Posts Tagged costs
Trying to define the market value of someone’s professional services is difficult when those services are typically paid at vastly different rates, depending on the payer, especially when the party paying is usually not the direct recipient of the service. So when an emergency physician provides clinical services to a patient, how are those services valued by different payers, and what does that say about the reasonable market value of those services?
For example, let’s say that you come to the emergency department with an acute asthma attack: you can’t breath well, and your inhaler hasn’t helped to break the attack. A pretty straight-forward case, really: your ER doc does a history and physical exam, orders up some oxygen and a few respiratory therapy treatments, some steroids, perhaps an IV to rehydrate you and get access in case your condition worsens and you need IV meds, and returns to re-evaluate you every 15 minuets to make sure the treatments are working. Two hours later, you are able to go home with a script for three days of Prednisone and a refill for your Ventolin inhaler as the one you have is running low. You get instructions on how to care for yourself at home, when to see your primary care doctor, and what you should do if the wheezing comes on again despite the treatment. Chances are, you will likely get a charge for this service from the physician for 99284 level care for around $320, give or take, if you live, let’s say, in central California.
If you didn’t have insurance, you would be expected to pay the full charge. Unfortunately, many patients can’t afford to pay; or could afford to pay but are just irresponsible, and don’t pay anything. If the patient pays nothing, the emergency physician may be able to recover about $45 from California’s EMS Fund, a tobacco settlement funded program that pays on average about 15% of the emergency physician’s fee.
However, if you were uninsured with a family income at or below 350% of the federal poverty level; or you are insured and have incurred high medical costs (greater than 10% of family income over the prior 12 months) with a family income at or below 350% of federal poverty, and you submitted a request for a discount; you would (by virtue of California law) only have to pay 50% of median billed charges of a nationally recognized database of physician charges, probably around $150.
If you were covered by your County’s new Low Income Health Program (a family of 4 making less than $41,000/year), the county may pay the emergency physician about 30% of the Medicaid rate, or a whopping $21.
If you were covered by California’s Medi-Cal program, one of the lowest paying Medicaid programs in the country: $68.
If you were covered by Medicare: the federal program would pay about $125.
If you had HMO coverage, but had to go to a closer out-of-network ER, your HMO would pay the ER doc between $140 and $250.
If you had PPO coverage, the plan would pay between $175 and $240, minus any co-insurance payment, and you would have to pay the rest up to the $320 charge.
So, for a $320 emergency physician service, the emergency physician might receive anywhere from the full $320 down to $21, and about 10% of the time – nothing. The average emergency physician in California provides about $140,000 a year in unreimbursed care.
Of course, in order to provide these services, the emergency physician has to spend $10 to pay for malpractice insurance, $30 for billing services, and additional costs for other overhead amounting to a total of about $55 for every ED patient treated (even if the payment is $0)
So, what’s the real market value for an emergency physician’s services? I would argue that it is the full amount that the emergency physician charges, as long as these charges aren’t significantly higher than what other emergency physicians in the same area charge, but then I just paid a heating technician $175 for 10 minutes of maintenance on our furnace. Others would argue differently, but their estimate would be based on their particular agenda: protecting those living in poverty, reducing costs for the employer, dealing with government budget deficits, or making higher profits for the insurer. Unfortunately, none of these advocates actually provides emergency care to anyone.
By the way, if you were suffering from a heart attack or serious injury, and the emergency physician (and his team) actually saved your life (it happens hundreds of times every day), the emergency physician’s charge would be around $800 to (rarely) $2000. So, what’s the real market value of YOUR life?
This post also appears on the blog The Fickle Finger www.ficklefinger.net/blog/
In yet another installment of “emergency physicians don’t know what they’re doing,” KevinMD provides a guest post by gastroenterologist Michael Kirsch, entitled Does the bulk of excessive medical care happen in the ER? At its best, the piece is uninformed; at its worst, it’s insulting and unprofessional.
So let me answer you here, Dr. Kirsch: No, it doesn’t.
Read this beauty from the author (I guarantee he has not practiced in an emergency department (yes, department) since residency):
These unneeded medical tests and treatments are black and white, not gray. It occurs every day in every doctor’s office, including mine. The most dramatic example of it, however, is the care rendered in our emergency rooms. The volume and expense of care given there routinely is absolutely astonishing. It is wasting a fortune of money and exposing patients to the risks and anxieties of extensive testing, even for minor medical conditions. Whenever one of my patients sees me in the office to review a recent ER visit, I try to disguise my amazement, as I look through all the lab results, x-ray reports, CAT scan interpretations and EKG tracings – often performed for some innocent complaint that has already resolved on its own.
The clencher, of course, is my bolded text for emphasis. Remove the retrospectoscope, Dr. Kirsch. It’s daylight out! If you’ve figured out how to divine “minor medical conditions” and “innocent complaints” from badness, boy, you should be writing our textbooks, because we dumb emergency physicians can’t!
