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From Pain to Poverty

“What am I going to do now Doc?” asked Mike, a down on his luck, 29 year–old recently unemployed truck driver, as he handed me his hospital bill.

Mike was seen at our local emergency department on a Friday evening with complaints of indigestion. Earlier that day he and his wife Susan celebrated their second anniversary by splitting a store bought pepperoni pizza. Mike had just lost his job and his wife, already working two jobs, managed to keep them afloat. When Mike later complained of indigestion, Susan became alarmed. She had just read about the symptoms of heart disease in the local paper. Mike wanted to get some antacids but Susan demanded he go to the hospital. Mike stated he initially protested, but when it came to his health he looked to his wife for advice.

He said he wanted her to drive him to the hospital and told me his wife wouldn’t hear of it. “We’re going to call 911, she told him. “You could die on the way to the hospital.” Now, Mike admitted, that made him scared and he quickly agreed. Fifteen minutes later he was on a gurney rolling through the double doors of the emergency department.

Physical assessment by the emergency resident physician came quickly followed by an EKG, chest x-ray, CT scan of the chest (“they said I might have had a blood clot”), and lab, specifically including cardiac enzymes. Mike said his only complaint was it took over five hours before he heard any news.

“Everything looks good,” said the resident. “Let me run all this past my attending and see if we can get you home.” Mike said by then his pain had been gone for hours and he relaxed by receiving the good news. When the resident returned, however, Mike said he knew something was wrong.

“Sorry Mike, but my attending thinks you need to stay for a chest pain evaluation, “ stated the resident with no hint of emotion. “Your first cardiac enzyme was normal, but he thinks you need another evaluation in six hours followed by a stress test, “ he continued.

Mike said he tried to protest. “But everything was normal? Can’t I just see my primary physician later,” he quizzed the resident. He said the resident looked down at his chart seemingly trying to choose his words and said, “Can’t be too careful with chest pain.” With that, the resident physician disappeared, followed by the nurse who quickly added insult to his non-injury.

“We don’t do stress tests on the weekends,” she explained. “The Hospitalist will need to keep you until Monday at the earliest.” Mike said upon hearing this news he protested, again wanting to just go home.

“Then you’ll have to sign out AMA (against medical advice). We can’t be responsible if you go home and have a heart attack and die,” she quickly added.

Mike said by then he was too tired to protest. The thought of dying at home also had him upset. He stated when he told his story to the Hospitalist, she just shook her head and laughed. “They just don’t want to get sued,” she explained. “We get these normal cases all the time. We try to tell them this can be handled on an outpatient basis, but what can we do?” She laughed again, which Mike took as a good sign he was really okay.

He left the hospital the following Tuesday—the heart scan machine was broken on Monday—with a clean bill of health and a diagnosis of “gastric reflux,” which I explained was the indigestion he first described.

I looked at his hospital bill. Charges for everything from the ambulance ride to the emergency department evaluation and eventual hospitalization with cardiac stress tests came to just under $11,000. This number was circled at the bottom of the bill with several question marks in red ink written to the side by Mike’s wife.

“We don’t have any money,” Mike explained. “Susan’s insurance won’t cover it, since we forgot to put me on her policy when I lost my job,” he continued. “We’re gonna have to file bankruptcy Doc. I don’t know what else we can do.”

What would have been a 15–minute office visit providing reassurance and education to a patient we knew quite well became a 72–hour ordeal by a health system treating a disease and not the patient, trading a patient’s pain for financial poverty. Surely we can do better.

On Labor Day Costs of Care asked doctors and patients to send us anecdotes that illustrate the importance of cost-awareness in medicine, as part of a $1000 essay contest aiming to shine a national spotlight on a big problem: doctors and patients have to make decisions in a vacuum, without any information on how those decisions impact what patients pay for care. Two months later we received 115 submissions from all over the country – New York to California, Texas to North Dakota, Alaska to Oklahoma. We feel these stories are poignant because they put a face on some of the known shortcomings of our system, but also because they unveil how commonplace and pervasive these types of stories are. According to essay contest judge Dr. Atul Gawande, a surgeon and staff writer at the New Yorker, “These [stories] are powerful just for the sheer volume of unrecognized misery alone.”

