Saturday, May 17, 2008

M.D.O.D. Scavenger Hunt

Dear Readers,

You have heard many of us say that medicine is not a business and that patients are not customers. Let's try a little exercise here. I really am interested in what you have to tell me. Just for fun, call up your local hospital and ask the following...

1. How much is an EKG in the ER?

2. How much is a set of cardiac markers in the ER?

3. How much is a chest XRAY in the ER?

Make a couple of calls on different days. One time say you are uninsured and are concerned about your bill and the tests above are what you have been told you will need and you want to be able to pay. Another time, tell them you have medicaid, another time tell them you have kick-ass private insurance with gold-plated benefits through the railroad or IBM or some shit like that. Let me know what you find out.

I suspect you will not be able to get this information at all. If you are able to get the information I bet you get different answers based on your level of insuredness (if that's a word), which will prove my point. In a business you know the price before you buy. In a cost-shifting game the price is hidden because some pay none and others pay a lot. Have fun!

Не волнуйтесь по поводу мужчина скрывался за занавесом. он с правительством и находится здесь, чтобы помочь вам.



  1. Help me help you.

  2. I've spent a lot of time thinking about this, what with the impending (given the probably outcome of the upcoming election) socialization of the "practice of medicine" as an institution in the U.S. - and what impact this will have on standards of care.

    As an economist, medicine is difficult to classify and categorize. I was speaking to a seasoned and experienced ortho friend at a social gathering recently, and he shed some light on the insurance/pay to play situation and the "Bentonville Effect" this has on medical costs and agreements with doctors.

    In the end, I think medicine is a lot like a national defense. Ultimately, Lockheed/GE is only going to be able to sell 2,000 F-22's/CT Scanners - regardless of how good they make it. Society needs to accept the value and cost of medicine.

    I look at high prices "at the pump" as a good thing. The more money that flows into medicince at the 'point of sale' the more investment money flows into the development of new procedures, technologies, medicines and most importantly, docs. The US has the highest cost of care in the world - at the same time, what share of advanced procedures and technologies are developed there? What share of top-flight surgeons and specialists are trained there, or come there to make their bones?

    I pay a lot for my health coverage; and I do so gladly and willingly. The doctors I've met and have known were well worth the cost; the solutions they provided and tools they used to reach them were amazing, even by my jaded standards.

    We can go for cut rate medicine. But it's one thing to be tooling around Baghdad in an unarmored HUMMVEE, it's entirely another to be tooling around the cardiac ward with out of date tools.

    They don't invent themselves. Surgeons don't train themselves, nurses don't, trauma specialists don't - it's not free people.

    If you want someone to do the dirty work of curing your otherwise incurable ailment, you've got to pay for it. Period.

    That's how I feel about it, at any rate.

  3. OK, so based on that, advice needed. I am leaving my corporate position to go out on my own. Insurance is a necessity but I am having a hard time figuring which plan is best; catastophic, or the more pricey "regular" insurance(single 33 yo female in good health). I will be paying full freight myself but either way, the ER doc will get paid ;) Any thoughts?

  4. anonymous,

    please do continue. i am very interested in your perspective. mine goes something like this. wall street has its 'triple witching days' and medicine in the US is now under perpetural quadruple-witching days.

    example: a 4cm superficial laceration to the arm in an otherwise healthy young man.

    what is done: break open sterile hypodermic and new bottle of lido with epi, numb wound, break open a bottle of sterile normal saline, irrigate wound with high pressure from a syringe with a splash guard, break open set of surgical gloves, break open pack of sterile suture and suture kit, sew wound, possibly after XRAY to rule out foreign body, dress wound. ER bill, probably $1200 to $1800.

    what could be done: break open sterile syringe, draw lido from large 'community' bottle with alcohol swab to top, have patient irrigate own wound in sink with tap water at moderate pressure, use sterile suture and one needle driver which is sterile, bandage. actual cost to me? about $15. reasonable bill to patient? $100 or so.

    why is it done the first way?

    1. inertia. even though tap water wound irrigation for minor lacs shows NO increased infection rate many ER and FP guys and nurses still use the $80 bottle of NS.

    2. fear of litigation. if a wound infection occurs, equally likely in both scenarios, the first treatment is more legally defensible as treatment number 1 sounds more 'medicine-y' to a jury.

