Throwaway05
1yr ago
Do you believe health systems should be forced to provide care for someone who has no willingness and/or ability to pay? (They are - if you walk into an emergency room and say I will not pay for any care you provide me they are legally required to give you the same shit as anyone else).
If your response is "you know what I don't want any medical care" then my complaint is withdrawn, but otherwise it sounds like you want to "steal" because you don't like how the process works and don't have a lot of information about healthcare economics.*
*From your other post it sounds like you've been on the receiving end of a practice called surprise billing, which is controversial and legislated against in some jurisdictions but exists for a complicated and justifiable reason but is still annoying, as is usual the problem is health insurance companies being pretty much straight up evil and then blaming everyone else.
As for your frustration with medical debt, if people refuse to pay their medical bills all the hospitals go under and nobody gets medical care. I can understand you're frustrated but these things exist for a reason.
I'm going to be a bit fiery here because this comment is top to bottom incorrect. It will never cease to amaze me how strong opinions on healthcare are with no experience, knowledge, or accuracy.
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The minimum amount (with room for a lot a lot more) of training for a physician to practice independently in the U.S. is 11 years (4+4+3), there are some exceptions but they are very rare.
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The person caring for OP who they are complaining about is a provider (a PA), not a doctor, and has a minimum (and essentially maximum) amount of training of 7 (4+3) years.
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Physician lobbying groups have spent the last 15-20 years heavily lobbying for people outside their "club" to able to provide healthcare (providers), because they could charge for it in a supervisory capacity. Now it's biting them in the ass because those providers are lobbying for independent care, providing inferior and infuriating care (often while identifying themselves as doctors) and increasing costs (PA/NP care costs more but it's in stuff that the hospital/ownership group gets to take a bite out of instead of professional fees, for example unnecessary lab testing).
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Fixing a nosebleed is harder than you think it is. A lot harder. A school nurse or a person at home can shove a tissue up your nose but that doesn't mean they are thinking about coagulopathy, and considering the risk of TSS, other infection, necrosis, know when to call ENT or to do a further work up and so on. Nasal packing for epistaxis is something requires a surprising amount of considering and critical thought, but you don't know that, the nurse doesn't know that, the PA probably doesn't know it, and an annoyingly large number of EM doctors don't know it. Ask a pediatrician.
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Physician professional fees are a small portion of the cost of healthcare.
Throwaway05
1yr ago
If you have your car repaired and drive off without paying you are going to get reported, and you certainly don't get to come back and demand the next issue be fixed. It's absurd. Even in outpatient land you can't fire a patient (even with just cause like total refusal to pay or blatantly abusive behavior) without jumping through a ton of hoops.
Rural hospitals and suburban/urban hospitals with poor payor mix (in a lot of areas/for a lot of types of care medicare and medicaid pay less than cost) are going under left and right, and other places are closing their EDs in an attempt to stem the bleeding associated with most of the people least likely to pay. It's not getting a terribly large amount of attention outside the field because it's mostly poor whites and the media/left feels awkward about leaving healthcare out to hang after so much superficial support during the pandemic.
This specific practice (this explanation is abbreviated)* is driven by insurance companies refusing to negotiate with physician groups and just say lol I'm going to underpay you, fuck you. When providers try and negotiate the insurance companies label this "surprise billing" and lobby jurisdictions to ban, knowing that the result is professionals have to just not get paid or accept the lowball offer. It's a negotiating tactic. In the last few years providers and low resource health symptoms have seen total crashes in economic health while high resource systems and insurance companies are doing fantastic, but they don't replace the resources that are closing and retiring.
About half of the psychiatrists in the country are able to retire and they are just fucking right off instead of staying and during a time of sky rocketing mental health crisis. We have limited ability to train replacements if we even wanted to (for a number of reasons) and the stopgap (Psych NPs) are uniformly terrible and create more work for the leftover physicians (psychopharmacology is a lot more complicated than most management, as in diagnosis).
*Their are other explanations, you have stroke and the one neurologist on call doesn't take your insurance. Either they let you die, or work for free/try and bill your insurance anyway.
Throwaway05
1yr ago
Surprise billing legislation (while superficially well meaning seeming) is a scam invented by insurance companies as a negotiating tactic, which is part of why its implementation is limited.
