28 May 2010

Friday Flashback - Perverse Incentives

Byzantine \By*zan"tine\ (b[i^]*z[a^]n"t[i^]n),
a. Of or pertaining to Byzantium.
A highly intricate system characterized by bureaucratic overelaboration bordering on lunacy
c. Relating to medical billing processes

I recently reviewed a chart for a patient who had been in a car accident. It was an old man who had sustained multiple injuries and was seriously ill, admitted to the ICU with multiple consultants. I was struck by one feature of the chart -- the bill was absolutely huge. Far beyond what is typical for even a serious trauma.

There were the standard items:
Critical Care, 30-74 minutes, $596
Chest Tube, $574

So a pretty sizable bill just there -- $1100. But that was in fact the smaller part of the bill. The balance:
Fracture care: Shaft of clavicle, $489
Fracture care: Nasal bone, $79
Fracture care: Rib, $239 x 3 ribs fractured
Fracture care: Metacarpal bone, $490
Fracture care: Pelvis, $1157
Fracture care: Medial mallelous of ankle, $705
So, for fracture care, the total sum was a princely: $3600

Now I should point out that these are gross charges (gross, indeed!), and actual collection on these charges may vary from 90% (in a commercially insured case) to about 30% (Medicare) to 0% (no insurance). But even so, look at the disparity! The fracture care is more than triple the cost of the actual life-saving treatment this patient required.

Just to be clear, the patient had sustained a head injury (fortunately, a minor one), requiring CT scan of the head and neurosurgical consult. There was the chest injury requiring the ER doc to cut a hole in the chest wall to let out trapped air and release the pressure which was preventing the heart from filling with blood. Internal injuries in the abdomen required consultation with a general surgeon. And the patient was elderly and frail, with other medical conditions and was in shock. The ER doc spent over an hour on this case alone, and did a tremendous job pulling someone's grandfather through the "Golden Hour." It's a Medicare patient, so he'll probably get $300 for his efforts.

BUT, he put on a few splints, x-rayed the right body parts, and did a very careful dictation noting all the injuries. And for that, he'll get three to four times the remuneration he did for the hard, scary, critically important life-saving efforts.

So, for the health policy types:
The system is fundamentally and irredeemably broken. Fix it now.

For ER interns:
In order to compliantly bill for definitive care of a fracture in the ED you must be sure to document:

  • The name of the broken bone, the anatomic location of the fracture, and whether it was open or closed
  • What interventions you performed (i.e. reduction, splint, strap, analgesia, ice, etc)
  • Post-intervention assessment (i.e. neurovascular status, pain level)
  • Follow-up plan
In order for the ER doc to legitimately bill for this service, you must actually provide the same care which would have been provided by a specialist. If follow-up with a specialist is required (say, for cast placement), the reimbursement will probably be split, with the majority going to the initial physician.

Sheesh, no wonder the average salary of an orthopedic surgeon is twice that of an ER doc, which is itself half again that of a family practitioner.

Originally Posted 09 July 2007


  1. And what in the massive health care bill that just passed will address this?

  2. Nothing. Of course, it won't cure the heartbreak of psoriasis either. It will shift the balance slightly back towards cognitive services, but only a tiny bit.

    The RUC needs to be rebalanced and the entire RVRBS needs to be recalculated form the ground up. Having said that, the probability of that happening is lower than the SGR getting fixed, and Congress can't seem to even do that.

    So I ain't exactly holding my breath.

  3. I am relatively new to your blog and find your daily postings fascinating. After reading today's post, I am never more grateful that I was born in a country (UK) and now live in a country (Canada) where emergency medical care won't bankrupt me. When I think of the countless times my younger brother (who was particularly accident prone) was in and out of emergency with head injuries from falling off some kind of apparatus (monkey bars lol), glass in his foot, broken fingers from falling off his bike....I mean he was the type of kid who could walk through an open field and trip over the one rock there....I don't think my parents could have survived financially if they had to pay every single time. I do not work in the medical field and have a great appreciation for the amazing work you guys do so I absolutely mean no offense. I guess as a person growing up with relatively free healthcare I find these stories astounding....

  4. Chest injuries can be exceptionally serious and potentially fatal – both external ones and internal ones. Many vital organs are contained within the chest, and damage to any of these can lead to lifelong health issues. A chest injury claim through the courts will require that you have legal representation. It is in your best interests to also use the services of an experienced personal injury claims solicitor when making a chest injury compensation claim to the Injuries Board.


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