Took my wife to the ED a couple of weeks ago...

[edinOH]

Nothing life threatening, just some protracted vomiting and diarrhea. It got to the point where I realized that inorder to get ahead of this thing she would definitely benefit from a couple bags of saline as well as an antiemetic.

So here we are at about 2am on a Friday night, she's retching her guts out and I decide to go ahead an suck it up and take her to the ED. Since I am a student, I have the school's student health plan. It is pretty good but there is a $1000 deductible which we haven't even touched yet since most of our routine care is handled by docs around town I know as kind of a professional courtesy. Anyway, I figure we will see a pretty decent bill from the whole thing, maybe $500-600 dollars but I doubt more since I have a pretty good idea what is going on with her and what she needs.

Long story short. Go to one of the smaller EDs here in town that isn't one of the primary EMS receivers because it is in fact a Friday night. Care proceeds realtively quickly considering what I am used to seeing in the University setting. By sheer coincidence I happen to be wearing my "College of Medicine" sweat shirt and once the doc notices this he asks me if I am in medical school and of couse I tell him that I am and that I will be going into EM next year. We shoot the **** for a while about mutual aquaintances in EM and where I'm applying and all that BS. Doc gets the orders written and nurses return to get it all started.

She gets her 2L NS, some toradol for "muscle aches" and some reglan for n/v. The doc had ordered Zofran but I quickly yet subtley pointed out that we were "cash payers" and would prefer the poor man's antiemetic! The doc said, "Oh yeah, that stuff is like $200 per dose!" He also understandably ordered a CBC and BMP since we were in fact in the ED. Mostly defensive test but I understand and would have done the same thing.

(yes I'm trying to keep this short)...

Got our bill the other day. Holy sheit! $949.76 for Hospital charges and $273.00 for the doc. I called the hospital to try to negotiate the bill down somewhat because all of us on this board know that the services she received cost no where near that. The best they were able to do was like $780.00 but I have a call into the "billing guy" hoping to get it down to $500. Even that is alittle much, but hey, I did go to the ED and that is about what I expected to pay. Even that is excessive though.

I'm sure I will call the EM group and ask them if they can "hook a brother up" you know? Of course I don't begrudge the doc his rightfull compensation but you and I know they pad those bills pretty high for the insurance companies and the nonpayers. (Both of these bills were sent to me by way of the insurance company)

Anyway, thought I'd share. Moral of the story. Uncompensated care makes the bill sky high for the rest of us and don't give zofran like candy.

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[DocWagner]

I absolutely agree...except I probably wouldn't have ordered a BMP or even a CBC (unless I was truly worried you had a surgical belly...that would've also brought the bill down), probably just a UA with preg.
But you are absolutely right!

 

[mikecwru]

Originally posted by DocWagner
I absolutely agree...except I probably wouldn't have ordered a BMP or even a CBC (unless I was truly worried you had a surgical belly...that would've also brought the bill down), probably just a UA with preg.
But you are absolutely right!

Oh, I don't think edinOH has consumated his marriage yet.

That insurance health sucks. Even ours isn't THAT bad... $1000 deductible?

mike

 

[DrMom]

Originally posted by edinOH
Moral of the story. Uncompensated care makes the bill sky high for the rest of us and don't give zofran like candy.

Sorry about your wife's illness & the big bill.

Unfortunately, you are exactly right. I spent yesterday shadowing an ER doc & asked him about various aspects of the practice. Here's some of what I picked up.

1. Only 5-10% of the patients seen in the ER are actually having medical emergencies. (I'm not saying that your wife doesn't fit into the emergency category.) In my short 8 hrs in the ER we saw multiple "my back has been hurting for days" (aka: narcotics seekers...usually), "I have a cough," "I have a toothache" , and one "I'm having bad menstrual cramps."