Throwaway05
1yr ago
The hospital and provider/provider group are definitely not making decisions based off of some credit reporting threshold, they don't have the time or energy for it and charges and costs are too often pegged to other things. The insurance company might be, can't speak to that.
I also make no claims as to if people aren't paying enough, I just want people to actually pay like they said they would (especially in the case of the ED where 9/10 visits are inappropriate and make things more expensive for the people who actually need the ED resources).
Now is the government or insurance paying enough, that's a separate question. No for some aspects of healthcare, in a very demonstrable sense (that is, if your hospital is being paid mostly by medicaid it WILL go out of business without another funding source like being directly propped up by the state government).
Another different discussion is "are providers overpaid" and while that's a much more nuanced question, in a very practical sense the answer is no - if you want to see a specialist outpatient (especially in something like neurology) you are going to wait two months or have private insurance. The healthcare sector of the economy has been trying to slowly boil docs with decreasing salary for decades and it's starting to boil over and you just wont get good care (or care at all in some fields like psychiatry) if you aren't rich. I'd not be shocked if life saving surgery is simply not available within the next 10-15 years because surgeons will just refuse.
But in this case the issue is that you have a problem with the customer service and overall service offered to you by your insurance company, and you are taking it out on the health system. The problem is the health insurance product you purchased not giving you what you want (because of blah blah negotiating with what's probably a private equity owned practice management group with no clinicians in the leadership structure at all). At no point was anyone directly in healthcare involved in what fucked you except for the person who actually helped with the epistaxis.
Generally speaking health systems are very willing to negate with patients paying out of pocket because the charges are made up as part of some bullshit voodoo dance with insurance and the government. The unwillingness to negotiate def increases the likelihood of that professional fee going to a private equity group (the PA probably got paid like 50 bucks for 30-45 minutes of work that was mostly invisible to you).
Throwaway05
1yr ago
And yes, the idea that you need over a decade of training to do the majority of what people are paying for in the healthcare industry is absurd and broken.
Just so so wrong. Even in other countries with faster tracking the thing that gets cut down is undergrad (which is fair but hard to do in America, has its own significant problems, and is logistically unfeasible without completely uprooting our system in a way that isn't happening, and only shaves off two years anyway). We have some good evidence for this in the highly limited care given by providers - the NP lobbying groups best data says that NPs outcomes in simple cases is about equal with physicians outcomes in complicated cases (of course they jazz it up but that's what their data says, never mind the MD studies). Keep in mind that doctors are also the only ones getting that much training, everyone else is considerably less....and it shows. Ask any psychiatrist off the record about how the NPs and PAs are doing and they'll be able to convince you to never send a loved one to either.
As for your other point, flow chart care just doesn't work, no matter how much the MBA types may want it to. Decision support tools are miles off, for some godforsaken reason you can replace artists with an "AI" but the EKG autoread (which is one of the most computationally simple tasks imaginable) would get people killed if put in charge.
In addition to the always underestimated medical complexity, you have the human element - patient entitlement these days is sky high (as exhibited in this thread), people are always demanding things that are not indicated or are outright bad for them (ex: antibiotics for viruses) and your flowchart clinic would be immediately going off the chart or burned down.
That's not taking into the account the unacceptability of failure and legal environment, as soon as someone dies because of an edge case (which happens all the time) flowchart clinic would get sued into oblivion.
If you accepted upfront that 10% of people are going to have an unnecessarily bad outcome and 1% of people are going to die unnecessarily you'd be able to do as you say, but nobody is signing up for that. We (rightly so) value human life too much for that.
Throwaway05
1yr ago
https://old.reddit.com/r/medicine/comments/da5ccm/in_california_a_surprise_billing_law_is/
In general you can dig around on meddit just search for surprise billing.
Superficially this looks more like a problem for docs than for patients (well fuck you guys just take a pay cut) but in general you want doctors to have more leverage and control because while they want money (just like anyone else) they came into the field despite the opportunity costs because they wanted to actually help people. The other interests are just trying to extract value for the least costs (insurance companies, private equity firms that buy physician groups and so on).
Physician power and influence (and self-employment) has been plummeting for awhile now and they essentially minimal influence over care and costs in a lot of settings which generates the stuff that pisses people off.
A doc can provide free care (and many did) if they aren't owned (by a hospital, practice management group etc).
