29 July 2009

Cognitive Dissonance

It was a busy, busy Monday evening in the ER, about nine PM.  A mother brought her 18-month-old daughter in for some remarkably trivial cold symptoms.  Despite the onslaught of patients, I actually got in to see her pretty quickly.  I glanced at her demographic page in the chart as I bustled in.  Hmm. Good insurance, has a well-respected local pediatrician: odd.  Not your usual fare for a totally non-emergent complaint.  More typically it's someone with no insurance who can't get in to see a PCP, or their PCP is at the Community Health Clinic which means that they essentially don't have a PCP*.  I wonder why they're here?

So I interview the mom and examine the kid.  Runny nose, mild cough, a little sneezy, red eyes that really aren't red on exam. No fever, even.

Afterwards, I'm chatting with the mom, I explain that the symptoms look pretty benign, and I ask her, "So when you called Dr Jones, did he tell you to come to the ER?"
"No, we didn't call.  His office was closed."
"Did you call the on-call number?  They always have a nurse and a doctor available for after-hours problems."
"Oh, no!  We didn't call that number -- it's only for emergencies!"
[long pause]
"And yet, here you are now.  In the Emergency Room."

She had the decency to flush a bit.

I sent them on their way with general instructions for a cold (no antibiotics!) and instructions to call their doctor for follow-up. 

She's gonna be so pissed when she gets the bill.  It'll be their $1800 cold.

* No offense to the CHC folks.  They do great with very limited resources.  But they are so overwhelmed that there is no capability to see acutely ill patients.  When I see a CHC patient in the ER for a non-emergent complaint, I don't give them a hard time, because I know that the clinic's next appointment is in October or so...


  1. Maybe you should start having the triage nurse give them an idea of what their bill will be, before they see you. This will cause many non-emergent patients to go home, making both you and them much happier.

  2. It's easy to blame the customer in this situation. But I have to agree with the lady that our health care system is very confusing. It is easy to make mistakes like this.

    One of a business's first priorities is educating the consumer. Where did we fall down? An $1800 lesson will be well-learned, but is far out of line with her mistake.

  3. So you think $1800 for a cold is OK but you diss the "procedure oriented" specialists?

  4. It needs to be said: No one is paying $1800 for the cold. True: a $1800 (or $700 or $2200) bill is going to be generated. No one pays that bill. Not the patient, not the insurance. The patient is likely paying $50 co-pay for the ER visit. The insurance is paying somewhere between 100-300 dollars after their negotiated rates with the hospital.

    Joe-- triage nurses cannot tell people what their bill would be because 1) they don't know -- pricing is incredibly complex and depends on a number of factors, including insurance contracts and 2) that has historically been construed as an EMTALA violation as you are coercing people to leave the ED without being seen.

    Frank -- stop holding hands and singing kum-bay-yah. Yeah--the medical system is complex. However, it is not so complex to know that if you have a problem that you think needs to be seen in the emergency room, then you can call the emergency number. It is helpful that they even use the same words.

  5. Anon 9:23 -- totally right. Still, there's always a "sticker shock" when the bill comes and the patient sees the top line, even if the bottom line is only $50.

    Anon 8:44 -- I'm not "ok" with it. It's asinine to come to the ER for a cold; it's a very expensive place to get care, and if you don't need the ER you shouldn't come here. Also, bear in mind that 80% of that hypothetical $1800 (a number I honestly pulled out of thin air, but is reasonably close) is the facility fee. This case probably coded out as a Level 2 and the physician's fee was probably a couple hundred bucks at most.

  6. Perhaps she thought that calling the emergency number would just end up with a recommendation to go to the ED anyway.

  7. Where is that written down? If I am scared and have a cold, do not go to the ER. I am not aware of a guide for the average person advising of appropriate and inappropriate use of emergency services.

    However, as a citizen,I have definitely heard that I can get seen for anything, anytime I need in the emergency room. I have even heard that the ER basically does primary care.

    I blame hospitals for allowing that confusion to exist (EMTALA too). Far from naivete, I believe that I am demonstrating the necessary business practice of thinking from a customer's perspective.

  8. Sure, nobody is paying $1800...except for the guy without insurance.

    The triage nurse can't tell the patient *exactly* what their bill will be...therefore the patient should be left completely in the dark as to whether they will be charged $200 or $2000. Yeah, that makes sense.

    The "Pricing is complex" excuse is just that, a lame excuse, and one that I've heard way too often. Last time I asked how much my (office, not ED) visit would cost, the doctor said, "Duuh, I don't know. I can have the front desk look it up for you if you like" and then left me sitting there in the exam room in pain for FORTY FIVE MINUTES. And I didn't have insurance then, so it's not like they had to call Blue Cross and ask or anything.

    So you're going to have to excuse me if I have a hard time believing that a guy with ten years of post-HS education can't figure out a way to post a freaking rate schedule on the wall or on a website without violating EMTALA.

  9. Don't they have any quick clinics around where you guys are? Around here (nth order suburb of DC), a sick kid on the weekend who's not obviously an emergency can just be taken to the nighttime pediatrics clinic--the wait is usually much shorter, and much more pleasant. Though usually, that on-call pediatrician number saves us a trip anywhere.

