6.27.2016

Healthcare Ain't Hamburgers: Why Bills from the Emergency Room Are so High

A few weeks ago, I was working the night shift in the Emergency Room and I got a call.
"My two year old have a fever of 100.4, that's bad right?"
"Not really," I said. "Kids get sick all the time, the fever is the body's way of fighting an infection."
I got a few more details, made a suggestions for dosing Tylenol and Ibuprofen and to encourage hydration.
"So I don't need to bring him in?"
"You are always welcome to," I said. "We're open 24 hours a day. However, we'd probably just give her some Tylenol. Based on what you've told me, it doesn't sound like an emergency."

What I could have said, but didn't, was that the Tylenol at the hospital would probably cost $500.

That's not really true of course.

 The cost of the medicine we give is not the cost of the service we provide. Staffing an emergency room with highly trained trauma and emergency doctors, nurses and technicians, keeping x-ray and lab technicians on call throughout the night -- costs a lot of money.

When you get into a car accident, or have chest pain at 2 am, all those resources are put to good use -- we work hard and earn every dime.

However, the Emergency Department (it stopped being a single emergency room years ago) is not really the place you want to take your non-emergencies.

By far the majority of patients I see on a daily basis do NOT need emergency care. A generation ago, few would have thought to go to the ER for a child's fever or abdominal pain after gorging on all-you-can-eat tacos.  Things we would have waited out at home, or just massaged with an ounce of regret, we now rush to the ER for an instant cure.

Not only do we want fast-food medical cures, we also want fast food bills. McDonalds sells $1 hamburgers for that price because they pay their workers nothing and make up for it on buying and selling in huge volumes.

Healthcare is not a hamburger. 

The Emergency Room can't pay teenagers to do our job at minimum wage. We have to pay highly trained people what they are worth. We have to keep the doors open and the trauma team ready to spring into action because real emergencies happen. When you come in needing only and band-aid, we are happy to help. If your 6 year old bumps his head, we are happy to reassure you.

However, you aren't paying for a hamburger, you are paying for our expertise -- education that costs thousands of dollars to establish and maintain. Emergency room doctors and nurses have to be ready for anything, so we study pediatrics, cardiac care, trauma, respiratory care.

Two recent articles illustrate the public confusion over what an emergency department is for and why it appears that visiting the ER is so expensive.

In The Case of the $629 Bandaid, Vox examines what happened when a came in to the ER for a little cut on his child's finger. The doctor (!) washed it off and put on a bandaid - then had the audacity to charge $629 for the service.

The article never questions why the parent didn't wash the cut off and put the bandaid on at home -- like millions of people do every day, instead it focused on how horrible our healthcare system was for charging a lot of money for this misuses of resources.

Going to the ER for a bandaid is like buying a Bugatti Veyron for a 1 mile commute to work.  You could just walk -- and it would be better for you. If you are choosing the wrong tool for the job, don't blame Bugatti for charging $1.3 million.

Part of this is the loss of the intergenerational knowledge that would allow us to turn to an older parent for advice and reassurance. Now we have the internet which deals only in horror and rare catastrophes.

It is also part of our on-demand culture that we expect immediacy and instant gratification from our services. The other side of this issue is from the Kevin MD blog.

In ER Misuse and Our Instant Gratification Society, we learn that many of the people who use the ER have access to other less expensive forms of healthcare, but they choose the ER because it provides the instant gratification that we have come to expect in our service-oriented consumer culture.

I have had patients in the ER at night who tell me they have a doctor's appointment for their complaint first thing the next morning but "I don't want to get up that early."

Where this really comes into conflict is when the ER is actually treating emergencies. The people who are in ER for something minor, often don't comprehend that we prioritize care based on the sickest first -- not on first come first serve.

I have had a 30 year old walk into a patient's room where we were doing CPR on a baby to ask why it was taking so long to get seen for her ear pain. I have turned around from putting a patient having a stroke on a helicopter to care for a 12 year old with belly-button lint.

The split is generational, too.

I see older adults who worry about their bills and avoid going to the doctor or the hospital when really they should. I struggle to reassure them that we just want them to have the best care they can and that the price to protecting their heart or their life is worth it.

On the other hand, I try to warn away people who probably don't need to go. I try to explain that it costs at least $500 just to walk through the door.

This is a fear I hear expressed by providers when there is talk about making healthcare free.

Sure it will help all those people who can't afford their medications, or put off coming in when chest pain because they are fear the bills that will follow, but it will also increase the casual misuse of emergency resources by those who can't be bothered to wait for their doctor's appointment the next day.

Moreover, patient satisfaction surveys now play a big role in how much or whether medical providers will get paid.

Yet they only survey people who use the ER but aren't admitted to the hospital (thus, likely not having an emergency) This pushes hospitals to enable those demanding emergency resources for non-emergent conditions. A doctor may spend three hours in critical care saving a man's life from a septic infection only to see if rating drop because he had to ignore the 25 year old who came in complaining of a sore throat for two days.

In the end, we all need someone to tell us that we're not having an emergency for all the things that likely are not going to kill us or cause permanent damage. We can wait until morning to go to the urgent care or see our doctor.

Until we understand that emergency rooms are for emergencies, we are all going to be less than satisfied.

Required Reading:
ER Misuse and Our Instant Gratification Society
The Case of the $629 Bandaid
The ER and Our Inverted Priorities
The ER is for Emergencies, from the Washington State Hospital Association






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