Thursday, November 08, 2007

I'd Rather Do it For Free

Thanks to GruntDoc for bringing this article to my attention. ERs are closing and some of the reasons why may surprise you.


  1. GREAT ARTICLE! Everyone with a voter registration card should be required to read it.

  2. good article!
    I'm curious to know the reasons why so many patients have medicaid and are using the ER so much...

  3. Call me out of the loop, but I didn't realise that insured folk, like myself, were the lowest percentage of ER patients. I know that if I need to use the doc-in-a-box I have to jump through rings of fire to get that ok'd, but I can go to the ER self-refered. Mind you if it turns out not to be an emergency situation I'll get a nasty-gram from my company.

    What would happen if Medicaid /Medicare patients had to get past tele-nurse or some such off site triage before being ok'd for emergency treatment?

    I'm just asking here, since I'm not a medical person, and have never played one on TV.

  4. These numbers (payments of ~33% medicare vs ~35% for uninsured) are exactly what we experience in our (relatively poor) population. In GruntDoc's blog, Shadowfax notes that he only gets 7% for uninsured. He needs to fire his billing company and collections agency. In fact, if we allowed our collections people to be more aggressive, we could probably get over 50% from our uninsured. Alas, I care too much about the plight of the poor to squeeze them dry. Well, at least 65% of them...

  5. dear m.e. the midwest mom,

    the tele nurse lines are a dismal failure. just to prove my point, pick any nurse advice line in your area and tell them the following...

    you are a 25 year old woman with cough and runny nose and fever of 101 for a few days and you came from work where there are a few other people with a 'cold' but your concern is that you have just a twinge of discomfort in your chest... you think probably from a particularly hard sneeze, and you want to see the doctor some time soon.

    you will be told, "go to the ER now". the reason? in a word, lawyers. even though only 1 in 10,000 of the hypothetical patient above will have either angina, pulmonary embolus, or thoracic aortic dissection, the liability and responsibility for catching this 1 in 10,000 is immediately transferred to the ER (and the cost to the nurse line, the primary doc running the nurse line, and me is in the millions if the zebra is missed).

    also, just for fun, call your physician's office at, say, 4pm, tell them you have an earache and that it really hurts. that's it. tell them you've been swimming for excercise. i would wager a good ammount of money that they will tell you to go to the ER.

    same with the previous post's topic, high blood pressure, call the nurse line and tell them that your blood pressure was 160/80 at walmart and that it made you nervous. probably 75% chance that the answer is "go to the ER"

    as i tried to explain in a previous post seen at this link...

    emergency medicine has become a victim of its own success and relevance. many primary care physicians are no longer comfortable taking care of potentially very sick patients in the office. this is partly due to liability, partly due to the fact that they don't usually have on-site lab and radiology, and to a large degree, due to atrophy of skills.

    in the ER we work from the most dangerous POSSIBLE diagnsosis down to the real diagnsosis. hence, we don't miss much dangerous stuff. this is EXPENSIVE. in the doctor's office they work from the most likely diagnosis. this is NOT SO EXPENSIVE.

    when the consequences of missing a rare but deadly condition are loss of career, license, large ammounts of money etc... it becomes easy to default to the "GO TO THE ER" answer.

    tort reform would go a long way to allowing primary physicians to practice more reasonably in this regard and would also free us up to use more clinical judgement in the ER. as it stands now, we have to be perfect, and we have to do it no matter what we are likely to be paid, and no matter whether our patients are citizens, criminals, drug abusers, liars, or simply neurotic.

    i'm not saying we shouldn't treat everyone the same and give everyone excellent care... we should certainly do this, i'm merely pointing out that Americans demand perfection from their physicians, and lawyers do too, and we are, through years of delterious legislation (which has shifted ALL responsibility off the patient for both health maintenance and payment), paid less and less for more and more.

    such is the life of doctors today. and i am not whining, i'm trying to speak dispassionately.

    something will give soon. if hillary wins doctors will still work, excellent care will still be delivered, but it will be done in such a way as to triage many people into slow death and chronic illness. i am against this, and, not as many will suspect, because of money.

    i think i'll make, perhaps, a little more in the initial years of hillary care. i will not, however, work as hard, and neither will my surgeons, cardiologists, and other sub-specialists. all specialty care will be rationed by the clock. rather than getting your coronary artery bypass graft within a day or two of diagnosis of your three vessel disease, you will get it in three or four months, if you survive that long.

    doctor's will not strike, we will simply fall into the malaise that is prevalent in the VA system, the DMV, the IRS, etc... there will be no sense of urgency anymore. the system will have it's choke point at the front door and will wait for people to go out the back door before letting the next person in.

    rather quickly, also, you will see springing up from the fallow earth, clinics and hospitals that provide excellent, immediate care delivered just as it is today, but only for those with private insurance or cash. another giant beurocracy will suck on the taxpayer teat, and within a few years we will be right here again, but with fewer excellent young folks choosing to pursue medicine as a career.