    3. drive to maximum billing. since treating docs can not guarantee payment on any particular patient, we chart the maximum possible on everyone to make up the shortfall. billing and coding pays us more for option #1.

    4. EMTALA. basically the driving force of number 3 directly above.

    5. JCAHO. procedure #2 is frowned upon by JCAHO for not being classic 'aseptic technique', statistics and studies be damned.

    6. corporate medicine. corporate medicine much prefers number 1 as they have to collect a lot to cover non payors.

    the time is ripe for private ERs. i may do it myself. one thing about ER medicine is that with hundreds of repetitions you get damned good at recognizing illness. labs rarely help me in about %70 of my patients. if a little assumption of risk were allowed for the patient, the patient and doctor together could change a $2500 chest pain workup into a $200 visit with almost no deleterious effect.

    right now, lawyers and the patients looking to 'hit the malpractice lottery' have eliminated patient's ability to assume any risk (and i know this is not peculiar to medicine).

    well, that's a 'sextuple witching day'.


  5. I'm so doing this. I'll report back as soon as I get some info.

  6. Oh my gosh. My I in a worm hole?

  7. oh, and anonymous, i think EMTALA would still suck huge monkey balls if it were funded, but it is not. it ends up being a federally mandated cost shift directly to physicians, hospitals, and taxpayers.

  8. 911doc,
    I didn't mean to imply that changes weren't necessary - but that the kind of changes that are being thrown around (centrally controlled health care/socialization) are toxic to an effective treatment environment.

    Based on the perspectives I have heard, medicine stands at the junction of cost pressure, legal pressure and social pressure (this being notions like "social health care" and EMTALA).

    To address these three issues, here are solutions:

    1) Legal pressure - end all medical lawsuits; begin criminal proceedings for doctors who are geuninely negligent (which based on my understanding already happens). If you die or are incapactiated/injured due to a physician's mistake, you aren't entitled to millions of dollars. First, it's unlikely that you'd have made it as far as you did without the doctor in the first place - it's uncharitable to sue someone who's trying to save your life. Second, shit happens - the fact that it happened in the presence of someone with financial 'presence' doesn't mean you should get compensated for your pain and suffering. That's like suing a girlfriend for cheating on you. Doesn't make sense nor pass the laugh test. Third, there's an acceptable amount of risk in the medical profession - we can do more to alleviate this risk (I believe, without evidence at this point) by reducing the pressure caused by frivilous lawsuits than we can by allowing them to continue and "weed out" the "bad" doctors.

    2) Social Pressure - This mainly applies to technicalities of medicine (such as the ER procedure you pointed out), so I can't speak much to this. I think there should be a lot more freedom in the practice of medicine, however. If you know a very little bit about the AMA and the *terrifying* amount of control they have over how medicine is practiced in America... It's an unsettling situation. This is great opportunity to invoke the "Betonville Effect." Most likely, the quality of the items at Wal-Mart is measurably diminished due to the cost pressure. I am therefore at higher risk for all sorts of negative shopping outcomes (bad bottle of shampoo, jeans that tear to early, not just medical stuff). That's a risk I accept in favor of the lower costs. It's a choice I make - I could save less than I do, and go to an upscale grocery with theoretically lower risk. But I don't.

    I do not feel "entitled" to the upscale grocery, however. I am making a choice to spend less and accept more risk. (Even if it isn't real risk).

    Your solution to this appeals to me greatly - the idea of independently established ER's which follow a different set a protocols designed to provide The same or 99% of the same level of care at a fraction of the cost for cash up front. This would - much as Wal-Mart has - shatter the traditional point-of-sale medical establishment. You for Federal Reserve Chairman, I say!

    The other notion that needs to be destroyed is that of entitlement. I know people who smoke 3 packs a day, eat expensive (That is, brand name) food, own big cable packages and nice TV's and cars - and insist to me that they don't have enough money to pay for health care.

    I don't own a TV, nor do I have cable. I own this computer, a bed, a desk, and two chairs. /furnishings. I do have excellent health coverage, which I pay for.

    My concern isn't that this person is too stupid to have health coverage - it's that the government, by FORCING this person to take health care, is taking away their freedom to choose a high-risk life style. It's not only stupid, it's against the fundamental principles of liberty (even if that word is tossed around more than...something that gets tossed around without significance...these days).