Shorter version: monopolistic competition = bad.
Throwaway05
1yr ago
I'm married to one, she disagrees. Most of her beefs have been with the embarrassingly dysfunctional nature of the hospitals she's been in that would never stand if there was real competition...
I refuse to believe she doesn't see a reduction in quality of care provided by mid-levels.
Ask her: "insert pet name here do you see any differences in quality of formulation and medication management (including things like benzo use) between NPs and MD/DOs?"
The rest of her relayed complaints are def real and accurate enough to make me believe you (and won't get any complaints from me, although as always theirs hidden complexity responsible for why those things are the way they are, especially the ED stuff).
Your nosebleed is not meant to be managed by an ED, your PCP should have same day sick slots. It's meant to be managed by a cost effective and cheap entity instead of the TRIGGER THE FULL IS THIS PERSON DYING APPARATUS (which they can't not trigger because liability). If they don't it's because PCPs are underpaid and overworked and most don't want to be one....
The AMA is the villain meme pisses me off so much because it's a "the sky is green" level take. At one point it might have been accurate but at this point the AMA has been lobbying against physician interests for decades and one of those things is deliberately increasing the amount of competition for physicians. Those idiots are on your "side."
And that's not getting into some of the shop talk level stuff here, you can't snap your fingers and make more surgeons for instance. If you gave every hospital a million dollars for every extra surgeon they trained (at the same quality as current) they just couldn't do it. For example currently we are talking about increasing the length of surgery residency (already 4+4+5+(0-3+)) because we can't train them adequately as is (because of the increase in robotic surgery and increasing specialization and IR and blah blah blah).
Throwaway05
1yr ago
Surprise billing pops up in two major places- the ED and for consult/pop-in needs.
The later is rarer, less obvious to patients, and harder to fix without big sweeping reform (I NEED EXTRA HANDS IN THIS ROOM RIGHT NOW or "is anyone at work right now who can help answer this question?" are hard problems) attempts at fixing the ED stuff break this process to and discourages those resources from being available. Nobody wants to risk not getting paid so community hospitals have an increasing dearth of specialists and then whole death spiral (for the health system) and poor quality of care things happens.
The issue with the ED is that the structure of American healthcare discourages physician self employment and physician owned practices, so one of the major driving factors here is that private equity groups have bought all of the ED doctors who aren't hospital owned and then start some fuckery with the insurance companies and this is one of the things that shakes out.
Realistically it's still a problem in physician lead healthcare but right now it's those large and connected industries fucking with each other.
Some breakthrough protection would probably help a lot "in case of truly emergent care needs the professional fees need to be covered by insurance but at no more than 110% of the fee schedule for the mean costs of in network professional fees" or something would fix the problem.
I'm sure that would have issues but the point is that the insurance companies aren't interested in fixing the problem they are interested in lobbying so that they don't need to pay for things and someone else gets the blame.
Throwaway05
1yr ago
-Hospitals can't tell you how much things are going to cost because they don't know and insurances won't tell them they how much they'll reimburse. Insurance rules are complex, constantly changing, and do so with no notice, if a place says "it will be 500 dollars after insurance" they have no idea if that's accurate or enough, and that's when needs are static. And that's if you pretend cost of delivering care is static. It isn't. If a surgery costs on the median X a specific instance could be 0.8x (healthy thin young adult, 1.2x (obese 50 year old), or literally 100x (patient has a complication, crashes, ends up in the ICU). Is the hospital supposed to charge everyone 1.5x to cover for the one person who explodes? That's like involuntary insurance. Places will offer elective and simple procedures in a fixed price fashion but they are very very cautious with that.
-Healthcare in the U.S. is collapsing, many disciplines are moving out of public insurance (most OP specialties) or private insurance (psych, in a limited fashion). Hospitals and facilities are going under with enough frequency it is approaching a full blown crisis, but most of us live in big cities with a famous name brand academic hospital that just put up a 500 million dollar building and has a million billboards. Easy to miss the crisis.
-This process is not designed to extract money unnecessarily from patients, the insurance company is refusing to provide the paid for service and instead of refusing to pay the insurance company for sucking balls the patient is fucking a different victim who is also legally prohibited from retaliating. I don't understand how the hospital/practice management group (and keep in mind that no clinician at any point is involved with any of this) is the villain because the insurance company refuses to provide insurance.
