Let’s say that you go to the ED with a complaint that could be an infection. The team is going to evaluate you to see if you meet sepsis criteria. I posted about that back in August right here on this blog. If the patient meets sepsis criteria, the nurse will enter a standardized set of orders for tests. Those tests include tests for lactic acid, a CBC, CMP, and if appropriate, COVID/Flu tests, urinalysis, and other tests. If the patient has a lactic acid level of 2.0 or more, they are going to get IV fluids. Lots of them, like 30mL per kilogram of body weight. If you weigh 100kg, that means 3 liters of fluid. The lactic acid level will be checked and rechecked until the level is below 2.0.
So think about this when you consider the cost:
- The triage nurse and their team briefly evaluates you and assigns you to the appropriate nurse.
- You then become one of the 3 or 4 patients that nurse is caring for. You get a full evaluation, including an EKG, an IV line, along with blood and urine tests. This nurse has years of education and years or even decades more experience.
- The lab team then runs the tests, the X-ray team shoots your pictures, a radiologist reviews them and sends the results to your nurse.
- The ED physician evaluates all of that information and, in cooperation with your nurse comes up with the treatment plan. Then he orders the medications.
- The pharmacy reviews the patient’s previous medications, condition, and the ordered medication to ensure that this is a safe course of medicine, then releases it.
- The nurse then triple checks everything and gives the medicine.
In all, a visit to the ED involves no fewer than 12 specially trained medical personnel, who perform tests and treatment across no fewer than 9 different specialties. Each of those people is college educated from a 2 year degree to full on doctors. Most of them have a decade or more of experience. That doesn’t count all of the other people involved from the hospital’s chief nursing officer, the administrative people, janitors, security, and others involved in running a large business.
Now consider that Americans demand flawless health care on a 24/7 schedule, and want to be seen and leaving the hospital in less than 3 hours. Sometimes, we actually meet that deadline. Most of the time, we come close, but there are too many patients there for too many silly complaints. I had a patient this week who came in for constipation and was demanding to know why we were so understaffed that he had to wait an hour and a half to see the doctor.
So if you want to know why it costs $10k for an ED visit, that’s why. The old saying is that all businesses offer one of three services:
- Good
- Fast
- Cheap
You can only get two- if it is cheap and fast, it won’t be good. If it is good and cheap, it won’t be fast. If it is good and fast, it won’t be cheap.
We as a nation demand good and fast. That means it won’t be cheap. On top of it, the patients want to be pampered like they are in a day spa. My patients are frequently more concerned with what I am going to feed them than they are in the quality of their care. They expect to be cured in an hour for a problem that has been years in the making: you are a long term smoker, a diabetic, are 100 pounds overweight, and have high blood pressure, then expect to come in and be cured of your shortness of breath in an hour so you can make it to half priced wing and beer night at your local watering hole. Then you blame the health care personnel when it takes too long.
Another of my patients came in and the first thing he said to me is that he wanted a sandwich followed by a cup of coffee brought to him every hour. I told him that I was holding him without anything by mouth at least until we were done evaluating him, so he demanded to see my boss. When the boss told him the same thing, he told us that we were inhumane for denying him food, then stormed out.
That’s my rant.
14 Comments
Boneman · February 27, 2024 at 5:58 am
Yeah, it’s crazy. The other side of the coin is when this Patient begins to lose his patience. My Dr. ordered bloodwork STAT. I scamper over to the lab EARLY next AM had EIGHT tubes drawn.
RESULTS POSTED on 15 February. I have seen them in the portal and they point to some serious issues. I also see that the ordering physician has NOT seen them. I lit up his “inbox” yesterday AM about it.
Crickets.
I’m pondering what two-thirds of the triumvirate of quality I’m experiencing here. I’m thinking good and cheap cuz it sure ain’t fast.
What I AM sure of… is it’s FRUSTRATING.
Today’s phone call to the office WILL be obstreperous.