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48 replies »

  1. It’s unfortunate that the fear of scenarios such as this keep many uninsured folks out of hospitals and doctor’s offices these days. Staying healthy takes on a whole new meaning if getting sick means either paying extreme charges or waiting it out without knowing if something worse is going on.

  2. Interesting Blog, even though this was not what i was looking for (I am in search of clinics like this one> http://www.ccsviclinic.ca/ )… I certainly plan on visiting again! By the way, if anyone knows of a good clinic that does CCSVI Screenings? BTW..thanks a lot and i will bookmark your article: From Pain to Poverty…

  3. “To a point. Governement run/controlled systems work with for-profit providers but control prices. Hospitals should be community owned non-profit with strict budgets that medical staff and administrators need to meet. No Taj Mahals and bonuses for revenue generation.”
    You do realize, tho, under that system, medmal as we know it is out the window, right?

  4. “That, and for-proift medicine. And for-profit insurance. Get rid of all these and watch the money get saved.”
    To a point. Governement run/controlled systems work with for-profit providers but control prices. Hospitals should be community owned non-profit with strict budgets that medical staff and administrators need to meet. No Taj Mahals and bonuses for revenue generation.

  5. No, every patient I see is not a potential law suit. But, I don’t know which ones are the potential lawsuit, and which ones aren’t. So, I got to treat them all that way.
    “That’s wildly exaggerated. According to the actuarial consulting firm Towers Perrin, medical malpractice tort costs were $30.4 billion in 2007, the last year for which data are available. We have a more than a $2 trillion health care system. That puts litigation costs and malpractice insurance at 1 to 1.5 percent of total medical costs. That’s a rounding error. Liability isn’t even the tail on the cost dog. It’s the hair on the end of the tail.”
    And this is completely erroneous. White it is true that the cost of premiums and settlements is small, the cost of all the extra labs, images, consults, and visits in order to prevent/cover a lawsuit is huge. That is where the money is going. That, and for-proift medicine. And for-profit insurance. Get rid of all these and watch the money get saved. You can deny the cost of medmal all you want, but there is no way I’m going to disbelieve the evidence of my own eyes of actually practicing medicine.

  6. “But critics of the current system say that 10 to 15 percent of medical costs are due to medical malpractice.”
    “That’s wildly exaggerated. According to the actuarial consulting firm Towers Perrin, medical malpractice tort costs were $30.4 billion in 2007, the last year for which data are available. We have a more than a $2 trillion health care system. That puts litigation costs and malpractice insurance at 1 to 1.5 percent of total medical costs. That’s a rounding error. Liability isn’t even the tail on the cost dog. It’s the hair on the end of the tail.”
    “You said the number of claims is relatively small. Is there a way to demonstrate that?”
    “We have approximately the same number of claims today as in the late 1980s. Think about that. The cost of health care has doubled since then. The number of medical encounters between doctors and patients has gone up — and research shows a more or less constant rate of errors per hospitalizations. That means we have a declining rate of lawsuits relative to numbers of injuries.”
    “Less than a year at 40 patients per day, sometimes more.”
    And every one is a potential law suit? Hardly.
    “I believe that it is the system itself which is corrupt and corrupting. True for docs, nurses, patients, lawyers, insurers, everybody. If you don’t start out corrupt, you will end up that way, without exception. The incentive structure is all wrong. This is why I don’t believe in health care reform, tort reform, or any reform. We are past the point of no return on reform. What we need is revolution.”
    I agree.