    3) Cost Pressure - Part of this is about consumer awareness, but a large part of it is, as you point out - physician awareness and investor awareness.

    But that aside, the fundamental reason health care costs are high in this country is because health technology is expensive. I understand that big pharma and the like are raking in billions. The reason that they do this - and must do this, is to bring in investor dollars. The first nuclear reactor cost a couple very little to build out of graphite blocks and uranium. The newest reactors costs 5-10 billion. They are better in every way than their predecessors. New stuff is expensive, and the only way to get that money together (concentrate it) is to demonstrate signficance for it. I have zero confidence in government led research, which means a massive private investment base for the development of new technologies (Not just medical, but that's the focus here).

    It's not a simple problem, and I understand that. This is exactly why I hate the "one size fits all" solutions proposed by the canditates running in the U.S. election this year. It's not a simple problem. Bulding a structure through which patient care can flow is more likely to be damaging that helpful (see your example of inertia).

    *shrug* 'Tis what 'tis.

  9. C,
    i am the wrong person to ask about this though some of my colleagues may have an idea. i think it is really incredible that i, a front-line doc, have no clue what kind of insurance is best for you. it kinda fits in with the theme of this post which is that our medical shell game is too complex and byzantine to understand... because, i believe, it makes no sense to begin with. good luck with your choices. a financial planner/advisor may be your best bet here.

    i couldn't agree with you more. i am going to bed after a bear of a night shift. will try to respond more later. absolutely spot on, but i don't have much hope that the kind of solution that you or i have in mind is politically viable. i fear the entitlement mentality is too fixed now. i fear that the best solution, the hardest solution up front, will never be chosen.

  10. Get some rest 911. Sorry your shift sucked.

  11. Here's the deal: I provide those services in the prehosptial environment. I have asked our billing people to tell ME what they cost. They will not. They will tell me, the one who is out there actually doing the billable hours service, treating patients, and then writing up the paperwork used to generate a bill, they will tell me only what OUR cost is. In other words, an amp of morphine (because we service the ghetto, we carry ampoules of morphine not prefilleds) wholesale is something like $2. That a full refill of an H-sized O2 tank is about $38 dollars. That a 1000 bag of NS is $2.80.

    But I am not supposd to know what it costs the patient. For instance, I know it costs a hell of a lot more than $10 in supplies for IV tubing, a needle, a bag, and 10 mg of morphine. I suspect it's on the order of several hundred dollars.

    They don't want us to know the costs because it might affect our provision of care. Meaning, if we get some shit bird who gets arrested and complains of "chest pain" concurrent with his arrest, we might not waste the money going through all the chest pain workup if we know it costs $800.

    People ask me all the time, "well, what is this going to cost me?" I have no idea. I should be able to provide a standard price list and say, "Our base charge is $750, plus $15 per loaded mile. If I put you on a 4-lead EKG, it becomes a higher level of service. So that adds $250, then if you need an IV or medications, it's an addition $38 for the veinipuncture, $25 in supplies, and $75 per medication per dose."

    You know how many fucking losers would simply refuse? A ton. They think its free. Nobody mentions cost. I had a patient with gout tell me he calls an ambulance beause he had no bus fare. Actualy quote, "I don't have any bus fare and my transfer ran out." I said, "You think this shit's free? A cab is a $15. This is going to cost you at least $500." He said me, "Motherfucker, I aint gonna pay you SHIT. I don't give a fuck what it costs cuz I just throw dem fucking bills in the trash. I aint got to pay you, or the hosptial. They can't deny me care."

    So on the receiving end, you get burdened with some loser who could have gone to urgent care. But because ambulances don't transport to urgent care (only ERs), he's now in your hospital.

    Personally, if I called an ambulance or went to the ER, I'd just make up some shit. Fake name, fake address, fake social. Self pay. I don't go to hospitals, and would never call an ambulance. I might work as a paramedic, but I can't afford the services.

  12. Oh good; we're all feeling pissy and rant-like. Guess my blog post today will fit right in.

  13. other anon & 911 doc,
    I wonder to what extent the billing department's unwillingness to disclose rates is out of fear of violating EMTALA or being convicted and hanged in the 5th Circuit Court of Public Opinion?