I do however very much appreciate all of the behind the scenes activity. My recen inpatient stay post op reminded me of all of the underpinnings and support staff that really run the show. Thanks for posting up the DATA… for without it all we would have would be an opinion. To paraphrase W. Edwards Deming. 🙂
Divemedic · February 28, 2024 at 7:47 am
I didn’t say that every single person who is in the health care biz is good at what they do. Some are good, while others are not. If you don’t think that your doctor is doing a good job, you can choose another. That’s an advantage between government health care and market based care that people don’t always think about.
Elrod · February 27, 2024 at 10:13 am
Americans, and I assume nearly all humans on the planet, routinely forget that “services” constitutes a partnership: customer/employee, patient/provider, passenger/airline, etc. “I’m paying you so I want this, that and the other thing, RIGHT NOW” seems to be the default setting.
When one takes an automobile in for service one does not simply park it in the service lane and leave, expecting it to be repaired perfectly by the time the owner returns from the coffee shop across the street.
By the same token, unless they’re unconscious or otherwise incapacitated, arriving at a medical facility places some amount of burden on the prospective patient to provide useful, and sometimes very necessary information to the providers to assist them in providing quality treatment, and cooperate as much as is reasonably possible; in both the auto and medical instances, the customer’s or patient’s job is to help them help you. Tell the mechanic what the symptom is, what measures you have taken to alleviate them, what other mechanics have tried (if applicable); tell the triage nurse/care nurse/doctor what the symptoms are, what meds you’re on, what previous treatments you have received, and from whom.
That’s not rocket surgery. People – at least American people – are now born clutching a smartphone so put your medical info on the fucking phone and keep it updated, add contact info for whatever medical professionals you’ve been seeing because, sometimes, a phone call to your cardiologist or allergist or oncologist can save hours, maybe days, maybe even be what keeps you functional and/or alive. If you don’t have, or trust, a smartphone, put it on a thumb drive, an SD card, or print a copy. .
Way back in my motorcycle road racing days we used a Magic Marker to write name and blood type on our stomachs and thighs because it might come in handy to whomever was trying to keep us alive should the worst happen. Technology has progressed well beyond that so use it and use it to best effect. It’s your ass on the line, it’s your job to help protect it. Life is not a spectator sport.
Grumpy51 · February 27, 2024 at 11:12 am
Considering that, nationwide, only ~ 5% of Emergency Department “visit” (man I HATE that term, you ain’t “visiting”, you’re being professionally evaluated by several professionals, see DM’s post) are truly emergent (care NOW or you die). Over 80% are classified as non-emergent/urgent (think clinic), so….. do you demand coffee and sandwiches from your family doctor?? Didn’t think so.
The easy, simple solution is (not rocket-science here) – we’ll do the MSE (medical screening exam) to make sure no immediate emergency. After that, pay $20 before ANYTHING else gets done.
Let’s see, that’ll slow down (not stop, humans are too stupid) the 2AM ED complaint of “I just want to get a pregnancy test” (or COVID/Flu/virus d’jour test). Might even slow down the “I’ve had back/leg/shoulder (your choice) pain for the past several years”
And when you wonder why your health-care team is jaded, it’s because I’ve spent the last 40+ years of seeing more and more stoopid people who demand more and more, “Press-Ganey don’cha know”. And don’t even get me started on admin who supports such stupidity. Any wonder why the experienced professionals are leaving in droves??
I never planned on retiring. Always considered their experience and knowledge I’d gained over the years were to benefit humanity. Now?? 2-3 years more, and I’m just done…..
Divemedic · February 27, 2024 at 12:02 pm
That’s because insurance never was intended to, and can’t work, if it pays for every little thing you want done. Imagine if car insurance covered fuel, routine maintenance, and even tires. How much would it cost?
So now compare that with health insurance. It’s gotten so expensive because the person who is choosing the service is not the same person that is paying for the service. People go to the ED, which is the most expensive health care that there is, and demand everything because they are not the ones paying for it.
Money, cost, is no object when you aren’t the one that has to pay the bill.