  7. @DeterminedMD
    I thank you for your compliments, but honestly doubt I deserve them. I haven’t done that much missionary work.
    As for the insurers and lawyers amongst us, well there will always be parasites in the world. If you are not a doctor, a nurse, a tech, or an allied health professional, you really don’t provide any health care and are just a parasite on the system. Just keep in mind that we are the good guys and they are the bad guys. It won’t make you much money, but will make you happy with your own existence. Money can’t buy that.
    But I don’t even hate the lawyers, insurers, accounts and billers. They are by and large honest Americans making a dishonest buck. To paraphrase Frank Herbert in Dune, we cannot hate them for this, only despise them.
    I believe that it is the system itself which is corrupt and corrupting. True for docs, nurses, patients, lawyers, insurers, everybody. If you don’t start out corrupt, you will end up that way, without exception. The incentive structure is all wrong. This is why I don’t believe in health care reform, tort reform, or any reform. We are past the point of no return on reform. What we need is revolution.
    I advocate total nationalization and seizure of assets, be they insurance companies, medmal law firms, medical practices, hospitals, laboratories, etc. Rebuild it all from the ground up. Preventative medicine, lifestyle changes, and child well get first priority. Your vignette about Provenge is a just another symptom of our broken system. Sad. I have no problem with Provenge if a someone wants to pay for it out of their own pocket. But we the people have no business supporting it. The people who advocate for Provenge are undoubtedly the ones who advocate against insurance companies paying for childhood immunizations and autism.
    I suppose an alternative to total nationalization would be total privatization. Either one would accomplish the revolutionary goal. Either way, a good number of good people are going to die. Unfortunately, I think more are dying, and many more scoundrels are enriching themselves, under the current system. So, revolution in either direction is preferable.

  8. Again, stop engaging this guy, Dr Vickstrom, I am beginning to wonder if he is not a covert operative for the legal system, or at the very least one of these annoying “devil’s advocate” debaters who just argue for the sake of keeping the dialogue up.
    In tune with that comment, I read your above comment about what your professor preached about patients looking to “slit your throats” and have to note a sizeable number of lawsuits are not intiated by patients, but, by the greedy bastards of the legal profession who talk patients/families into pursuing suits just because the outcomes were not, as MtDoc noted, certainties. This is the main reason why physicians as a whole detest the legal profession, as lawyers make life black and white when care is gray, and also why the legal profession attracts a lot of characterological disordered people in the first place!
    Per your comment above, “Personally, I am betting on a complete collapse of our society before we have the fortitude to address this baby”, you are right on the money. Human nature is dictated by tragedy and failures to create change, and in the end we are a species of pendulum behaviors, just getting bashed at the end of every swing.
    And, I salute you for your work as a medical missionary. At least it speaks for what you are, a doctor who treats people, not a cash cow seeker.
    Wouldn’t surprise me if someone took a swipe at your backround!
    Oh, and by the way, here is something I read at THE WEEK magazine, in the Nov 26 editorial by William Falk, page 7: a new treatment for advanced prostate cancer, Provenge, is being reviewed by Medicare/caid at a cost of $90,000 for increasing survival rates for 4 months; and what does he say to this–“Is it worth that much to give a terminally ill person a few more months, it sure as hell is, if it’s your life or that of someone you love.” And that summarizes a sizeable reason for health care expenses out of control, hey, let’s keep terminally ill people alive for another 4 months, on someone else’s dime, ’cause we are owed every moment to live on, as sure as hell we deserve it.
    Probably written by a boomer!

  9. @Peter,
    “So, you do all those tests because you don’t want the inconvenience of going to court once every 10,000 patients?”
    Yes. Being accused of a crime you didn’t commit, and being held responsible for things you cannot control is not an “inconvenience.” The hate and rage this inspires in someone with even a smattering of a sense of justice and self-respect is incalculable. A medmal lawsuit may be just a business transaction to you, but to me it’s a question of honor and competency. In the medical profession, the stupid, the lazy, and the ignorant are looked upon as having all the worth of child molesters. What to you is an “inconvenience” is to us Armageddon. It all depends upon your point of view.
    Exactly how many years would it take for you to see 10,000 patients?”
    Less than a year at 40 patients per day, sometimes more. Do the math. Don’t forget that we often work nights, overnights, and weekends.
    I have as much use for trial lawyers as I do for insurers. Both are parasites on the system, battening off other people’s tragedies to make their ill-gotten gains. Until we get rid of them, them, the health care budget is going to continue to bloat.
    As I posted above, I don’t believe in “tort reform” as such. Those laws have done nothing, and won’t. There is going to have to be a catastrophic system failure before the system itself changes. Then tort reform will seem like a quaint historical artifact.
    Peter, I’m not asking this to be cruel or humiliating, but do you really have any idea what you are talking about? Your comments on the practice of medicine, the nature of medmal lawsuits, really leaves me wondering. If so, you are not alone, many who comment on this blog are not qualified to have an opinion on the practice of medicine, but do anyway.