  6. 911: first of all, I agree completely. second of all: 'settle down Beavis"

  7. Do you shine your pants?

  8. huhuhuh... you said 'douche' or something

  9. I had to take my 8 y/o to the ER on Sunday morning. It was, as expected, a pretty long wait. I asked the check-in attendant if there was an urgent care clinic close by or another option. She referred me to a private ER.

    Upon signing in to meticulous building (and rooms!) with 1 family in the waiting room, I noticed a huge sign that hung on the glass partition:

    NO TRICARE (military insurance for those who don't know)

    The doctor was thorough, pleasant, caring and obviously has a corner on a market out here in the Houston, Texas area.


  11. Is what pink describes actually "legal"???

  12. Well explained 911! Kudos on the excellent response.

    To address methemwm's reasonable question, I'll provide an example of why a good idea often doesn't work. Two years ago, I practiced in an area that borders a state with a huge medicaid problem. Their legislature came up with what sounded like a reasonable plan to try and both cut down on ER visits and encourage patients to see a PCP for their routine care.

    The plan was simple. If your PCP was open, you were expected to go there for care. You could come to the ED if you thought it was an emergency, but if it wasn't, you would be expected to pay the bill. If the care we provided was non-emergent, medicaid paid us nothing.

    If we examined the patient, told them that they didn't have an emergency and needed to see their PCP, we'd get paid $25 for a "medical screening exam" (as long as we provided no treatment).

    If the PCP's office couldn't work the patient in, they'd fax us a referral form and we would get paid the $8 that the PCP got paid for seeing the patient!

    During nights and weekends, the patients were "automatically referred" to the ED and we got our $8 each!

    After about a month, the medicaid patients started waiting until after 5pm and on weekends to come to the ER.
    Ultimately, since the PCP's didn't really care about the $8 and would prefer to see a patient with "real" insurance and make more, they just faxed over stacks of blank signed referral forms for us to complete.

    The whole system was ultimately a joke.

    911 is spot on with his descriptions of the "Go to the ER phone nurses". They're a waste of good computer bandwidth. A recording would be more cost effective.

    One rub for me is that it is impossible to sue a judge for performing their professional duty and virtually impossible to sue a lawyer for malpractice. I on the other hand can do everything right and still be sued. It's clear who writes the laws!

  13. yes. i do not know the ins and outs, but i believe there are ways to do it. i think doing it as a hospital would be very difficult as if the hospital had an emergency department then emtala would apply and the hospital would be overwhelmed just based on the ER.

    the typical response from the left side of the aisle will be to outlaw these clinics and hospitals and THAT is the point at which people will finally understand how our system has been hijacked.

  14. i can't help wondering the reasons for visiting the er of the commenters here. i somehow thought e in er stood for emergency.

    i think, as 911 says, 'emergency medicine has become a victim of its own success'. it is no longer emergency stuff. it is trivia. it is about getting so called service.

    i think the public needs to be educated. do not come to the emergency room unless it is an emergency. otherwise wait until the big light is in the sky.

    i also think er personnel need to start turning people away at the doors. if it is not an emergency, find a place called convenience room. go there.

    this is why i don't think i could work er any more. hats off to you guys that do, though.

  15. dear bongi,
    your heart's in the right place BUT i am here to tell you that with the patient population we take care of that no ammount of education will cure this ill. the fact is that for many, they know that they will never have to pay a dime for the best medical care anywhere in the world. there is no consequence to riding the ambulance in for their headache. the worst place to be here is a lower middle class person with a job but no insurance because YOU will pay something and probably get into credit trouble because of it. now YOU are disincentivized from coming to us even in a true emergency. IF, however, you have some throwaway form of insurance, like MEDICAID or any of the state supporte programs for the uninsured, then, by law, we must see and treat you and woe be unto us if we fuck up. as a painful aside, these patients are almost always the ones that are the most demanding, most litigious, and hardest to truly CARE about. if they had to pay even ten dollars in cash every time they came in the problem would quickly vanish. if they had to pay, as they do in MEXICO, to ride the ambulance IN the ambulance, the abuse of EMS would cease as well.

    this is not rocket surgery (to quote david lee roth), but is completely incomprehensible to hard lefties. if it is not incomprehensible, then it is worse, it's vote buying.