Yes, the epigastric pain is just innocent GERD after it gets better and the patient doesn’t deteriorate (hint: sometimes it’s an appy, like I diagnosed just last week!). Unfortunately, according to a Lancet study, 7% of patients with ischemic chest pain actually felt better after a GI cocktail. I’ve seen patients with tender abdomens with no other complaints who have STEMIs. I’ve also seen sharp, right-sided tender chest wall pain with an NSTEMI. We all have.
In the Emergency Department, I lack the benefit of knowing my patients. I often do not have the luxury of knowing their medical problems or medications, as they themselves often do not know them; I often have patients who cannot provide history to me; I often have patients who only have non-specific complaints: “weakness.”
I probably do order more tests than your average internist, but two points: don’t you think there’s a referral bias toward emergencies in a patient presenting to the emergency department? And two, how much of adult medicine is a waste? The vast majority of antibiotics for upper respiratory infections are prescribed by primary care physicians, not emergency ones. And we could certainly find an easy whipping boy in the PSA, which is ordered routinely across the country, yet where’s the data behind it? Apparently there’s no risks or anxieties to ordering cancer screening tests (many of which have a ton of false positives).
ER physicians should practice the same style of medicine that we all were taught to do during our medical training. Take a thorough history, perform an examination and then make appropriate recommendations. As a gastroenterologist, I see patients with chest burning in my office several times a week. The medical history allows me to determine if the chest discomfort is innocent or suspicious.
So you’re a gastroenterologist and you see chest burning. So, yeah, with your gigantic referral bias, most of your patients with chest burning probably do have GERD. I take all comers: the rich, the poor, those with a great primary care doctor and those who haven’t said a word to a physician in 20 years. And it’s now up to me to determine if this chest burning is of a concerning nature. (And by the way, the more we’re (we being emergency physicians) learning about acute coronary syndrome, the more we’re recognizing that the classic “crushing chest pain” is just as atypical as “atypical” symptoms of shortness of breath, abdominal pain, or weakness, especially in women or the elderly.) And what if it’s suspicious? What’s the “appropriate recommendation?” Go see your cardiologist? Go back to your primary care doctor? Get a stress test with a 70-80% sensitivity (thereby missing 20-30% of patients with significant coronary disease)?
The recommendation, of course, is simple. According to Dr. Kirsch’s office (which I just called), here it is: “If this is a life-threatening emergency, hang up and dial 911.” To be taken by an ambulance — likely under the direction of an emergency physician — to be evaluated by … an emergency physician.
If an ER physician, or any doctor, thinks his patient’s abdominal discomfort is from constipation, then treat it accordingly and arrange for proper follow-up in the office.
Uh, trust me, we do. I disimpact with the best of them and give enemas when appropriate. But when it’s an elderly patient with a chief complaint of “constipation,” you better be damn well sure of your diagnosis: abdominal pain in the elderly has a 10% mortality rate. And they’re also classic for having 5-7 days of abdominal pain that turns out to be an appendicitis. Funny how they present like that. (Also: “follow-up in the office?” How about our 45 million uninsured patients who lack an “office” to follow-up in?)
Let’s play a numbers game, too.
- Emergency care costs less than 3% of the nation’s 2.1 trillion dollar health care expenditures. That’s 63 billion dollars.
- I don’t know what percentage of care Dr. Kirsch considers excessive, but even if all emergency care is excessive, then that means only 3% of medical care is excessive. (If that’s all, I’d say 97% with a purpose is pretty good!)
- Using some back of the envelope numbers from the 2002 Journal of Gastroenterology, if today we’re doing 20 million colonoscopies at $1,000 a pop, that’s almost 1% of all health care expenditures, just to put that in some perspective for the GI folks out there. Ahem.
I’ll concede one point to Dr. Kirsch: I see a lot of “innocent complaints” in the Emergency Department. It’s our nature, thanks to EMTALA. When EMTALA was passed, we certainly started seeing more patients with non-emergent complaints, but now the two are all mixed together and it’s often difficult to tell them apart. If some other physicians are willing to step in and offload the emergency department of some of our patients with “innocent complaints,” please, go right ahead!
(I didn’t think so.)
Until then, we’ll continue having the proud duty of caring for all patients with all complaints all hours of the day.
It’s really easy for everyone to call bullshit on the Emergency Department (my motto: you’re not getting out of here without a troponin!) when they have the benefit of days, weeks, or even just a few hours of observing the patient. Or some basic labs, or an EKG. But there’s no way in hell I’m going to stop putting the dangerous diagnoses in my differential alongside the more common ones. I’d ask Dr. Kirsch where he’d go if a loved one had, say, a bicycle injury. Would he be satisfied with a history and physical and a quick discharge home with a diagnosis of “contusion?” Of course not. When it’s your loved one, you want the x-ray to rule out the fracture. (As I’ve written before, often the physical exam just isn’t that hot.)
Until I start critiquing polypectomy skills or demanding an endoscopy outside of normal business hours, it’s probably best that you stick to the GI tract, Dr. Kirsch.