  10. “If the patient were the one in ten-thousand case where the pain was cardiac and an adverse event would have occurred, the doctors would have wound up in court trying to explain to a lay jury why they didn’t admit the patient etc.”
    So, you do all those tests because you don’t want the inconvenience of going to court once every 10,000 patients? Exactly how many years would it take for you to see 10,000 patients?

  11. @Peter,
    The author of that article has his thoroughly up his rectum. If he thinks that a couple little tort reform laws are going to change a cent, he is wrong. To change medmal, we are going to have to change society’s expectations of medicine. We are going to have to change who sits in judgment over what is a mistake and what is not. Then, we’re going to have to wait a generation for guys like me to get old and retire. The socialist in me also argues we have to remove the profit motive from medicine, completely. Because now we’re in the habit, and it’s going to be a bear to change that habit. Now, I’m lucky in that I was trained to separate in my mind what I was ordering for medical necessity, and what I was ordering to cover my butt. I’ve also spent time as a medical missionary in a developing country. I know how to practice medicine on a bare-bones shoe-string. But I’m sure it’s not that clear to many of my colleagues. So no matter the reform, we are looking at a long, structural slog. We’ve spent a lot of time and money screwing things up in this country, and we’re going to spend a lot of time and money getting ourselves out of it. Personally, I am betting on a complete collapse of our society before we have the fortitude to address this baby.
    When I was a student, I had a professor who taught us to view every patient not as someone who needed our help, but as someone who would turn and slit our throats for a percentage if we gave them half a chance. My colleagues will not want to cop to this, but many physicians will say that they view their patients not as people in trouble needing their help, but as predators who are hunting them, hoping that they make a mistake, so that they can sue them and hit the lottery, and retire happy. This really used to bother me in my idealist phase of medicine. Now it doesn’t, as I have come to see that we have the system that people want and deserve. They say they don’t, but their actions say otherwise. So who am I to deflect the arrow of justice?
    @Margalit,
    “At point does the concern shift from patient suffering to winding up in court?”
    The question presumes that the two concerns are mutually exclusive, and thus are not both present at the beginning.

  12. “To act conservatively would save the patient some money, but if you’re wrong the patient could suffer and you’ll wind up in court.”
    At point does the concern shift from patient suffering to winding up in court?
    I do understand the over-utilization, or perceived over-utilization problem, but it is hardly the biggest problem we have. Every day millions of folks have chest-pain-heartburn symptoms. Most just swallow some chalky liquid or pill and move on. Few die because they misdiagnosed themselves and few others panic and go to the ER. Is this really breaking the bank? Or perhaps the fact that we are paying exorbitant prices for each and every medical service is the real culprit?
    http://www.ifhp.com/documents/IFHPPricereportfinal.pdf

