Best in the world, my a$$! – Emergency Departments and Networks

When I was a sophomore in college, I was playing an intramural baseball game against a bunch of upperclassmen. One sunny Sunday afternoon, I hit a nice shot down the third base line, and took off for first. But the first baseman might have been a bit inebriated. He was also easily twice my size. I remember him suddenly stepping into the basepath, and I remember literally bouncing off his stomach before I hit the ground.

I also remember the sound my arm made as it broke. A number of my friends reported that they could hear the crack as well.

I was in a great deal of pain. One of my roommates ran to get his car, and pulled it onto the field. Everyone loaded me into the back seat, and my roommate took off for the hospital.

It turned out that I’d broken both the bones in my left forearm. The pain was so bad that when they turned my arm over to get an x-ray, I nearly passed out. The idea that I could be a good “medical shopper” at this point was laughable. I was hurt, incoherent, and going to get care wherever I could. Today, the health care system requires us to be better. It demands that we go to emergency rooms that are “in network”. People actually do this! But it turns out that even when they do, they’re still getting screwed:

When Jennifer Hopper raced to the emergency room after her husband, Craig, took a baseball in the face, she made sure they went to a hospital in their insurance network in Texas. So when they got a $937 bill from the emergency room doctor, she called the insurer, assuming it was in error.

But the bill was correct: UnitedHealthcare, the insurance company, had paid its customary fee of $151.02 and expected the Hoppers to pay the remaining $785.98, because the doctor at Seton Northwest Hospital in Austin did not participate in their network.

Yep, it turns out that even if you go to a emergency room that’s “in network”, the emergency room doctor may not be. Think about that. I mean, asking people who are acutely injured or sick to have the presence of mind to be able to shop around is already insane, but then it turns out THAT IT DOESN’T EVEN MATTER.

How common is this, you might ask?

When emergency medicine emerged as a specialty in the 1980s, almost all E.R. doctors were hospital employees who typically did not bill separately for their services. Today, 65 percent of hospitals contract out that function. And some emergency medicine staffing groups — many serve a large number of hospitals, either nationally or locally — opt out of all insurance plans.

That’s right, two-thirds of hospitals have out-of-network doctors working in their in-network emergency rooms. Good luck rolling the dice! And this doesn’t help:

Dr. Jeffrey Bettinger, chairman of the reimbursement committee of the American College of Emergency Physicians, said that out-of-network emergency room doctors were an unusual phenomenon and expressed doubt that the practice was widespread. When it occurred, he added, it was typically because of insurers’ unwillingness to pay doctors a reasonable rate compared to what they pay hospitals for their services.

The average salary of an emergency room physician was $311,000 in 2014, rising from $247,000 since 2010 — a period when many other types of doctors experienced declines in salaries, according to Merritt Hawkins, a physician staffing firm.

Either the NYT is wrong with their “65%” figure, or else the American College of Emergency Physicians is woefully uninformed. (UPDATED: Or, maybe both are right. It’s possible that the 65% of EDs outsourcing doesn’t add up to lots of out-of-network services. The Texas data in the NYT story tends to make me doubt that. But if the ACEP has data that makes them so sure, I wish they’d share it!) And don’t think this is something people can “learn” themselves out of:

When Dr. Michael Schwartz’s daughter went to an emergency room in the Philadelphia suburbs for a reaction to a medication in 2010, she went to an in-network hospital, Bryn Mawr. She was there for a few hours on a cardiac monitor. While most of her care was covered by his family’s insurer, Capital Blue Cross, a bill of more than $2,000 from the out-of-network E.R. physicians for cardiac monitoring was not.

“I tried to negotiate with the physician group, but they wouldn’t budge,” said Dr. Schwartz, a pediatrician, who ended up paying $1,200, the amount his plan required for his share of out-of-network care. “It was ridiculous. I’m a physician and I understand how this works. There was no sign saying, ‘Our physicians are out-of-network.’ ”

If a local doctor can’t figure out how this works, then the rest of you have pretty much no chance.

Best in the world, my ass!


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