Return health insurance to what it used to be- a way to cover for major expenses like surgery or cancer, and let people pay out of pocket for routine stuff. Then market forces will bring prices down- “What do you mean that it’s going to cost $5,000 for an MRI? Never mind, I don’t need that.”
In the past week, I have seen two patients with toothaches, a woman and her boyfriend who wanted to be tested for every STD because it burned when he peed. We tested them for syphilis and chlamydia. When we explained that the ED doesn’t test for HIV or Herpes, they stormed out.
A drug user came in because he took a pill that he called “flake” and said it didn’t feel like the other times he had taken it, so wanted to be checked out. He flat out told the nurse caring for him that he was a drug dealer, and the two black males with him were his “posse.” When he had been there for an hour, he got angry and left.
The list goes on and on…
D · February 27, 2024 at 11:16 am
Well…there is another part to that. Insurance fucked everything up. My numbers may be off a bit as I haven’t checked into prices lately, but you’ll get the gist of the problem.
I witnessed it in the dental industry. Before the 2007/2008 recession, almost no dental offices were in bed with insurance companies. They had public pricing that (for example) might list a root canal at $500.
Then the economic downturn happened, and insurance companies made their grab. The insurance company for the largest employer in the city said “We insure XYZ corp. You need to be ‘in network’ with us. If you don’t, we’ll be sending *all* our employees to your competitor who will be in network with us by the end of the month.”
Dentists were desperate for money, so they signed up….and the insurance companies said “I see you’re charging $500, since you’re “in network”, we’re going to cut that by 15%, so now you’re going to bill us $425 for a root canal”. (And the patient is going to be responsible for $25-$50).
The dentists all screamed “that doesn’t cover the costs of labor, we’re going to go out of business”.
Those that survived, jacked their rates every year while the insurance companies jacked their cuts. Eventually root canals cost ~$1,500, insurance companies got billed a much smaller amount which covered time and materials, and the patient’s co-pay ended up being a little bit of profit for the office.
Now most insurance plans don’t pay crap until you pay some obscene number out-of-pocket (like $6k)…so patients are paying the inflated costs *and* the cost of having insurance, and dentists are making a significant profit–especially on patients without insurance because it’s illegal for them to bill a lower cost to uninsured patients. Something allegedly in the law where you have to publish your lowest price and that’s what insurance gets to negotiate from.
Joe · February 27, 2024 at 11:25 am
$5000 at the WFMC (World Famous Mayo Clinic)? That’s freaking cheap. My daughters ED visit at the mother ship for broken finger (yeah Rochester doesn’t have a doc in the box anywhere, imagine that) was about that for her to be turfed off to the ortho residents . (which is an ok result)
SoCoRuss · February 27, 2024 at 1:48 pm
I agree somewhat with your info on US medical care. But I have seen personally that you can get all three levels of care sometimes. My wife and I like to go to Aruba and Bonair for vacations. They are Dutch islands. Out of the 5-6 times we went there we got sick twice, food poisoning or some such crud. The first time we tried for several hours to contact our insurance company, TRICARE ( that’s the coverage for military and retirees) to find out procedure for med care. Finally said fuck it and went to ED on Aruba. Went in and saw there were appox 10 persons already there and though oh god it will be hours. Nope 25 minutes and we were taken into a room. In walks a guy in sandals, shorts and Hawaii shirt. Thought it was someone coming in by mistake. Nope, it was the doctor, he ran tests figured out what was wrong, gave us scripts for meds and a couple suggestions for great snorkel sites. We went to hospital pharmacy and were done and gone total time 1.25hrs. The bill for us was $210 USD each. All levels of our care there was excellent and met all 3 levels given above. We then spent 6 months fighting American insurance coverage to get a partial reimbursement because you are supposed to know you will be getting sick or hurt BEFORE you leave for the trip and get the medical care approved before time, it wasn’t worth the time on the phone. So a couple trips later I got sick that time, just went back to ED got treated and paid appox same amt for me and again got excellent treatment. So I just said fuck it paid in cash. I know the dutch have a national healthcare system that is taxed, but my point is it is possible to get good healthcare if you really want it. I have traveled the world in my military and civilian life and I never got better care anywhere than that island.