    Given that restriction of speech is based on the interperetation of it by the receiver, who wouldn't be hesitant to disclose pricing? It's almost certain that giving information to patients will be interpereted in both real court and PO court, as pressuring the patient?

    I love a world where knowledge is considered poison.

  14. This comment has been removed by a blog administrator.

  15. Interesting reading

    Scroll down for the votes.

  16. anon. i do not think the failure to disclose this info is based on EMTALA, i do think it is to obsfuscate the situation for the public and for doctors.

    i believe that there are people receive different bills and charges based on how much they can pay. in other words, i believe the well insured get raped and the uninusred pay nothing and those with no insurance but some money get taken to the cleaners.

    it's all a direct outgrowth of the unfunded mandate of EMTALA. EMTALA either needs to be funded or repealed. i go for repealed. political suicide i know, but it's criminal.

  17. 911Doc
    You are right about bills based on ability to pay, but not like you think. See

    I think your challenge just unmasks the hospital industry's desire to obfuscate the money flow, for whatever reason. I think the hospital industry realized a long time ago that the EMTALA / Medicare burden would thin out the hospital industry, as the state funded "indigent care county hospital system" was offloaded to all hospitals years ago.

    For a while, the hospital industry could extract a profit, even with the cost of the unfunded mandates, from insurance companies. Now, however, this is not the case, because costs have skyrocketed, insurance companies must show a profit, government regulation is much greater and compensation negotiations are much tougher. The only place left to cover the unfunded mandate is off the back of the guy who actually pays his high-deductable bill.

    So what does the individual payor do? He clamors for socialized medicine. He wants it all for nothing, just like his ultra-low copay coworker. Can you blame him?

    I foresee the day when hospitals, faced with the declining medicare reimbursement, forced mandated care and crushing administrative costs drop medicare entirely. Then, it all goes away (until the government try to retaliate through the legal system alleging collusion, or anti-trust, or rico, or something). And it is coming soon, when hospitals realize that medicare patients have to go somewhere.

    (As an aside, the private ER's in this area seem to be doing quite well. Kinda puts to rest the typical carpeted section argument that the ER always loses money thrown at ER groups when it is ER contract negotiation time)...


  18. actually igloodoc, this does not surprise me. the people that are hardest his ARE the ununsured, but they are the uninsured who actually have a job and some money. there is no point in collecting from people with no money, but if you have a twenty thousand dollar medical bill (that before EMTALA would have been about $7000 as a rough guess) and you have any assets then the hospital will try to collect. if you live in the projects and have 'no money' then there is no effort at collection. if you are insured, your copay skyrockets but the insurance company pays the inflated remainder. it's absolutely criminal.

  19. In all service industries, different levels of pay are required / requested for the exact same service rendered ALL THE TIME. This happens in law practice constantly. Of course you get the dollars from the people who can actually pay... this is not exactly a revelation. Your 'test' doesn't prove shit.

    The difference is in how the law deals with the different service industries. You are required to provide services with or without pay. I agree this is unique (and unfair). 'Proving' that a specific service costs different things to different people doesn't NEED proving. This is simply the fate of the service sector.

  20. dear karo,

    first, thanks for pointing out to me that medicine is a 'service sector' industry. i did not know that we are in the same category as casinos, hotels, resorts, law, and the local rub-and-tug whorehouse. now i feel better.

    but even if wall street considers medicine to be a service sector industry, we are not service sector in the following ways.

    to do what i do i need very expensive equipment, products, kits and the like. those most certainly have a definable and real cost. my training is, arguably, as quantifiable monetarily as, say, the training of a navy pilot.

    now let's consider law. there are a few hard costs... secretarial, library, westlaw and nexus fees and the like, and a lawyers training costs are extremely variable based on whether you go to harvard or the local night school. the costs are books and classroom space. no cadavers, no labs, no surgical gowns, scrub sinks, instruments etc... in fact, law schools are a scam, but i digress.

    my point is that even if i give you that medicine is a pure 'service industry' which i do not believe, then the difference is this.

    if i want to go to the local cat-house for a round-the-world and glazed-ham with two shemale bodybuilders (if you are one then i apologize), i CAN, in fact, know how much i am going to pay to get my hambone boiled before said boiling. sure, i might get charged more than the trucker who comes after me (pun intended), but i know what the damage will be.