  10. Joe,

    1. EMTALA and case law make it pretty clear that any discussion of finances must wait until after initiation of care. In the old days, the registration clerks were trained to perform the "wallet biopsy" first and if the patient were uninsured, they would either ask for cash up front or warn the patient what the possible costs might be. This was construed as being threatening, and quite honestly it was intended to scare off people who probably couldn't pay.

    2. So many factors go into the ER bill, from the E/M level to radiology, labs, god help you any procedures, etc. It's not like you can post the five-level E/M chart with prices and have that provide patients with any meaningful information.

    3. Why would the hospital do that anyway? It's bad for business and bad for patients. If the guy in the waiting room with indigestion (that turns out to be an MI) leaves because he's scared off by the price list, that's bad for him, and even if it turned out to be non-cardiac chest pain it's a money-loser from the hospital's point of view.

    The hospital has to perform a delicate balancing act on message:
    Between "You can always come in to the ER" and educating people as to the appropriate use of the ER is not easy.

  11. Joe:

    As far as I can tell, medical billing is opaque by design. This facilitates the cost-shifting that seems to go on all the time.

    Also, I think the hospital has zero incentive to dissuade people with insurance or money from coming to the ER for non-emergency stuff, which is what a fee schedule will do. Ultimately, either my insurance company or I will pay for the services I consume, when I come in with a trivial complaint, and the hospital will make money.

  12. "It's not like you can post the five-level E/M chart with prices and have that provide patients with any meaningful information."

    And does the lady coming in to the ED because her kid has a runny nose need radiology, labs, procedures, and the five-level E/M chart? No, she needs to know that walking in the door will cost her $1500 "facility fee" plus $2-300 to see the doctor.

    The line about how it's bad for the patient doesn't hold water. Sure, it would be bad for the guy with the MI to go home. It would also be bad for the guy with indigestion to lose his house because of an unnecessary ED visit.
    Like it or not, ultimately it's the patient that needs to decide whether an ED visit is in their best interests. By withholding the cost from them, you are almost certainly decreasing the probability that they will make the choice that is best for them.

    (By the way, would you like to buy my used car? I won't tell you how much I want for it, because then you might get scared off and miss out on the unparalleled bliss of driving my car, and that would be bad for you. Trust me, I have your best interests at heart. Just send me a blank check and I'll send you the car, OK?)

    As for why a hospital would do that...well, other than "because they have a shred of human decency left", I can't think of a good reason. You are correct that scamming money out of scared and desperate people is very, very good for business.

  13. I have to tell you, when I call my doctor's office--or my boys' doctors' offices, or hell, even my dentist's office, and I get their voice mail (because they've "stepped out" or are at lunch), all the messages say that if you feel you need help right away, to go to your nearest emergency room.

    Now, I know better than to do that, of course. Once you've had three boys, you get to the point where you're well aware of the difference between a cough and a serious, bronchial cough presenting with dehydration and a fever that's approaching brain-damage levels. You know what you can disinfect and slap a butterfly band-aid on and what you need to have sewn back together by the pros.

    But when you have that first baby, and he's wailing because he can't breathe through his nose and no amount of your best show tune renditions will calm him down and you're low on sleep yourself, the phrase "need help right away" kind of takes on new meaning.

    Just saying.

    (As a kid, when I came down with a walloping case of what appeared to be the measles, the clinic sent a nurse to our house first; once she'd determined what was wrong with me--measles--a doctor then came and took over. I wish there were some sort of off-hours middle-ground care available here, especially for new parents.)

  14. Hey Joe (7:08a, 10:55a, 12:12p),

    Get a job troll. :P

  15. I don't know why everyone feels so strongly that we need to convince Joe that it is functionally impossible to give people meaningful billing information, but I want to chime in too:

    You take the kid with the cough and runny nose and send him to three diferrent ERs and you will get three very different bills. People practice medicine differently. When you walk into my ER and get me, you get my workup and evaluation.

    Doc 1: history, physical and discharge.
    Doc 2: history, physical, chest xray (+$200 and radiologist bill) , IM steroids (+$150), CBC and blood cx (+$200)
    Doc 3: partial history (doesn't capture a social or family history -$40), physical, A&A rx (+$100), neb to go home with (+200).

    How on earth would a triage nurse know how a doc will chart, what they will order, etc.? This is a very staightforward case. Imagine if it was a 37 year old woman with right sided chest pain (that bill could be $200-$10,000).

  16. Mother brought 8 month old baby into my ED one morning for URI symptoms. After H&P and counseling, the mother's reply was "how long will it take to get our discharge paperwork, we have an appt with the pediatrician at 11am for his regular checkup and don't want to be late?"

  17. This is not hate on joe but reality check...who pays their bill anyways? Most of the time we do. Do you really think that the lady who called EMS for her chronic back pain b/c she could not get a ride to the ED, is paying for her visit? As a physician the billing doesn't affect me,I get paid by the hour. So her EMS transport, IV pain meds, x rays or MRI ( all physician dependent of course) probably costs a lot of money. Since she doesn't have insurance or transportation, I am pretty sure joe and the rest of us taxpayers end up covering the cost. It is sad for everyone involved. It is especially sad for the guy having an acute MI waiting for EMS when they are overloaded with a bunch of crap.


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