• CNN.com: Why emergency rooms don’t close the health care gap

    There have been a number of stories in the media lately detailing how far hospitals will go to collect on unpaid medical bills. I thought this was a good time to highlight both that practice, and how it runs counter to the myth that we have a universal system because “you can always get free health care in an emergency department”.

    I wrote a column on the subject at CNN.com. Go read it!


    • Great article!
      Covers the issues clearly.

    • I thought the idea that we have a “universal system” is that people who don’t have insurance and don’t have money get care in emergency rooms. The point being that the public is paying for them in one way or another, so Obamacare is not adding a huge number of freeloaders who can’t pay for their healthcare.

      In other words, we don’t have the benefits of a universal system, but we do have the costs.

    • “the myth that we have a universal system because “you can always get free health care in an emergency department”.

      For something to be a myth shouldn’t there be widespread belief in it?

    • While its true that EMTALA requires only stabilization of emergency situations, that doesnt mean the doctors/ER obligation ends there. Part of the reason the ER costs so much is because doctors treat non-emergencies all the time. Just because they arent monitoring cholesterol levels doesnt mean they are treating only emergencies.

      Consider this scenario: 25 y/o man with leg abscess comes into the ER, he’s had the abscess for a week. He’s not ill appearing, not having fevers. Thats NOT an emergency, and by EMTALA regs the doc could easily discharge the pt from the ER and tell him to follow-up with his primary care doctor. But that almost NEVER happens. Why? Because the ER doc is guilty of breaking a “standard of care” if he doesnt I&D the abscess, despite the fact that its not an emergency and the pt is totally stable.

      ER docs are held to a MUCH higher standard than just the EMTALA law.

      Also consider that ERs are starting to get reimbursed in part by their “patient satisfaction” ratings. Patients arent going to be very satisfied if the ER follows the bare-bones EMTALA regs but doesnt provide any other care beyond that.

      • You’re missing the point. That’s still acute care, and a small subset of acute care at that. Can I get a screening colonoscopy in the ED? A checkup for my child’s ADHD? How about his developmental delay? His autism?

        Can I get therapy for my depression? Can I get chemo for my cancer? Can my father get radiation therapy for his prostate cancer? Can my wife get a mammogram? Can she get a prescription for birth control? Can she get a refill on her allergy meds?

        None of those things will happen in an ED. I could do this all day. The ED serves up a very small part of health care. And no matter what your experience may be, many, many patients get turned away for non-emergent care all the time.

        • So what’s your plan to make sure the 8 year old in the middle of Uganda gets all the medical care they need?

          If the high road is to take the stand that medical care is a right, which it seems the point is here, what limits the discussion to just Americans? What about the rest of the world?

          • So if I can’t make the whole world perfect, then I should stop trying to make things better in my backyard? That’s really your argument?

            There are only hundreds of posts on this site detailing how things are not nearly as good in the US health care system as they should be, especially given the money we spend. This has nothing to do with the “high road” unless you think demanding more bang for the buck is somehow un-American.

          • Having worked in many developing countries, I can testify that they take the right to health care more seriously than the US and in many cases do a better job of providing access to basic health care (not just emergency care) .

        • Oh I agree with you that the ER does not provide comprehensive primary care. But your article (purposefully or accidentally) gives the wrong impression that ERs wont treat anything beyond a life/limb threatening situation and that’s not the case. ERs do far more than the mandatory minimum that EMTALA requires.

    • There have been a number of stories in the media lately detailing how far hospitals will go to collect on unpaid medical bills.

      Most of our insurance premiums is not insurance against above average cost but prepaid healthcare. So advocates of prepaid healthcare must explain why it s preferable to prepay than to pay after receiving care.

      Problems with paying after care:

      1: It can be difficult for the provider to collect.
      2: Lack of ability to make decisions in certain emergency situations.
      3. in some cases it causes people to wait longer than optimal to get treatment.

      Problems with prepaying:

      1. Encourages overuse.
      2. Encourages quixotic attempts to extend the lives if the terminal.
      3. Discourages self treatment.
      4. Aligns providers and patient against payer.
      5. Allows providers to more easily collect for care that failed to benefit the patient.

      A benefit of paying in the rears is that should motivate the providers to get the patient back to a productive state.

      Note the state could pay Providers after care in cases of bankruptcy putting certain limits on how the bankrupt can spend on other things .

    • Why is there such a fixation on the cost of emergency care? It accounts for 2% of all healthcare spending. It seems there’s much lower hanging fruits if 31% of healthcare spending is on administrative costs.

      Aaron brings up a really important issue, but his tone in the piece seems a bit off – less than amiable toward emergency care providers. They are the only speciality that can’t choose their patients, and I think there’s something to be said for that. It’s not that they inherently don’t wish to provide the services you list, it’s that they are not the best trained or equipped to provide those services – you don’t even have the continuity of care that you’d get with an primary care doc. Emergency providers shouldn’t be responsible for those services simply because the overall health system neglects to otherwise provide them. Oh well, someday we’ll see healthcare as a human right. I thought we figured it out in 1948, but I guess not…

    • This is a brutally difficult issue, and Aaron is doing well at it.

      My own long term solution would be to fold emergency rooms in with police and fire services, and pay for them with taxes, not user fees.

      Some of the people who call the police and fire departments have relatively frivolous concerns, but this can be dealt with by the professionals on the scene.

      It is better to be a little imprecise and offer services to everyone in the community, and pay for it with taxes on everyone in the community.

      The taxes would have to be federal in nature. Too many cities and states are out of money and/or have no ability to raise taxes.

      I could see a 1% increase in the payroll or income tax raising $60 billion.

      Each emergency room would receive a global budget allocation on day one of the fiscal year. They could still charge $50 per visit so that people did not abuse the service.

      There would still be details to work out…..the main hurdle is who pays when a person presents to the ER but then must be admitted to the hospital. We may not have the money to make the whole episode free.

      The ER’s would have to pay civil service salaries, and this may make it hard for them to recruit specialist MD’s. However, most of the ER visits do not require a top specialist anyways.