    likewise, if i want to go to vegas, i may pay a different amount than the retiree arriving the next day to stay at the bellagio, but i will know what i will pay because they will tell me.

    this is decidedly not true in medicine. i, a humble 'service sector' worker, have no clue what i will bill for any patient on any day and neither do they have any clue what their bill will be. my point is that you can not, therefore, 'shop' medicine and make informed decisions.

    this makes for a 'legalized' wealth redistribution scheme from doctors, hostpitals, taxpayers, and insurance companies TO, as it turns out, people who haven't bothered to get insurance, can't afford it, are in the country illegally, or have chosen not to get it because they are 23 years old and have never been sick. medical insurance then becomes an afterthought as one can 'always go to the ER'.

    now, and without reading EMTALA, many people have discovered that the ER is, really, free, as is the ambulance ride, as is any surgery or procedure we are under legal obligation to provide, AS LONG AS they have no significant assets. a logical but real perversion of this is that the unisnured fat, forty female with gallstones can come to the ER twenty times for exacerbations ($3000 a pop or so) for free, but CAN'T get her operation until she has an infected gallbladder, which then qualifies her for "free" care as the first is NOT AN EMERGENCY but the second IS.

    it takes a specific personality to abuse this as you might imagine, as those that feel that they don't deserve 'something for nothing' do not make a habit of riding the ambulance in because it's cheaper than the bus or a cab, nor do they choose me as their primary caregive because 1. it's stupid and 2. i'm more expensive than the family practice guy or internist down the street. in fact, it is precisely these good citizens who often wait too long to see me for their chest pain because they are worried they won't be able to pay. reward bad behavior, punish good. great.

    the WORST burden, therefore, is carried by folks with a job and no insurance. folks who might just have bought their first house or car but have found, due to twenty years of reverse-market forces, that they really can't afford insurance AND a house or car. so, EMTALA punishes all of the above and has crushed the best medical system in the world for short term vote-buying and political power by the writers and signers of the law
    (AND in the name of 'fairness').

    in fact, it is tremendously unfair, and, if unchanged, will turn our 'best care for the most possible' system into a 'mediocre, rationed care for all' system.

    you may just love the fact that people who never plan on doing anything other than living welfare check to welfare check can get the same care as i can, but this will only be true for a short time and is not true outside of major cities right now.

    and finally, since you, apparently are a lawyer, and i, apparently a doctor, are both in the 'service sector', i might argue that you resemble a true 'service sector' worker (a prostitute to continue the above analogy) much more than i do, as a prostitute merely takes advantage of her gender and some profane language d'art to fleece the john (and you your law degree and some arcane language d'art).

    i and my colleagues, on the other hand, can save your life with a chest tube or an intubation or many other ways, based on unique and perishable skills that were learned, relearned, and perfected in concert with technology and science.

    in other words we need more doctors than lawyers, lawyers are much more fungible, and, our country would be in better shape if there were fewer of them.

    have a good day counselor, and sleep well... douchebag.

  21. 911:
    Why the tantrum you big baby? You have gone on a major league tangent from my point: The same service provided may have different costs based on ability to pay. Not that complicated. Well, at least for us lawyers.

    And medicine, whether you like it or not, is a SERVICE. Esp. for the providers (doctors). The doctor provides a service for a fee. Just like a hooker. Except instead of a blow job you end up with a finger up your ass.

    I have a test. Call up 10 law firms and request the price of litigating a murder trial. Guess what, genius! You may get different answers and not only that, you will probably have people tell you they have NO IDEA WHAT IT COSTS!! WOW! How amazing!!!

    Get a fucking clue "doctor".

  22. Ouch. Has Devorrah seen this?

    I called the closest hospital today and did not make it past the price of the EKG. All they wanted to know was why I was asking, since obviously there was no emergency and I was not on my way to the ER.(They did not say this, but it was heavily implied.)
    That was embarrassing and I am not calling again. :-)
    I totally flunked. Sorry.