-As is usual for legislation, surprise billing stuff has a tendency to be written by corporate interests that have a financial interest in making the stroke attending and the ED fast track PA the same situation on paper.
Throwaway05
1yr ago
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Everyone has an opinion about healthcare, almost nobody expressing this opinion has the slightest idea what's going on and that often includes people in healthcare, often this is downstream of politics (ex: docs foaming at the mouth at anti-vaxxers, or advocating for "socialized" healthcare without knowing what that means) or arrogance (the "medicine isn't hard or complicated" crowd you see here frequently).
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Yes follow the money. Some high resource health systems are doing well, but many health systems are being bailed out or going under. Salaries are decreasing relative to inflation (or just overall), burnout is increasing and we've had a bunch of major major strikes/threats of strikes over poor pay and working conditions (like unsafe nursing staffing ratios). Meanwhile:
"The nation's largest insurers, UnitedHealth Group and Elevance Health, reported profits that were 28 percent and 7 percent higher than the same period last year, respectively. UnitedHealth raked in $5.3 billion, while Elevance took in $1.6 billion.
In contrast, some of the nation's largest health systems, HCA and Tenet, saw their profits fall dramatically compared to the third quarter of 2021. HCA reported $1.13 billion in profits, a decrease of 50 percent. Tenet took in $131 million, which is down 70 percent since last year."
Notably HCA and Tenet are both pretty evil companies (large for profit health systems) that will do WHATEVER to make a buck (and have been in legal trouble over it).
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Medical billing isn't "ridiculous" okay well it is, but it makes sense and is a well defined system that a lot of people don't understand... but again people don't understand it but everyone is forced to interact and therefore has opinions. Providers become the punching bag for appropriate medical decisions patients don't understand and administrative/billing decisions that providers have zero control or influence over (having being pushed out of medical leadership and admin for decades, sometimes by complicated government mandate).
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Speaking of which why is this shit so expensive? People like to blame salaries and labor shortages but that's a lack of understanding at best and jealousy at worst. Our population is getting less healthy (and other countries are catching up in costs as they become like us) and care is getting more complicated and expensive for good reasons. Additionally regulatory and administrative burden means lots of extra hands sucking at the teat. It's similar to academia (think professor to admin ratios, self-inflicted wounds like DEI staff etc).
Throwaway05
1yr ago
Healthcare provision outside the U.S. is structurally different in a number of ways that fundamentally change the feasibility of what you describe like:
-Rates of nonpayment being orders of magnitude lower (a huge chunk of ED care is just not paid for by anybody, in most countries some combination of less recalcitrant insurance and single payor takes care of this).
-Our population is sicker and requires more care and more complicated care and more variable care (the number of patients with BMI over 70 in most countries is close to zero and that kind of stuff is more expensive to deal with and more variable than diseases of poverty).
-Other countries can ration and not engage in heroic care
-Related to that most countries don't have the legal environment. Malpractice related stuff is a huge driver of U.S. costs and complexity.
-You don't know what's going on under the hood with your bill, does the health system automatically write off most of the encounter for tourist patients because it's easier than trying to send a bill to another country? Is that care funded by something specific?
-The type of care where this likely to be relevant is stuff I'm doubting you are getting (how are you getting operated on in multiple countries????).
-Where are you getting this impression of U.S. healthcare? Costs are skyrocketing and health is plummeting but that's not a sign of health. Physician salaries have been decreasing relative to inflation for decades, not sure where you think higher salaries are coming from.
-Shockingly people are not willing to work at places which underpay or have a risk of not getting paid at all, this is doubly a problem because it's incredibly hard to get physicians and to a lesser extent midlevels to work outside of a major metropolitan area. Increase the risk of you not getting paid and nobody wants to work there. A hospital can't exist without providers. This is one of the causes of the death spirals leading to hospital closures recently.
-So is your claim that wanting to get paid for doing work "unnecessary?" That kind of attitude is why people are leaving medicine in droves. Not just doctors, nurses too.
-The villain is the health insurance company for not providing the agreed upon service, but if you say "no I'm just going to steal from someone else and demand the right to continue stealing" than the villain includes you. Again we aren't talking about a heart attack here, we are talking about care that shouldn't be initially triaged by an ED.