2. The self pay patients rarely pay, so that means that the insured & those self pay who can scrape it up have to make up the difference. The Dr I was with said that at most of the hospitals (his group covers 4-5 ERs) they actually get paid about 70% of the physician fees they bill. At the hospital I was at (which sees mostly low income, self pay) they get paid 40%. Both of these #s are quite low (most practices are closer to 90%).

I hope that the hospital will be willing to work with you!

 

[edinOH]

Mike,

I'm waiting for just the right time! It's those damned headaches!

Dr Mom,

I guess you are learning what EM is all about! lol My wife's situation definitely wasn't an emergency. It wasn't necessarily "urgent" but rather something that needed to be taken care of. I'm sure you have experienced the same with your kids.

 

[blackcat]

edinOH
ihope you wife is doing better.
i hope that you get that bill down.
i also wouldn't have ordered the cbc/chem.
this is part of the practice that i don't know anything about since i've been working in a military ED for 4 years.
noone pays...which has all of its inherent problems.
as long as the wife is doing well, you will forget about the bill.

btw, hopefully as an EM resident you will be able to slide her in the back door and give here what she needs.

 

[DrMom]

Sure have, but we have a couple of good after-hours clinics nearby so we have avoided visits to the ER thus far.

BTW: I absolutely loved my day in the ER. Definitely at the top of my short list!

 

[droliver]

On a related note:


http://www.al.com/news/birminghamne..._standard.xsl?/base/news/1041243330132870.xml



Jeffco pulls plug on health plan for poor

Preference for ERs doomed project

12/30/02

ANNA VELASCO
News staff writer


A three-year test project trying to get uninsured patients out of emergency rooms and into primary, preventive health care has ended a year early because of lack of interest from the people it was supposed to help.

The Coordinated Health System of Jefferson County ended its project called HealthPlus this month and withdrew their last year of funding totaling $150,000 from the Robert Wood Johnson Foundation.

The group a public-private coalition of doctors, hospitals, Jefferson County government and the county Health Department plans to stay together to continue to try to improve health care for the county's uninsured poor.

But few uninsured emergency room patients showed interest in the project that offered follow-up care at public health clinics.

The idea was that many patients could stay out of crowded, expensive emergency departments if they got adequate preventive care. Those who needed treatment from specialists would get referrals from the clinics to private doctors who volunteered with the program, and hospitals would provide free care for hospitalized patients.

However, few signed up for the program and even fewer kept their follow-up appointments at the clinics.

With only 500 patients enrolled so far, Coordinated Health System knew it would not reach its goal of helping 3,000 patients, said Michael Griffin, the group's executive director.

The project started at Baptist Medical Center Princeton and later expanded to University Hospital and St. Vincent's Hospital.

"I think what we found in this particular instance, if you build it, they will not necessarily come," said Dr. Michael Fleenor, health officer of the Jefferson County Department of Health.

Focus groups showed that many patients perceived the care to be better in emergency rooms than at public health clinics and more convenient because ERs are always open.

"They're choosing where they want to go, money or not," Griffin said.

The project showed patients opt to go to the more expensive emergency rooms than to the clinics where they pay on a sliding scale, Griffin said. The difference is emergency departments don't require money up front while the clinics do, he said.

The programs nationwide that have been successful in getting patients out of ERs and into primary care have offered financial incentives, such as free medicine or free doctor's visits, Griffin said. But the Coordinated Health System, as a coalition, did not have the authority to offer either, he said.

Members of Coordinated Health System will meet in mid-January to discuss how to continue as a group.

"I think everybody still wants to play some major role in working together for greater access to health care for the uninsured," said Bob Chapman, chairman of the group and CEO of Medical Center East's parent company.

Coordinated Health System first formed in 1996, when the county's Cooper Green Hospital had serious money problems. Doctors and hospitals joined forces to come up with a plan for the uninsured if the hospital for the poor closed.

Cooper Green did not close, but the group has continued and the newly elected County Commission is once again pondering its hospital's fate.

Charlie Faulkner, president of Baptist Princeton, said he hopes the new commission will work with Coordinated Health System when deciding how to spend the county's health care money.

