Proud members of the Vast Right Wing Conspiracy. We strongly believe in personal freedom, responsibility, and gun rights. We also believe in the 90/10 theory. That means that 10% of the people have 90% of the talent. Unfortunately, we are not in the 10% category. However, the rest of us are still better than 90% of the politicians.

Monday, April 25, 2011

A Tale of Modern Healthcare, or why does this cost so much?

Daddy Bear made me think with a post he put up a few days ago about fixing health care and I just had to add my .02.

Listen, y'all, this is a true story. Names have been omitted to protect the worthless.

One morning I went in to round and found a new admit on my list, a patient who had been cured of his cancer 5 or 6 years earlier.

Apparently he woke up on a Sunday evening feeling constipated. Rather than doing the obvious and just buying a laxative somewhere, he had his girlfriend drive him to the Emergency Room.* On arrival at the ED he was told they were very busy and it would be 8 hours or so before he could be seen.**

Finding the idea of waiting his turn perturbing, and being under the mistaken impression that people who arrive by ambulance are treated first***, he had his girlfriend drive him home and called an ambulance.

Now, the ED at the hospital was truly so busy that they were on diversion.**** That being the case, he was taken to the Brand X hospital across town. He was treated for the constipation, but because he told them he was a cancer patient and was unable to give them more information, having apparently forgotten that he was cured years before, they wanted to do an abdominal CT to make sure it wasn't due to something more serious than a diet of macaroni and cheese. He refused, because they weren't his doctors. If that had to be done it should be by his doctors. So, at 3 am, he having already pooped several times, they called to arrange a transfer to the hospital he had originally walked into 13 hours before, my beloved workplace. He was accepted by the fellow and loaded into another ambulance for the trip across town. Thus he was in bed on our service when I arrived at work.

When asked why he didn't just buy a laxative he responded, "I didn't have a slot***** on my Medicaid and would have had to pay for it. The hospital is free and has cable."

Having the accepted him for transfer due to worry about possibly recurrent disease, and liking things like eating and sleeping under a roof making my licenses precious, the prudent thing for me to do was order the scan, even though he had had clear scans 3 months prior to this admission. Once the CT was done, and he was shown to still be disease free, I discharged him.

An episode of plain old constipation generated 2 ambulance trips, and Emergency Dept. visit and a hospital admission. So his disinclination to spend $3.00 at the store for something he could get for free on his Medicaid cost the taxpayers something above $3,000.00.

This is why I think that there should be a $5.00 co-pay for ambulance trips and Emergency Dept. use for people provided with health care bey the government. He would have spent the $3.00 rather than $5.00 and this entire saga would have been avoided. And this is by no means an unusual tale. $5.00 is not beyond the means of the truly ill poor, but won't be spent by those who are like this man.

In the San Francisco paper a few years ago I read an article about a homeless man who had made more than 1200 trips to the ED in 5 years. When he wanted to get warm, or a meal, or needed a bed when the shelter was full (what we refer to a 3 hots and a cot) he just went to the ED. He even admitted to the reporter that if the ED looked too busy and he though he would have a long wait he would call an ambulance from the park across the street and claim chest pain in order to be treated faster. This is not only incredibly expensive, it's dangerous to the truly ill who are pushed back due to the urgency of treating a suspected heart attack. Abuse of the Emergency Medical System, (EMS and EDs) should be subject to a fine and/or jail time, just like abuse of 911.

*Yes, lots of people think that way, he's really not at all unusual.
**They prioritize by how sick the patients are and plain old constipation is pretty far down the list for an ED.
***They still prioritize by sickest, it's just that most people who need an ambulance are sick.
****Not accepting any ambulance traffic but still having triaging and treating walk-ins.
*****Medicaid in AR pays for 6 prescriptions a month.


  1. A few years ago I worked at an orthopedic offive in Kentucky. They had a lot of the same problems, if the doctor saw patients in the ER then they had to be seen in the office for their followups.

    Kentucky had just gone to a $2 copay for office visits for Medicaid patients. It was hard to believe the amount of complaints that we received, people claiming they didn't have the $2, it was ridiculous, and then smoking a few dollars worth of cigarettes in the parking lot and talking on their cellphones while waiting to go back and get their almost-free drugs.

    We were very, very close to refusing to accept any new Medicaid patients anyway since the pay structure was so low--I remember that an MRI (I don't remember of what part) cost $3,000 for a cash patient, it was $1800 for Anthem and $300 for Medicaid. I( always thought it would help things if they passed a law saying all payment methods were required to pay the same amount for the same service, but what do I know.

  2. I wish that we could just reform our entitlements, but I think that the political will isn't there for a soft landing - there's going to have to be buildings burning and looting in the streets before we fix the system.

    Too bad.

    This used to be a pretty decent country at one point.

  3. Even here in "socialist" sweden, doctors appointments have a co-pay(ER co-pay is about $23, or at least that's what I payed last time I came in, for some stitches, and I used a taxi to get there). You don't need to pay on-site, the bill arrives in the mail.

  4. I agree much of the frivolous use comes from the patient end, but I'm seeing more and more from the provider end.

    There's a hospital in my area that doesn't do OB, and for whatever reason, ambulances seem to automatically take any pregnant woman with a preposterous complaint there, first. So then they put them on an ambulance and send them to me.

    Now, I know (believe me, I know) that liability in OB is insane. But we're talking pregnant women with a hangnail, an earache, fungal dermatitis... stuff that could be adequately treated by the guy behind the counter at the drug store. Yet these people - ER physicians - are sending them across the city for $1000 because they're too afraid to practice basic common sense if the patient is a pregnant woman.

    The patients are bad, but we're not much better.

    Even in the story above, dude ordered a CT scan he knew was unnecessary. And I can't help thinking his $3K estimate for unnecessary care would have been a bit higher if he'd included the CT.

    Carmel IN

  5. This story is all too familiar. I work in EMS and I have a man that I have transported to the hospital over 100 times in the past year. There are two other shifts in my station that have done the same.

  6. This is why I think that there should be a $5.00 co-pay for ambulance trips and Emergency Dept. use for people provided with health care bey the government.

    Nice thought, but you'll never see that under EMTALA. We thought of it too, when I was a resident, and it was instantly shot down.

    (Being a small facility, the hospital eventually worked out protocols for certain "frequent flyers" in an effort to contain costs.)

  7. Make it a $5 copay for allED or ambulance trips, and implement a post-visit review process. If the ED visit or ambulance ride was found to be unnecessary, tag on a $50 charge.

    And if they get get other assistance from the state - welfare, food stamps, etc - just electronically deduct that $50 straight out of their other benefits.

    Ambulance Driver

  8. Can we just make it policy that if you're there for frivolous reasons, you automatically get a foley one size too large, regardless of if you need one?

  9. @Cybrludite Why stop at one size too large, make them play for their frivolity, the more frivolous, the larger the foley!

  10. I work in EMS and have a few clients who have hundreds of trips logged for barely credible complaints. We are not allowed to turn down patients as long as they have a complaint that is even "marginally" medical. I think the day isn't too far off that we will be able to triage some of these patients in the field and refer them to their primary care physician instead of the ER.

  11. Fraud waste and abuse seems to be rampant in a lot of these programs. Since I put those posts up, I've been getting an earful. Malingering is the term for this, I think. Or you could just call it fraud.