plans.

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.

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Re: How to Minimize Your Emergency Care Expenses

Post by dodecahedron » Sat Jan 20, 2018 2:49 pm

CppCoder wrote:
Sat Jan 20, 2018 2:35 pm
That surprises me only because by the time one gets to medical school age, I would assume that one has been a patient or had relatives/friends who have been patients and seen the horrors of balance billing.
That is likely true of students who are just now reaching medical school age, but it is a relatively recent phenomenon. Most physicians in practice today made their vocational choice decades ago, before the advent of managed care with narrow networks, high deductible plans, etc.

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Re: How to Minimize Your Emergency Care Expenses

Post by dm200 » Sat Jan 20, 2018 2:50 pm

We have been fortunate to have not experienced such high expenses.

1. Have knowledge of alternatives to the hospital ER. Investigate use of urgent care facilities.

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.

4. Do you best to be and stay healthy.

5. Educate family/friends about not panicking to Press you to go to hospital ER when not needed

6. Know all the details of your health insurance and, if possible, pick a plan that can minimize expenses.

In our case, our Kaiser plan offers 24x7 urgent care facilities that are low cost and provide car for (in my opinion) 99% of the things we might otherwise go to the hospital ER. They can keep you up to 24 hours - just like a hospital at a fraction of the cost.

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Re: How to Minimize Your Emergency Care Expenses

Post by dodecahedron » Sat Jan 20, 2018 2:53 pm

dodecahedron wrote:
Sat Jan 20, 2018 2:49 pm
CppCoder wrote:
Sat Jan 20, 2018 2:35 pm
That surprises me only because by the time one gets to medical school age, I would assume that one has been a patient or had relatives/friends who have been patients and seen the horrors of balance billing.
That is likely true of students who are just now reaching medical school age, but it is a relatively recent phenomenon. Most physicians in practice today made their vocational choice decades ago, before the advent of managed care with narrow networks, high deductible plans, etc.
Edited to add: I do wonder about whether the current state of affairs in medicine is not discouraging young folks from wanting to become physicians. Burnout rates are high. Suicide rate among physicians is higher than general population. I know a number of physicians who have decided to do other things in life, some not by their own choice due to substance abuse issues.

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Re: How to Minimize Your Emergency Care Expenses

Post by CppCoder » Sat Jan 20, 2018 2:57 pm

dodecahedron wrote:
Sat Jan 20, 2018 2:49 pm
CppCoder wrote:
Sat Jan 20, 2018 2:35 pm
That surprises me only because by the time one gets to medical school age, I would assume that one has been a patient or had relatives/friends who have been patients and seen the horrors of balance billing.
That is likely true of students who are just now reaching medical school age, but it is a relatively recent phenomenon. Most physicians in practice today made their vocational choice decades ago, before the advent of managed care with narrow networks, high deductible plans, etc.
I agree. That's why my original quote was (added emphasis below):
I can't imagine anyone going into medical school today doesn't realize this...they still go.
Just out of curiosity, are the numbers of medical school applications or number of graduates decreasing because of this phenomena?

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Re: How to Minimize Your Emergency Care Expenses

Post by namekevaste » Sat Jan 20, 2018 2:59 pm

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."
Doctors have tried to organize - here is a phenomenal example of a physician leader doing this https://www.cnbc.com/2018/01/18/hospita ... mpany.html. However, big pharma and for profit health systems have powerful lobbyists. The ones who should really organize and do something are the voters.
Last edited by namekevaste on Sat Jan 20, 2018 3:59 pm, edited 1 time in total.

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Re: How to Minimize Your Emergency Care Expenses

Post by dodecahedron » 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.

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Re: How to Minimize Your Emergency Care Expenses

Post by ResearchMed » Sat Jan 20, 2018 3:11 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.
WCI posted above that based upon presenting symptoms, something like 90% of ER visits were appropriate; based upon final "knowledge", far fewer.

But we only have the PRE-visit symptoms when we need to make that decision, "to ER or not to ER", and the cost of getting that wrong, by being too cavalier ("oh, it's probably just indigestion!") can be very, very high.

RM
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Re: How to Minimize Your Emergency Care Expenses

Post by nisiprius » Sat Jan 20, 2018 4:02 pm

Thanks, WCI. Very interesting. I wonder if you'd have something to say about another problem, which is that as nearly as I can tell, in terms of procedure codes and so forth, doctors cannot predict exactly what they will be doing and thus the procedure codes are not known before the procedure has been performed. This means that the common advice that, to avoid surprise bills, "get the procedure code and call the insurer," is basically non-actionable.

A friend of mine ran into this. She had made an appointment for a surgical procedure she was told she needed. She had read that insurers sometimes balk at paying because the procedure is sometimes performed as an elective cosmetic procedure. After dozens of phone calls and runarounds, she finally found an office that told her that their records showed she was scheduled for a procedure coded as 22999. She then called her insurer, who said she needed to call Medicare, who (after several waits on hold and referrals to other offices) said that according to what she was seeing on her screen for code 22999, they could not give a reimbursement amount for this procedure code or state whether or not Medicare covers it.

After a little more detective work, she found out why: 22999 is simply the code for "Surgical Procedures on the Abdomen." It doesn't say which procedure or why it is being done.
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Re: How to Minimize Your Emergency Care Expenses

Post by jayk238 » 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.

raddoc101
Posts: 19
Joined: Fri May 27, 2016 12:56 pm

Re: How to Minimize Your Emergency Care Expenses

Post by raddoc101 » Sat Jan 20, 2018 4:35 pm

Great post.

I wish we got 250 from Medicare for a CT. A Ct Abd/ Pelvis with contrast pays the radiologist 93 dollars. For all billing, we average about 25% more than medicare, but of course, the private insurance at 2-3x averages out the no pays.

"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.

I wanted to respond to that 9000 dollar CT bill thread, but it was locked too soon... That charge makes me sick as a radiologist. The radiologist at most is getting 300 dollars - costs (private practice). If they're employed by the hospital and get even a great amount/ RVU (50 dollars), then they'll make about 125 dollars (2.5 RVU for a CT Abdomen and Pelvis).

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ram
Posts: 1085
Joined: Tue Jan 01, 2008 10:47 pm
Location: Midwest

Re: How to Minimize Your Emergency Care Expenses

Post by ram » 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.
Ram

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