"If we're going to be successful in doing something rational with indigent care in the county, it's got to be a group effort," Faulkner said

 

[edinOH]

and just to clarify a couple of things...

Her belly was "tender" on exam because she was sore from the vomiting. Nothing focal or too impressive. I think that was the reason for the blood work.

There was no hcg ordered because she was obviously not pregnant at the time if you know what I mean.

 

[overnight]

Woman of reproductive age comes in with hx of severe vomiting, diarrhea and some abdominal tenderness (I don't care if it's from the vomiting or from a too-tight belly shirt)--and some of you guys wouldn't order a CBC/BMP?
The woman's husband is a future doc who's concerned enough to bring her to an ED.

I guess you've ruled out any metabolic or hematologic abnormalities on yr physical.
(SOmething the lawyer might ask you...)

 

[tonem]

EdinOH,

I'm glad your wife is doing better. I had a similar experience last year. Late one night I made the mistake of poking my head into a room where an intern was starting a central line to tell my resident that I was going somewhere or other. Just as I was leaving I heard a yelp and was sprayed with blood from across the room (don't ask me how). Anyway to make a long story short, employee health was closed so they sent me to the ED to get my eyes flushed. I was there long enough for a tech to flush my eyes, and receive bloodborne pathogen "counseling" from an ED attending. Two weeks later I got the bill for $900. I was more fortunate than you in that I ended up having to pay a $20 deductible for the ED visit because medical students aren't "employees" and aren't entitled to workman's comp for on the job injuries and exposures.

I agree with DocWagner in that high ED bills are probably the result of uncompensated care and unnecessary tests performed for CYA purposes.

 

[The White Coat Investor]

Similar story, similar price. I took my wife in (to an ED I had rotated in) about 4 am one morning when she woke me up c/o cramping belly pains. Previous dx of UTI 2 days previously, currently on day 2 of cipro. Now with mild flank tenderness, the cramping pains, urgency and dysuria but no fever. (Yeah, I stuck a thermometer in her mouth and poked her in her back before giving her her two options: wait 6 hours for the urgent care to open, or go to the ED now. ) She chose the ED, and when your wife wants care, you take her in. She got the whole 9 yards: CBC, BMP, UA and Cx, IV Gent, po Levaquin with 10 days to go, 4 of Morphine, 2 L NS, some antiemetic, po Vicodin to go and a warm blanket. Bill was over $1100, $650 after the insurance got a hold of it. Also have a $1000 deductible, so $650 out of my pocket. And I'd pay $650 again to show my wife I care about her comfort enough to drag her into the ED at 4 am a few hours after my previous shift had ended. At the same time, I think it is entirely appropriate to ask patients what their paying status is, and consider not ordering the "less useful tests." You all know there are many ways to treat these situation, all within the standard of care.
Incidentally, 4 am is a great time to go the ED, just be sure to bring donuts for the staff. (Trust me, it gets you much better care.)

 

[DocWagner]

Overnight,
just responding to your question. One must ask oneself "what advantage will the CBC and BMP offer" if it fits the history and physical (suspecting gallbladder or appendix) then order the tests... but a shotgun approach is not how you should run an ER. And I would bet the tests were only ordered because he was a med student, though it is strange no UA or preg was ordered. Serial exams (before and after rehydration/antiemetics) is far more reliable than a CBC (what if you suspected appendicitis and the CBC was normal?). That is how you answer the lawyers question.

 

[southerndoc]

Originally posted by DocWagner
One must ask oneself "what advantage will the CBC and BMP offer" if it fits the history and physical (suspecting gallbladder or appendix) then order the tests... but a shotgun approach is not how you should run an ER.

This is in no way intended to flame or put down EM (I am actually considering it as a specialty)...

What are the EM programs that teach EBM pretty heavily?

I've seen a lot of unnecessary tests ordered by EM docs. It seems like every sniffle that comes in gets a full workup. I thought it was just the hospital that I worked for prior to medical school (worked as a paramedic), but I've seen it at my teaching hospital, other hospitals where I now transport patients to, and hospital ED's where family members have been treated.