BUT, I don’t believe our current American healthcare or banking or any other fucking system that supposed to be a “FOR the People” system as setup today can ever be fixed with the country we have today that’s ruled by fucking corporations. Until the whole fucking system totally crashes and burns then the bastards that caused this are hung in the public square to make a point, nothing will change, NOTHING….
Divemedic · February 27, 2024 at 8:08 pm
I would point out to you that you probably didn’t get great care. Let me explain:
Whatever your medical problem was, could have been one of several things. The way to control costs and time of treatment is to treat the most likely cause, and ignore the less likely.
For example, if you go to the hospital complaining of a fast heartbeat, the easiest, cheapest, and fastest way to treat this is to give you a liter of IV fluid and a couple of doses of adenosine. That will fix most of the people who have it. This way takes an hour and will be successful the majority of the time and at minimal cost. The downside is that this way will occasionally miss a patient who is in real distress, and they will die. But hey, for most of them it was cheap and fast.
The most complete way to treat it is to add blood tests, chest x-ray, a 12 lead EKG, and three Troponin levels drawn from your blood over a three hour period. There will also be tests for infection, pulmonary embolism, and a list of other potential problems.
The second way takes more than four hours and will be correct all of the time, but it will be slower and more expensive.
We here in the US could be just as cheap and fast if the American public would tolerate their medical industry playing the odds, but here in the US, Americans want their care to be perfect, and that standard is enforced by ambulance chasing medical malpractice lawyers, who are the reason why I carry a million dollars in professional liability insurance. In countries with government healthcare, the employees are protected by qualified immunity and their biggest motivator is to be under budget. Which direction do you think they choose to go?
So yeah, you may have been able to get out of there quickly and cheaply, but what if you had not been one of the majority and had lost that particular gamble?
b · February 27, 2024 at 2:10 pm
I’d buy your explanation (and really, I do) but according to what we are told every one of those “specialists” are paid a pittance. Does it really add up to $10K an hour?
At the end of it all, make no mistake, I want the best care when I truly need Emergency Services. (I’m one of those where it it ain’t spurting or unstoppable bleeding, it’ll wait until the clinic opens, so I may be atypical here). Very few times do people really need “emergency” care. But since the courts and government have mandated that
emergencies” cannot be turned away, many people who can’t afford , (generally) due to lifestyle choices, a clinic, now go to the emergency rooms. How much of my bill goes to pay for their care?
Aesop · February 27, 2024 at 6:57 pm
“That’s my rant.”
And that’s why I had “DLTDHYITAOYWO” in block letters on the front of my hospital ID badge for years, until a sharp-eyed and savvy house supervisor saw it, knew what it stood for, and made me remove it.
Pt: “Why, if you don’t do ___________, Right Now, I’ll LEAVE!”
Me, with 100+ people in the ER waiting room and all the ER beds already filled:
“Don’t let the door hit you in the ass on your way out!”
Walk in entitled, earn my contempt. 0 to Go To Hell in 0.6 seconds.
@Grumpy: My cut-off is $50, cash, on the table, before we’ll see you. For every swinging Richard that walks in, including illegals and homeless. If it’s a bona fide emergency, on-the-spot refund. If it’s even just serious, but non-emergent, money back. But if it’s the 90% bullshit (which we know is nearly everything by how sharply the census drops on a rainy night), it’s forfeit on the spot, forever. The hospital would either cut visits for b.s. by 50% overnight, or issue across-the-board 20% pay raises on the proceeds from that plan. Revoke EMTALA, and we could institute it tomorrow.
@b,
1) Those specialists all have to be paid to be there when you need them. They don’t drop out of a hook on a vending machine for anybody’s specific case.
2) All the equipment they need to do their jobs, from band-aids to CT scanners, has to be there too, 24/7/365, just for a hospital to hang out its shingle. Anyone who doesn’t want first-world care is welcome to try their hand at ditch medicine, without darkening our doorstep, with my sincere compliments. {cf. the standard commentary about a person who defends himself in court, and triple it for medical care}.