  23. dear karo,

    you are a first class lawyer i can tell! (and after reading your comments i have no idea why people make jokes about lawyers).

    as you can see from the comment after yours, one can not even get past the hospital operator to get an answer which is, in fact, answerable, ie. how much does an ekg cost?

    an ekg, counselor, is an "electro-cardiogram". it is printed on a cheap piece of paper and the machine itself costs around $4000. it reads "electrical waves" sent out from the "human heart" as it goes through "systole and diastole", and it gives the evaluating physician an idea about whether the patient is having a "myocardial infarction" or "heart attack" or "the big one".

    were you to buy a machine and the paper and print one out you could guage the cost, but no one will tell you how much you will be charged for it because there a dirty secret behind the answer.

    let me get this straight "counselor"; if the hospital wants to charge you $3000 for a physician interpretation and $50 for the piece of paper then you say fine? if they want to charge you $100 for it then you say fine? and if they want to charge you to for someone else's ekg you say fine?

    i guess it does take an attorney's brain to feel good about this state of affairs.

    come to think of it though, you actually must be just a marginal attorney because your analogy about a murder trial does not hold.

    first of all, folks charged with murder they are provided with a public defender and that public defender is paid a set salary by the government. so, in this scenario, an accused murderer may ride on the taxpayer and get a defense that may or may not be good based on the quality of the public defender and his case load.

    alternatively, if one has means, then one may hire johnny cochrane (may he rest in peace). while johnny cochrane may not be able to tell you before the trial what the cost will be, he WILL most certainly tell you how much he gets an hour and you can therefore decide if you want to risk him running up three thousand hours on you.

    also, lawyers fees for standard things like wills, trusts, estates, and divorces ARE compare-able and ARE advertised in the yellow pages and online, ie 'no frills divorce' by j. humpadonkey esq. $1000.

    one can also go to legal zoom and do a lot of "legal things" yousrelf (but i know this is risky as law is so hard and only lawyers can understand it 'cuz of all the big words and writs and shit).

    legal adversising may be misleading, though it's hard to imagine an attorney speaking out of both sides of their mouth, but one may get an idea, and a fairly accurate one, of the cost.

    as it turns out this is true for medical procedures too! ones that fall outside of EMTALA. lasik, vasectomy reversals, boob jobs and the like. caveat emptor rules and these procedures are within most people's means if they plan for them.

    and just so you know, you have not yet seen a tantrum, counselor. i'm just getting started on you and folks like you who have the barely disguised arrogance of people educated far beyond their intelligence.

    you, liberals, and your lobby have killed the most noble profession in the land and have enabled a nearly communistic wealth redistribution under the guise of feel-good liberalism. as with all such plans the results are now being recognized as disastrous.

    but the real reason for my pique, you small brained wiper of other people's bottoms, is that 7 years into my career i find the walls of medicine crumbling around me. i am unable to give the best care to all of my patients because i can't find a specialist to take them from me in a timely fashion, and time, with say, an "intracranial bleed" is of the essence. that means life and death, "counselor".

    on a typical ten hour shift, "counselor", i spend three on the phone begging and pleading. it's your fucking fault... you and freaking entitled douchebags like you.

    whilst jealously protecting your own asses, money, and interests by killing tort reform and the like with the most powerful lobby in washington we "service industry doctors" are finally getting what we deserve eh?

    you have no fucking clue what we do and no respect for it either, but i know that if you came into my ER with an injury or an ill family member you would be the loudest complainer and most demanding patient (and i would give you the best care possible in spite of it).

    counselor, if this is your case you lose by summary judgement and are instructed to repeat L1. fucking douchebag.

  24. "j. humpadonkey esq"

    If I were drinking I would have spewed it all over my screen.

    Doc, you rock.

  25. 911

    I have nothing to add to your eloquent rant... If you, or someone you love, has been injured in an accident, call the law firm of j. humpadonkey, esq.


  26. 911,

    Rest that pimp hand.

    I really had to smile today, especially in light of your (oh, sorry, MYSTERIOUS DR.X's) post. In our outpatient drawing room, just a stone's throw from the ER, there sits a cash register. You heard me right. Want a CMP? Well paying customer, just check the chart on the wall for convenient pricing. I don't remember the specifics, but a CMP is in the neighborhood of $33. CBCs for $25. We take cash. You guys should drop one in the ER.