So I get the consensus that a lot of unnecessary tests are ordered frequently by EM docs. I'm not so sure it's a shotgun approach as it is more a CYA type situation though.

Is anyone aware of strong EBM programs that shun upon rather than encourage ordering of unnecessary tests?

Cheers!

 

[DrQuinn]

Most, if not all EM residencies should be using EBM as their philosophy. However, you have to remember that a lot of times, a shift is "attending-dependent." I would guess there are always one or two attendings at each residency that order more tests than they need to be. These tend to be older attendings (in my experience).

Like, we had one attending at an audition rotation I did in Nov... this 25 year old came in with cold symptoms, and a sore throat. Nothign in hte history of physical suggested any epiglotteal disease... but my attending went ahead and ordered a soft tissue neck... couldn't visualize the epi on that... then took a laryngoscope and viewed it to make sure it wasn't swollen.

This was your run of the mill snotulitis cold that everyone else had... NOTHING even remotely suggested anything otherwise.

Goes to show that some people just practice different medicine.
Q

 

[mikecwru]

Originally posted by QuinnNSU
Most, if not all EM residencies should be using EBM as their philosophy. However, you have to remember that a lot of times, a shift is "attending-dependent." I would guess there are always one or two attendings at each residency that order more tests than they need to be. These tend to be older attendings (in my experience).

Like, we had one attending at an audition rotation I did in Nov... this 25 year old came in with cold symptoms, and a sore throat. Nothign in hte history of physical suggested any epiglotteal disease... but my attending went ahead and ordered a soft tissue neck... couldn't visualize the epi on that... then took a laryngoscope and viewed it to make sure it wasn't swollen.

This was your run of the mill snotulitis cold that everyone else had... NOTHING even remotely suggested anything otherwise.

Goes to show that some people just practice different medicine.
Q

Another thing (and I'm not saying people don't do whacky stuff that is unnecessary): if these people have been doing this for 25 years, their judgement is a lot better than ours. A lot of diseases, we know by a few lines out of a textbook while they may have seen multiple cases. They know when to be worried. I've seen lots of cases where I thought the attending was going overboard and I turned out to be right, but I also have had at least two instances where I (and "textbook teaching") was proven really wrong... one was a classic nursemaid's elbow that turned out to be a bad fracture ("get an Xray before you pull on it") and one kid with the sniffles that turned out to have bad pneumonia... nothing good by hx or physical to suggest it ("get an CXR before you discharge").

[2 instances out of an EM month; I've been proven wrong more than 2 times in all of med school ]


mike

 

[shaft]

We had a lady who we thought pretty much had nothing, but was having a heavy menstural period and was undergoing surgery soon and was concerned. Her platelet count came back at 3. (3 thousand but you know what I mean)
I think it is not only attending dependent but dependent on the acuity of the ED. Some EDs have a bunch of not particularly sick people come in and they are probably going to be more likely to be choosey about tests...

 

[EMRaiden]

There is something to be said for driving home after a 12 hour shift knowning that the CBC or CT or LP, etc was normal...and nothing worse than kicking yourself mentally for a couple of days wishing you had done it.

Also, as one attending told me- you can buy a lot of head CT's with one million dollar lawsuit.

My 2 pesos...

 

[Coleman]

I agree with EMRaiden. In EM, you are asked to make crucial decisions with so little information at times, that making arguements for the sensitivity and specificity of a certain test are waranted (i.e. high res CT), but nit pick about CBCs and chemistries is a little more questionable. Like edinOH said, looking back, he too would have ordered them for his wife. Given the rest of the presentation (abdominal pain? hx of amenorrhea?) you should justifiably order an ultrasound (or do it yourself if you're able) and type and cross. Point being, EBM is great, but there is almost no 100% sn and sp in any test.

I sympathise with you edinOH, I've paid the bill myself and it hurts, like you said, we are paying for others free ride.