Throwaway05
1yr ago
The unnecessarily is doing work for me but I can't construct any real numbers without a lot more clarification and information, for instance you could do OP's flowchart suggestion if you were cautious and dumped people to a real level of care at a drop of a hat (this is basically how urgent care works, anything that shouldn't actually be managed by a primary care gets sent to the ED and billed by the ED and the urgent care).
The idea that medicine is somehow not complicated is a common one but is indicative of near absent epistemic humility. I'm a doctor and probably in greater than 90th percentile knowledge of other specialties and I can't use the other disciplines algorithms at a standard of care level. The field is big, technical, but also fuzzy (thus the "Art and Science of Healthcare").
We can see this in revealed preferences in innumerable ways (ex: calling consults even when we are 95% sure what is going on because we don't want to make a mistake or get sued).
Throwaway05
1yr ago
These days physicians aren't in charge of anything, we've been pushed out of administrative and leadership roles (for a combination of reasons including legislation and the fact that nurses are scrambling for admin roles etc. etc.).
I'm not sure that's the correct read from the Epic devs you've spoken to, it's pretty common to use Epic installs as a way to hone broken processes but that's in the limited domains where physicians have control over workflow, which isn't too much. The admin side of things do want to make things more efficient and sometimes that works but other times things are weird for a reason (such as excessive regulatory burden) and people coming in from non healthcare business just can't get the complexity through their heads (Epic is generally good about this, but Apple and Google both dipped into healthcare IT and fled for a reason).
It is true that lots of doctors have limited technical ability and don't elect to use tools like hotkeys and that's probably what the devs are talking about. It's also true that doctors spend a lot of time complaining about documentation and administrative burden but then don't optimize their personal workflow. That's not a new problem though.
Re: the 500 dollar rate. The PA isn't getting paid that, 450+ dollars of that fee is going into whoever owns the PA (likely a private equity backed practice management group these days). Also possible that the charge is that high as part of the insurance negotiation dance and whoever owns the PA is just an asshole (again more likely with the outside investment). Also possible that OP is confused and it's supposed to be overall professional fee charge for the facility the ED is an extremely high level of care and the average patient might be using the services of 30+ employees or something else crazy like that (a lot of which is invisible like the cleaning staff and unit clerks).
People aren't supposed to go to the ED unless they need it.
Also for a lot of visits you don't pay for the service you got, you pay for the rule out (which may or may not involve additional testing).
Throwaway05
1yr ago
Is this for real? The person billing OP wasn't even a doctor, and no PA, NP, or doctor is getting paid that much for that type of work. Blame the admin and the billing people for the number, the PA has no control over it and is making 1/10 of that sticker price.
Again, as stated elsewhere doctors have been lobbying for their own competition for years, who proceed to do the same job for cheaper, with less training, and do a demonstrably worse job.
I'm always flabbergasted at how little people seem to know about this in relation to how enthusiastic their beliefs are.
Also the NHS is collapsing.
Throwaway05
1yr ago
Ah you took this a different angle than everyone which is a better one.
-Restrictions on open immigration are not unique to medicine, no field wants to import competition and generally countries don't want to fuck over their knowledge workers. While the U.S. is notable for you needing to redo residency, that doesn't mean it's actually possible to move over (Canada and Australia will happily take U.S. docs but Germany is incredibly hard) for other reasons.
-Related to that, most countries aren't excited about this because in many countries a lot of people want to move to the U.S. because it's the U.S. or because salaries are higher. If you offered everyone in the NHS the chance to move to the U.S. healthcare in England would collapse instantly. So both the push and pull are blocked.
-Despite this if you wanted to import family medicine doctors (the only area that has true real need) from other countries I don't think anyone would complain, including the family care doctors.
-Training is strictly controlled in the U.S. and is better than elsewhere (mostly by being harder, potentially for no reason) but is also very much so less variable. You picked good countries but you couldn't do this with say India because of the training programs are absolutely U.S. grade and some are incredibly deficient.
-We don't have much of a shortage of doctors in most specialties, we have an allocation problem. Most doctors want to live in a relatively small number of urban areas so those places are flooded and everywhere else is lacking. The reasons for this are complex but increasing supply is unlikely to fix it, but doctors for clamoring for an increase in supply (in the form of residency spots) ANYWAY and have zero control it - blame the government.