    I get the feeling that the lab's attached to the hospital only for the sake of proximity and maybe alacrity. Reminds me of a damn factory. In any case, this was about the only example of fairly transparent pricing that I could find in the hosp., short of those "healthy heart" screening tests that really shouldn't count here.
    Now I don't know how this works exactly, or even if it's all that relevant, but I can't be a douche's a link!
    "ATKINS (DIET) PANEL"- SPECIAL!! This Panel saves you another $82!!!"

    Do they have lawyers in Russia?

  27. I posted two long comments--are they still in line, or lost?

  28. "Karo":
    You got served, B!

  29. If you pay cash at the clinic I practice at an EKG is $75, Lipid Panel $55, not sure about the other common tests as the writing on the menu is a little faded. Quite a few immigrants pay cash here, good people.
    Karo, is it a coincidence you chose the name of an antidiarrheal as your alias? I paid $300/hr plus expenses for my little legal trouble in $10,000 deposits paid in advance. Money well spent, if I'd relied on my public defender I'd still be in jail.

  30. A friend, age 59, recently got a hip replaced in northern Arkansas. She's very healthy except for the damage from arthritis. She told the docs and hospital up front that she'd be paying cash and they gave her the prices -- total of either $1800 or $18,000, I don't remember now. She asked them after all was finished what would have been the price if she'd had Blue Cross/Blue Shield. The answer was $55,000. She was furious. She believed the hospitals and doctors were ripping off insurance companies, and wrote to her congress critter. Doctors and hospitals would do well to publicize specifically why charges vary because people just don't know.

  31. For the life of me, I don’t understand how anyone felt EMTALA wouldn’t do anything but bankrupt medicine. Our insurance premiums have risen while our benefits have lowered. I realize I’m paying for the illegals and anyone else who can’t or won’t pay their fair share. You can’t run something at a financial deficit and expect the system to remain viable. And you certainly can’t expect those of us who pay huge insurance premiums to support the entire system. Hello, we’re being bled dry.

    I look at it this way; I’m a writer and get paid royalties for the sales of my book. How would I feel if my publisher told me that my royalty checks were going to be forcibly halved so they could give that money to those who can’t afford to buy my book. Bullshit, is what I’d say. If they want my book, they’ll have to get a job and earn the money just like everyone else. And what would happen if my publisher continued to rape my royalty checks? I’d go to another publisher or quit writing.

    Karo said:
    And medicine, whether you like it or not, is a SERVICE. Esp. for the providers (doctors). The doctor provides a service for a fee. Just like a hooker. Except instead of a blow job you end up with a finger up your ass.

    Service industry my little dimpled butt. I’m not sure what docs are, but they ain’t in the service industry. People in the service industry get paid for their services, and no one holds a gun to their head to provide their service. You want legal advice or a hamburger, you pay the lawyer or McDonald’s up front. Folks may call up ten different lawyers and get ten different quotes on the costs of a defense, but lawyers ALWAYS get paid. Docs are forced to treat anyone and everyone regardless of the patient’s ability to pay.

  32. Devorrah says: Okay, break it up you two. Neither lawyers nor doctors are strictly service providers, and neither is uniformly stupid or greedy, though lawyers are much closer. Consider Morris Dees, my hero, of the Southern Povery Law Center, who won a judgment against the KKK, and, ummm, okay, never mind. It should be obvious, though, that MDs endure many more years of education, training and brutal sleep deprivation than lawyers.
    Both professions deliver some "services" that seem relatively simple and uncomplicated and for which a fee might easily be estimated in advance, i.e. an uncontested divorce or treating a boil. The reason people seek out professionals (that's us, gentlemen, yes I am a member of the California bar) is because complications can ensue which can endanger a patient's health or financial well-being. What if the husband is hiding assets or the boil is actually MRSA, then you're glad you have a doctor or a lawyer on hand.
    The difference, of course, is that you are unlikely to DIE or suffer permanent or even transient physical pain, disfigurement or injury if an attorney is not on his or her game. Even the foulest child rapist has multiple levels of appeal/recourse before the switch is thrown (except in Texas, of course). Yes, there is malpractice, but how often do doctors NOT want their patients to have the best treatment possible. In cases of extreme negligence or obvious misfeasance, malpractice is appropriate, but a human, humane standard should be applied to medical practice, not an insanely unrealistic, superhuman one.
    The problem isn't just the attorneys who bring the suits, it's the legislatures that allow it, but it's mostly the bizarre culture of entitlement that has somehow crept into our society and killed any sense of personal responsibiility. I see this in my kindergartene very day, the parents who never send a snack because they know I'll feed their kid rather than see him or her go hungry. Well, today I ran out, and they went hungry. Maybe their parents will finally get the message after 8 mos., but I doubt it. They'll just be mad at me for not shopping.
    In conclusion, we routinely trust doctors with the things most precious to us--our loved ones and our health, and let's face it, most people wouldn't want an attorney to even come near their loved ones. I hope you never have to watch as doctors frantically try to save your gruesomely injured child--I have, and rather recently. How often do you hear a client say to his doctor what I said to my son's doctor, i.e. "If you ever need a kidney, call me." I know whose side I'm on here.