  16. Bongi,

    I work in medicine and have for 15+ years. Trust me when I say, I don't use the ER for a ridiculous reason. The last time my daughter was seen by a doctor was 2 years ago, and that was for a well-check visit.

    No, it was not a cardiopulmonary arrest in an 8 y/o. It wasn't a seizure, coma, CVA or MVA; however, when dealing with children, sometimes it is prudent to not wait that extra 24 hours when symptoms dictate and the PCP says so. M'kay?

    Was she as critical as the others in the waiting room, pending patients, or possible ambulance transfers? How in the world am I supposed to know?

    All I knew was that she was still coherent, able to speak and walk (as were the others, but that's another story)... and thus my question about the urgent care clinic.

    The one listed in my book was 60 miles away, and the loverly insurance company said in their voice mail to "call back during normal business hours" because I wanted to find a closer urgent care. Great help, right?

    FWIW, my co-pay is 150.00 for ER visits and urgent is 75.00. I would have GLADLY paid half-price if it meant driving less than 60 miles of uncertainty. Oh, and the nearest hospital had she needed to be admitted would have been 60+ miles away.

    And, I paid up front to the private ER, as I would have in the ER, because that's how I roll. I pay ENOUGH in monthly premiums (almost 1000.00 for a healthy family of 4) to pashaw savings.

    So, really, piss off with your ass-umptions.

    I was merely trying to relate the sign I saw because it directly related to the article posted.

  17. Here is a link to the facility to which I referred:

  18. Is a child with a bladder infection an emergency? No. Is a child with pyelonephritis an emergency? Yes. What's the difference....a few hours or days.

    What IS and ISN'T an emergency is a subject that even insiders can't agree upon. Pink made a choice to go to the ED, made a choice to pay the extra, and made a choice to wait patiently while more serious patients were seen. I can't say that I mind that at all.

    But when minor patients bitch about the wait, my standard comment is "'Emergency' isn't defined by the fact that you are here".

    It brightens my shift to walk out of some cluster-fuck drunken asshole who took too many pills, has 4 people holding him down to get an IV started, questions my heritage, and vomits on my shoes...only to pick up a chart for a nice person with a relatively minor problem that's grateful that we're there.

    When I bitch about the abuse of the ED, I'm not referring to patients like pink. I'm talking about the patients who come 20 times a year for demerol shots for their chronic back pain, or 15 times a year for toothaches since they can't afford a dentist (even though they smoke 3 packs a day and are on their cell phone). I'm talking about the people who have seen 5 different doctors in the past 2 years and no one can figure why a pain shoots out of their big toe and back into their eye socket.

    I mind the people who won't go to the health department for their STD because there's a $10 charge and they can get care "for free" in the ED.

    I mind the parents who bring their kids to the ED for fever because "I can get Tylenol for free here".

    That's what I mind!

    Some studies have even been done to show that if ED's depended solely on funds garnered from true emergencies...they'd all go bankrupt.

    The solutions aren't easy, nor are the issues. Surely, Hillary and her band of "experts" (which doesn't include a single practicing physician) can figure this all out! Fortunately, I don't worry about Hillary too much since I don't think Congress will let her make too many changes....but I may be wrong.

  19. *murmur of agreement*

    my feelings precisely, i need the 'not so sick' patients inbetween the time intensive ones no doubt.

    one thing that is being floated but will not pass legislative muster is to allow physicians to deduct the cost of the free care they give. even a 10% write off would make a huge difference but, well, i'm a rich doctor and unfeeling and uncaring etc... so that won't be so popular.

    off to my yacht.

  20. I don't worry about Hillary too much since I don't think Congress will let her make too many changes

    I'll worry for the both of us. Frankly that woman scares the crap out of me. I can't wait to get some of this into my writing...

  21. Lynn: can we get a share of the book profits? Just make the check payable to the IRS and put my ss# on it!

  22. I love yall. Intelligent, and to the point, yet hilarious.

  23. i got tired of patients on cell phones. i bought a cell phone blocker over the internet. they are illegal here so i ordered mine from england. it's the size of a small pager. when i walk into a room where a patient is on their cell phone and holds up their finger for me to wait a minute, i just click it on and poof they are no longer on their cell phone. it's also great at the movies.