-Physician political influence is abysmal right now, we've spent decades propping up our own competition, everyone hates us (because of envy of salaries, political involvement with covid, accusations of racism etc etc) and what lobbying we do do is just left wing politics.
-Physician pay is not unbelievably excessive. The average family care doctor makes 220k. That's a lot of money, but the ceiling is low and it comes with unbelievable sacrifices to that point. When people think of ridiculous pay they think of the orthopedic surgeon making 750k but those guys are less than 1% of doctors, over 90% of doctors are in primary care in some form and those people aren't making the "real" money.
-Medicine in general can be described as a skilled trade, that's what nurses are. Physician work cannot. In the U.S. doctors get training in (and are expected to use these skills) teaching, leadership/management, and research science. Depending on the field soft skills vary from mandatory to almost all of the job (as in Heme/Onc, Psych, and Palliative). On top of that some fields do have the manual skills. That is not an upscale plumber. In the U.S. we've made many attempts to drop in people with less training and skills and they do a demonstrably worse job and unlike in emergency plumbing people actually die.
Throwaway05
1yr ago
Pretty normal to sign a document that says you are financially responsible for accrued charges.
Consider that when you walk into the ED with chest pain you can end up with a million dollar suite of cardiac surgery or thirty cents of tums and everyone has limited idea to predict which it is going to be ahead of time.
Throwaway05
1yr ago
I learned how to effectively grade scientific literature by looking for places where you'd see the hordes of "SOMEONE IS SAYING SOMETHING WRONG ON THE INTERNET" types and seeing what they said, and then after years of that picking up the skills myself.
Go to /r/medicine or other similar places, look for the hot button stuff, see what people say and complain about. At first you'll be missing context but you'll pick it up. Bonus points if you also go to the other places with different levels of training like /r/residency.
Be aware of the biases of the various areas though (anything remotely political is DOA on meddit, it's appropriate to hate midlevels but the residency subreddit takes it a little far).
Very common for industry adjacent people to do this, you'll see consultants, tech people, and lawyers pop in with their expertise because they are following or work or because of a partner.
Most of the mistakes people make are pretty basic- assuming it's simple and easy, or because they are falling for one of the agenda pushers (including us).
If you look closely you'll probably see one of those situations where three people with over 20 years of training and who very are on top of it are articulately arguing over if something like if "is a bandaid is actually a good idea or not" and you'll be like Jesus this is a nightmare.
Throwaway05
1yr ago
You'd think so and it's a fair question which is why I gave example somewhere else in this soup of comments. Elective procedures, stuff done at an outpatient surgery center, cosmetic things. Low rate of complications, low rate of fuck ups, pretty simple with a lower range of prices. Sure. Places will do that.
Hard to do for symptoms for so many reasons (is that headache a migraine, a stress headache, or a brain bleed? You are complaining about 8 things and the real problem is heart failure etc etc, the pain is referred and it's actually a very different kind of thing).
Once you've figured out what's going on it's feasible for some things, but the American population is really unhealthy and the one person where you open them up, find out it's bowel cancer and not appendicitis costs hundreds of times more than the regular appy.
It's the equivalent of those housing developments where everyone shares water fees but someone has a pool that they keep emptying and refilling every day.
Throwaway05
1yr ago
Nurses are leaving bedside nursing in droves and while some specialties are keeping up with retirement rates we are slipping behind our overall healthcare needs.
My problem is not that OP has a moral requirement to pay a bill no matter how stupid it is, it's that he doesn't know if it's stupid or not in this case, he (and everyone else) is blaming the wrong parties (the PA has no idea what's being charged and has no control over it, blame the insurance company or the hospital/practice management group that owns the PA). He also went to an inappropriate level of care and was surprised that costs were excessive. If you get admitted and demand to be in the ICU instead of on the floor it'll be your fault when the bill is an order of magnitude higher.
Throwaway05
1yr ago
Again, the entity extracting more money and surprise fucking over the patient isn't the hospital or the healthcare provider it's the insurance company.
OP paid the insurance company for a service (covering healthcare needs) and then the insurance company was like lol nah we aren't going to do that, and instead of refusing to pay the insurance company or complaining about the insurance company they take it out on essentially a third party with no control.