  33. ruby,
    you are not a douche or a douchebag. what you describe is what we could have and IF we had such an a la carte system where everyone was informed about pricing and made their own decisions and, with informed consetn, were allowed to assume some rish, then the current crisis would vanish and we would be back to physicians WANTING calls from the ER because the call would mean income in the form of a patient who would pay for their services or at least TRY TO PAY.

    also, just like life prior to EMTALA, large charity hospitals would flourish and provide state of the art care for all, though certainly with less frills and probably not quite as quickly as the private sector ones.

    it amazes me that people want the government to 'fix' health care. every large governmental beaurocracy has the same flavor of mediocrity, whether you are talking about the DMV or the post office or the paper-jockey portion of the armed services (i am specifically excluding our fine warriors who are without equal in teh world, but they are motivateed by a similar desire for excellence that used to pervade the medical community).

    i don't know how they do it, or why, but have you ever seen a postal employee speed up when the line is out the door? have you ever seen one forego their coffee break when the line is out the door? me neither.

    anonymous' example of the aunt who payed cash (almost certainly $18,000 for a hip replacement, is classic and the woman herself a saint. she is wrong in only one respect i think. unless the doctor did his own billing, which does happen (but is rare as it is so byzantine and nonsensical) that billing firms usually do this, then the collections and billing aspect is on auto pilot just as i have said, and insurance companies take it in the shorts to keep the hospital afloat due to EMTALA. the game is to shuffle piles of money around to pay for the free care mandated by EMTALA and to stick the next poor sap with the bill. why this is surprising or mysterious to anyone is surprising and mysterious to me.

    honestly, i have NO FREAKING IDEA how much my bill to my patients will be. it is embarrassing to answer, "i have no idea" when the occasional conscientious patient asks me, but the answer is not knowable.

    so here's an idea for you attorneys out there. if, in fact, there is such a lack or transparency in medical billing anc collections due to EMTALA could it amount to a "qui tam" cause of action against billing companies, hospitals, and the government? is this a viable option to rescue health care?

    someone needs to shoot the damned thing dead or people will be dying in the streets and soon.

    this is not hyperbole, rural communities have lost the capability to do trauma surgery because...

    1. standard of care concerns... being held to the standard of the mecca which is reachable by air ambulance. trauma surgeons therefore do not practice in rural settings and move to the big cities where they won't be on call every night.

    2. there's no money in it anymore... used to be covered by auto insurance but no more... used to be trauma centers saved the rest of the hospital but no more.

    3. 'only guy in town' issue. if you are the only trauma guy in town you will never sleep, and, unless your hospital is a 'trauma center' you may not be able to get the OR up and running in time to save the patient.

    4. mecca on 'divert'. even the meccas are full, not at the front door with their ability to get someone into the OR, but at the exit because they can't get patient's discharged to rehab because, drum roll please, according to EMTALA rehab is not an emergengy, so, post-operative trauma patients who do not need a surgical bed in the hospital stay there anyway while their rehab is done, gratis, at the trauma center, blocking the ability of the mecca to take care of the next multi-trauma or GSW.

    the answer is easy. the fear-factor and race card will prevent it's implementation and doctors, insurance companies, hospitals, attorneys, and medicaire/medicaid will continue to be the only entities talked about in the debate. the one key piece that will always be OUT of the debate is the patient, and that patient's responsibility to themselves and to their fellow citizen's to haul some of their own baggage.