  24. oh my goodness, please tell me where i can get one.

    thanks for the kudos emergencyemm.

  25. I'm going to piss off all the liberals in the audience, but how about requiring a little job action for these 22-year old able-bodied people with 2 or 4 kids in order to get "assistance" from the govt?

    If you want to choose to live purely off the money of others, you should be out of the category of "government assistance" and into charity care. It should not be mandatory for people to provide assistance to people who are simply choosing to be unemployed for whatever reason.

    I'm not talking about the truly mentally ill or those with bona fide disabilities; everyone who works in an ER knows who I'm talking about.

    If some of these people who use ERs the most had an obligation to be at work (and consequences if they didn't go), the amount of time spent in ERs for sniffles and in bed with some new guy having another to have another child would go way down.

  26. heartless and cruel you are ma'am! i'm a romanian/cherokee indian/pacific islander/ mexican/ dutch person with all the glory and grandeur attached to my heritage. i demand respect and free stuff!

    NO TRICARE (military insurance for those who don't know)

    Those are the same three that won't pay me to assist.

    911 That was the best summation I have read yet.

    Bongi, I agree, you (I, we) may not get paid either but at least in the OR it sure is a lot more fun to not get paid from an anesthetized patient was can't cuss, insult, complain, and demand while you're treating them. Of course that's easy for me to say, I don't have to do rounds....bahhaha!

  28. here is the site i bought mine from. there are several out there.

  29. 911 doc, no clever comment here, just thanks from a patient for your easy-to-understand explanation of what er docs have to go through. I didn't know.

  30. Holy Cats. Do you think we should get the lawmakers to hang out and observe in a busy ER for about a month straight before they can enact any more laws? It can't be a bad thing getting them a little perspective.

    Thanks for the replies. Next time I have to use the ER I'll send a bunch of flowers and a nice note. That'll throw you all off.

  31. ladies,
    happy to help. really, i don't think that any ammount of knocking on the head is likely to change the outlook of our legislators. you are assuming that they want to past the best and most reasonable laws. cynic that i am i believe that, especially on one side of the aisle, legislators want little more that re-election. i would like to be wrong about his.

  32. Nurse K,

    How about a random drug test once every couple of months? No passie, no bennies. I have to pass one to keep my job. Why in the hell shouldn't moochers have to pass one to benefit from my taxes from said job (and higher premiums)?

  33. oh God bless you PINK! four letters and two words... ACLU and liberal democrats.

  34. How about a random drug test once every couple of months?

    Dear Pink, our physicians are writing the prescriptions; one could hardly fault the patient for taking what was prescribed to him by 8 or 9 different doctors that week.

    I don't really care if you do coke on the weekends or evenings as long as you do your required job during the week. If you have to have a job, you'll maybe have built-in incentive to not use it anyway.

  35. After a long day, I found a few more things that I mind:

    1) 18 year old female who missed her period, has nausea and breast tenderness and had 2 positive pregnancy tests at home. She comes to the ER for confirmation. Yes, you're pregnant. We use the same pregnancy tests you buy at WalMart.

    2) A woman who comes in with her kid demanding "shots of Bicillin so we won't get sick over the holidays". They have a PCP, but he wants $75 to see them. So she wants it free.

    3) The lady with a scheduled hip replacement in 5 days who "just can't wait any longer" and wants it done on Saturday, right now.

    4) The lady who can't stand up straight and her family is sure she's had a stroke. Turns out that her drug screen is positive for everything EXCEPT marijuana. When confronted, she says "maybe they're putting something in my weed"!

    These are things that I mind.

  36. Nurse K,

    I'm talking about lazy-ass welfare recipients. And, I am sure you know as well as I, most drug seekers will be positive for other substances such as marijuana and cocaine. I'll give you that cocaine metabolizes w/i a few days, but pot sure doesn't...especially in the chronic user.

    So, while the "system drug seeker" may be able to justify the Vicodin or Perkie, he or she WON'T be able to justify the weed or crack/coke.

    That's is to which I am referring. One less moocher off of the government's dole is a start...right?

    Or would it hurt "the children?" ***cough, cough, puke, spit**

  37. you may want to visit our sponsor,, they do it all for the children.

  38. Poops trong? Asian poop?

    Poo strong? Smelly poop?

    Poop ST rong? Having a shit during an EKG?

    Dammit! Don't confuse me and have it all "for the children!"

  39. Po'opst Rong 2nd year MLB out of LSU