 

[DocWagner]

I am sorry if I started an accidental flame war.
I just wanted to point out that a UA an HCG would have been the FIRST tests I would have ordered...treated, then perform a serial exam.
I mean, if you are called at 2 in the AM on the floor for a patient with nausea and vomitting...what are you gonna do first? You would do an exam, treat, then repeat the exam and then order a test if needed (likely NOT a HCG in that case).
Though this case (with an educated medical student) is different, one absolutely CAN NOT approach every patient with N/V and a non surgical abdomen (or without co-morbidities)with shotgun tests like a CBC or BMP. A BMP would yeild very little unless prompted by an abnormal dip or a known comorbid state (ie needed an anion gap etc). Likely it would bankrupt your group before long.
Sorry, I just thought letting a fertile female with a history of nausea and vomitting go home without a UA or HCG was weird.
Wasn't my intent to start a debate...but it is cool to discuss such topics.
Take care...by the way, the Fiesta Bowl was the best bowl game I have EVER seen!!

 

[Ctrhu]

Best game, but Miami was robbed with that bad call. There was no pass interference and Ohio State shouldn't have been given the first down and goal.

 

[edinOH]

Oh but I beg to differ...

The Miami defender was all over the receiver before he made his turn in the endzone. He was holding him from the line of scrimmage and continued to hold him just before he turned to look for the ball. The original call would have been holding on the defense but it became pass interference once the ball was thrown since the receiver was held while the ball was in the air.

That was probably one of the best football games I have witnessed in my life time. Instant classic.

And no the "OH" in my name doesn't stand for Ohio. I am an Oklahoma fan myself.

 

[DrMom]

Originally posted by edinOH

And no the "OH" in my name doesn't stand for Ohio. I am an Oklahoma fan myself.

Really? Where are you from?

 

[edinOH]

Well I don't go to OSU. What does that leave?

 

[DrMom]

K- got it. (but your profile doesn't give any information, so I couldn't make assumptions )

 

[mikecwru]

Originally posted by edinOH
Oh but I beg to differ...

The Miami defender was all over the receiver before he made his turn in the endzone. He was holding him from the line of scrimmage and continued to hold him just before he turned to look for the ball. The original call would have been holding on the defense but it became pass interference once the ball was thrown since the receiver was held while the ball was in the air.

That was probably one of the best football games I have witnessed in my life time. Instant classic.

And no the "OH" in my name doesn't stand for Ohio. I am an Oklahoma fan myself.

What the hell does it stand for then? I worked with you in an ED in Ohio... did you mispell OK or something?

mike

 

[edinOH]

This is true. I did work with you in and ED in OH.

 

[docB]

I would have done the UA/ UPT bit too. I'm a big fan of repaeting labs. I had a pt sent to the ED by the OB/GYN clinic for a transfusion for a crit of 16. She had DUB and the clinic had already put her on hormones. They just wanted me to transfuse her 'cause they can't do that in clinic. I went ahead and checked a CBC with the type and cross and lo and behold the Hct was 40. Held the blood, rechecked it again and it was 41. Turns out that the OB/GYN clinic has their own CBC machine and it was on the fritz. The repeat lab saved the patient and unnecessary (and possibly dangerous) transfusion.

 

[edinOH]

Update to the story...

The hospital agreed to reduce the price from $949 to $700. I called the ED group's billing company. No love. $273 is what I owe and that is what they expect!

I didn't talk to any of the docs of course and it isn't like I'm going to call the guy up at home. So I guess in the name of greener pastures in the future I will send them a check tomorrow. I do think 3 years from now if I'm ever in that situation with the roles reversed, I'm going to either forget to turn in my billing form or make it obvious that this is a "professional courtesy."

But like I said before, I don't begrudge the doc his rightful compensation nor do I have a problem with paying the full bill. That's life. I have a hell of a lot better financial future than 99% of all the other pts. seen in the ED at any given time. And for that I am grateful.