3) A standard capsule of regular-strength Tylenol retails for about 12.5¢.
Plus the cost for the nurse who’s triple-checked it before giving it to you. Plus the pharmacist who checked your medical history and the order, and the pharm tech who dispensed it, before we get back to the doctor who wrote it, the lab techs and specialists who ran and interpreted your tests, and the clerks who made sure who you are and what prior records for you were on file. Then the building itself, utilities for it, staff to maintain it, and the insurance for all of them to keep it open every time some asshole thinks a minor error should be paid out like a Powerball Lotto win. As already noted, that packs on an awful lot of overhead.
But yes, you pay full boat plus, because your insurance is paying for the 20 other uninsured/indigent/homeless cheapskates, welshers, and various wastes of skin and oxygen who’ll never see a bill (nowhere to send it anyway) and wouldn’t pay dime one even if they did, with zero consequence.
Have a chat with 50 governors, 100 senators, 435 congressweasels, and 12 presidents since Eisenhower about why there are 40M illegal aliens and 50M homeless crazy drunken dope addicts soaking up free healthcare in this country like a sponge.
Then we can talk about why all the beds in the hospital are full, and why you had to wait in the lobby with your stroke or heart attack for half an hour just to be seen.
And then we can consider how long McDonald’s or Burger King (or any other business in the entire effing country) would stay open if the Congress mandated (but didn’t fund) that everyone who walks in the door must be given a combo meal, whether they could pay or not.
Related: Anyone, see if you can guess why Kaiser closed ERs forever in 95% of their facilities the year after EMTALA was passed, and of the ones they still have, why most are now located in industrial areas with little to no foot traffic, and minimally lit with bare minimum signage.
This isn’t a hard problem at all.
Start making people pay to play, or refer the ones that cannot to government-run facilities that would be to customer service and quality assurance what the DMV and post office are.
Just like transportation: People who can pay for BMW care get it. People who can buy a Ford or Chevy get that. Everyone else gets a used Kia, a rusted Corrolla, or rides the bus.
Dirty Dingus McGee · February 27, 2024 at 7:25 pm
In May 2021 I had an area on my upper thigh that was swollen and not going away. Finally went to an Urgent Care. They took one look and sent me to the ER at the hospital down the street, part of the same group. 9 am on a Wednesday morning, Short wait, in to get looked at, blood sample taken. Less than 30 minutes in comes a nurse with a needle. Whats that for? Your diabetes. What diabetes? My blood sugar was over 500. Behind the nurse came a doctor with a surgical tray. Whats that for? Need to get a drain in that RIGHT NOW. White blood cell count was over 23K IIRC. I was admitted right then. By 4pm the next day I had surgery on the area, an infection that had gone sepsis. Over the next week, I was discharged the following Wednesday night, I had up to 4 IV’s running, vitals taked every 2-3 hours. After I was discharged I had to follow up with wound care as they wanted the opening to heal from the inside out. First 2 1/2 weeks wearing a wound vac and visits every other day, next 4 weeks visits every third day with me changing the dressing in between visits.
The first bill I received from the hospital was for just under $95K. The wound care visits were $150 each and the wound vac was $500 for “rent”. Once all the bills were added together it came to just over $145K. My insurance covered around $100K. Was it worth it? Well, I’m still processing oxygen so yes.And it could have been worse. According to the surgeon if I had waited for another week, at minimum I would have been in ICU. I can only imagine what THAT bill would have come to.
Stealth Spaniel · February 27, 2024 at 11:43 pm
My mom’s standard reply, when she was in ER, to jackasses showing up moaning and groaning and wanting a Priest for Last Rites BUT they also wanted a hamburger with all the fixings……She would look them straight into the face and say, “Hungry already?? Wow! We do perform God’s work here. And quickly!!” Then she would bustle on to the next bed. No one got their hamburger.
Tree Mike · February 28, 2024 at 2:02 pm
Pretty frickin’ expensive sammich shop, for no sammich. No wonder he stormed off. SHEEEESH!
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