If I wire transfer some money to 419 scammers and then walk into a bank and punch an employee in the face for allowing me to get scammed then I'm the asshole.
The ED is literally required by law to provide care regardless of insurance status, ability to pay, or appropriateness of that level of care. There's literally nothing the ED can do to stop this, it's OP's job to go to an appropriate level of care, think critically about whether an ED visit is required, investigate his insurance, or get new insurance.
OP and the Hospital are both victims of the insurance company being an asshole.
Throwaway05
1yr ago
Negotiating prices for services is not "extracting" money unexpectedly, being unaware of what the insurance will cover is not "surprising fucking over," the insurance knows what they will pay for and we often don't and have to fight them, even for clearly necessary stuff.
Hospitals can't know (as in knowing and changing your decisions as a result is illegal, specifically for emergency medicine) what the insurance is going to do, the agency is extremely limited.
In response to this sort of fuckery places have literally closed their EDs. Hospitals are going out of business at record rates and posting record lows for profit. Meanwhile the insurance companies are posting record highs.
What are they supposed to do? Break the law and not treat the guy? Just not get paid and then go out of business? Stop victim blaming.
And that's completely ignoring the other layer of this which I can't verify with the details OP provided, but the PA is probably owned by a third party - a private equity group that does enjoy the revenue associated with skull fucking patients and everyone in healthcare would love for that behavior to get banned but we don't have any control...
I don't know how the fuck the scummy companies won the psyop where they blame everything on doctors who have zero administrative or financial control.
Throwaway05
1yr ago
(and yes I know you asked for a general primer but the point is to build knowledge of the unexpected complexity).
Here's an example-
https://old.reddit.com/r/Residency/comments/104bwb4/why_was_damar_hamlin_in_the_sicu_after_his/
Why is Damar in a SICU (Surgical Intensive Care Unit) - some people are saying that's best practice, some people are saying that's best quality of care, some people are saying that's because of the resources specifically at UC and some people are saying it is because the case is high profile. And you can find someone saying the opposite for each of those. Everybody knows what they are talking about.
No way to know unless you work there and were involved and some combination of those answers is probably correct.
Stuff is very resource and facility dependent and a lot of things don't have strong consensus.
Throwaway05
1yr ago
Short version: costs are weird, sometimes outright unknown (the accounting for some stuff gets bizarre), charges are generally inflated as a result an annoying dance with insurance companies and the federal government to get things paid for (ex: for a lot of stuff medicaid and medicare pay less than cost so things get...creative and the insurance company goes "we'll pay you 1.05 times the cost...").
Professional fees are like likely to do this because it's a little more obvious to pay out a portion of a staff members salary based off of how long the encounter is supposed to go (very doctors, NPs, or PA are self-employed these days, almost everyone is "owned" sometimes by a hospital but also by....).
Based off the absurdly inflated price and and the lack of willingness to negotiate (most health systems will be flexible with cash pay) (and also the fact this is the ED) the PA was probably owned by a practice management group which is when a PE firm buys a physician group and does things like cut salaries, raise prices, and be an asshole (and give the money back to whoever is invested in it). It's a huge problem right now.
It is also possible that this primarily driven by what happens when your insurance company just refuses to pay for things but that's less likely.
You should get insurance, this is what it is for. If you have a plan but it has a super annoying deductible....well yes that's how it works (if you don't and you were cash pay you should call the billing department as the other user pointed out, and then get insurance).
I'm not sure if this will help but you should consider that (while it may appear superficially similar) medicine is not going to be like going to a mechanic. When you go to your dealership the work of analysis and diagnosis is often not paid for, then they'll tell you how much it is to fix the issue and you can take it or leave it. The cost is the labor and parts and replacement and repair. When you go to the emergency room you are paying the staff for the time and resources it takes to figure out what is going on. The treatment is often cheap (medicine, a splint, whatever) but the imaging, labs, and professional fees are time consuming and expensive. As a layman you aren't going to know what is going on under the hood (for instance in this case adults generally don't get nosebleeds that are bad enough to bring them to the hospital, so it could be because it's hella cold and dry outside, or it could be because the patient is having issues with clotting blah blah).
If you have chest pain and go to the ER, and after talking to you they give you tums and tell you to avoid spicy food the bill isn't for the tums it's for making sure you didn't have a heart attack.
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