You felt sick after lunch and your work friends just convinced you it could be your heart. They call 911 and before you know it, you’re strapped to a stretcher in the back of an ambulance careening around corners, running lights with sirens on the way to the local emergency room. The pain completely subsides and now you wonder if transient heartburn will end up costing way more than it should. Well, you’re probably right!
The majority of emergency room visit costs are not controlled by physicians, nurses, or the paramedics caring for you when you come to the hospital emergency department. In fact, most of the decisions affecting your healthcare cost for such an episode, including tests and even the decision to hospitalize you, are now nearly hard-wired into the healthcare system in the interest of safety. Of course, the subsequent billing associated with that care is as well. It turns out, most of the treatment in the scenario posed above has been pre-determined by protocol. Some of those protocols are dictated by policies based on regulated standards of care for reimbursement, by government and corporations running the hospital. Those businesses include the one that owns the emergency medicine contract, as well as, the hospital itself (under the influence of the particular hospital administrators in leadership) and even the emergency medicine transport system responsible for bringing you to the hospital. We need more reasonable balance between meeting safety standards and the prudently applied guidance of board certified emergency medicine specialists.
The fundamental causes of added cost are also, ostensibly, aversion to risk and liability. A more cynical view is that our healthcare system capitalizes on the collective fear of everyone involved for the financial benefit of all the stakeholders in the business, except the patient. Including the pharmaceutical industry, that profit from fear is now estimated north of about $4 trillion. Here is a brief overview of the systemic constraints that inflate cost in a potential emergency.
1. The paramedics may know it’s extremely likely that your symptoms were the result of downing that fajita and caramel-colored, caffeinated, acidic, diet drink you just threw up, but their protocols tell them not to think, but to transport. Meanwhile, that ambulance ride just cost you anywhere between $600 and $2,700.
2. When you arrive by ambulance (or if you were to walk in to the main entrance) you, or the individual helping you, will be asked for identifying information including, name, address, insurance (or lack thereof), and the reason for your visit by a registration clerk. That stated reason for your visit entered by registration (before a triage nurse confirms your vital signs) will be reflected on a tracking monitor throughout your visit. Depending on your insurance, you may be charged anywhere from $50-150 based on your copay and if you’re uninsured, between $150 and $3000 depending on your condition.
3. After registration, a triage nurse (RN) or other designated individual, will assess the severity of your condition, determine which care area is most appropriate for you (most often without consultation with an emergency physician) and order a battery of tests based on the use of protocols and computerized order sets ranging from level 1: $670 to level 5: over $6000. These charges do not include medication, supplies or special imaging tests such as X-ray, CT scan or MRI. Moreover, the triage designate (usually a nurse) may initiate emergency “codes” (e.g. for suspected strokes, trauma or heart attacks) without medical consultation with an emergency physician on duty examining the patient and include all of the above costs or more.
4. There is a possibility that a patient may be “downgraded,” in other words, de-escalated, and sent to the waiting area by the triage RN. No cost involved here this just creates the inconvenience that others who are perceived to be more critically ill will now be treated ahead of you.
5. It is at this point that you will be medically screened by an emergency physician. Once the emergency physician investigates the history of your condition and examines you, she/he will order diagnostic tests, including blood tests. EKGs, X-rays and CT scans, call in other specialized consultants and occasionally cancel some of the unnecessary testing that was ordered previously in order to expedite care. Shorter length of stay (LOS) is correlated with higher patient satisfaction scores but not quality (see earlier post on this subject).
The emergency physician then creates an electronic chart based on the care required and provided, often modifying the level of care initiated mentioned above. That care will be reimbursed to the company that hired the physician based on the review by a medical billing company hired by the corporate practice or the hospital. Most emergency physicians are not partners in said practice and have no back end control over how much and when patients will be billed. The majority of the time they are being paid an hourly rate regardless of the amount of care they provide. Those corporate entities can however pressure individual practitioners into higher cost behavior by having zero tolerance for any unforeseeable events.
If, for instance, the physician judges that your condition was in fact the result of transient gastritis or reflux brought on by a bad burrito and corrosive soft drink, it is within their scope as your advocate to treat you by simply canceling all tests, interrupt the process leading to admission as well as a potentially needless visit to the cardiac catheterization suite. They might reasonably treat you with an antacid and discharge you to follow up with your primary care physician who will judge if you need referral to a gastroenterologist who will check for the less serious peptic ulcer disease. Alternately, you could be whisked on the telemetry unit at a cost of $2000-$3000 per day or double that or more if you’re admitted to the ICU.
Finally, it is within your right as a patient to interrupt the process at any point and do what many intelligent patients do: ask to see the emergency physician first. Most caretakers are incentivized to reduce their risk exposure out of fear of retribution or liability for ever misjudging a serious medical condition. You can demand to see a physician before any testing is ordered. You have a right to engage in shared decision making at any point in your care. Patients even have the authority to leave against medical advice if they feel they are being compelled to undergo testing and treatment as a result of the fear of legal retaliation, through a resultant missed or delayed diagnosis. Know your rights and value the doctor-patient relationship: it could be the difference between 50 bucks and 10 grand. More importantly, it might save you the risks and complications of tests and procedures you may not even need.