  13. Most doctors would probably say that a reasonable standard of care in this case would have been to do the initial studies in the er to rule out a cardiac etiology for the pain. At that point the risk assessment would suggest a very low probability that the pain was cardiac and a very high probability that it was due to reflux, and the patient could have been discharged on therapy for this. Note the operative word “probability”.
    The problem is, as other doctors have pointed out, that society is not interested in probabilities, it wants certainty (or as near to it as we can come). If the patient were the one in ten-thousand case where the pain was cardiac and an adverse event would have occurred, the doctors would have wound up in court trying to explain to a lay jury why they didn’t admit the patient etc. This is the actual standard that doctors in this country face, not a “reasonable” standard. It is very possible that the jury might decide for the doctors in such a case but equally possible they could find for the plaintiff. Thus most physicians would in practice act exactly as the ER doctors in this case did, probably while thinking at the time “this is crazy”. Why should they not? To act conservatively would save the patient some money, but if you’re wrong the patient could suffer and you’ll wind up in court. The fear of lawsuits is very pervasive with every decision we make. This is a major incentive to act defensively with NO incentive not to. If society demands close to 100% accuracy in cases like this, it’s going to cost a lot. I personally think society can’t really afford this but I don’t know of a way to change it. The patient always does have the option of not following the doctor’s advice, in which case the responibility is his or hers for an adverse outcome.

  14. Paolo,
    That is a decent post. Had not thought of it that way. Good call. Until people remove their heads from their recta, we will continue to behave as if we have infinite resources. Reality bites in the end, though.

  15. Peter – Engineering is a good example of an area that deals with risk and where cost-benefit analysis is done all the time. You could build a bridge that withstands a level 9 earthquake, but it might cost you 10 times as much as a bridge that withstands a level 8 earthquake. You could design a DVD player to have the same reliability as satellite electronics, but the DVD player would cost you $10,000. Almost nobody would buy it.
    Similarly, you could spend 10 times more money on health care procedures and probably get a little more reliability, but that additional gain would come at a cost that society cannot bear. A mature society understands the need to make these trade-offs. You design only for level X bridges even if level X+1 earthquakes are possible. You hold engineers/doctors accountable for following the minimum guidelines, not for preventing the theoretical worst-case. There is no 100% certainty, not even when building bridges.

  16. Would have to agree with you, DeterminedMD and rbar. Although my criticism of health care deform is based on its essentially capitalist/corporatist approach. I would much rather the non-profit, socialist, civil-service model myself. But there is room in the world for different approaches, which many people forget. I think there is a place in the world for for-profit, lots of money medicine. It’s not for me, but may be for others.
    Engineering Peter? Really? You mean an engineer who designs something, chooses the materials used, the method of fabrication, the conditions for use, and the useful life expectancy of something? And you equate this to the practice on medicine on random human beings I encounter? Bad analogy. Way.
    Unrealistic expectations + No responsibility for patients + Unjust responsibility for physicians = exorbitant health care costs
    That’s the basic equation I learned in residency. Something will have to give, or we’ll just go broke. It’s that simple. Our society is going to have choose one day or another, or the choice will be made for it.

  17. Forget Peter, his rigidity and inflexibility is very apparent in his comments, and that kind of mentality is only part of the problem, so don’t waste your typing and energy in trying to get through to him.
    Look, for the other readers either part of the thread or silent readers at large, physicians are the definition of “no good deed goes unpunished”, and we need to take back our portion of the “patient-physician” relationship while the profit mongers and non clinical supervisors try to continue destroying health care under false pretenses, if not florid greed and selfishness as their driving forces.
    If you as a physician support this disgusting effort to destroy health care as initiated by the idiots in Washington DC, good luck in your careers if we can’t defeat your cluelessness or sheer stupidity in buying into political falsehoods. It is this simple, and to rationalize, minimize, and just blindly defend false interests to help the public, well, liberal thinking is not going to save the world, nor is the equal rigidity of conservativism going to do any better either.
    See the reality it is as of late 2010. I just can’t understand how people underestimate the enemy until it is too late, and watching the sheer ignorance on their faces as they are about to be decimated is beyond pathetic.
    Face it colleagues, our compassion, caring, and empathy is being used against us. Don’t believe me, I’m sure politicians and their allies will prove me wrong. Pay no attention to the lights at the end of the tunnel. Nor the engine of the massive truck behind those lights!!!
    And who advocates best for you? Check the freakin’ mirror!

  18. Peter,
    again, I have heard all kinds of suggestions for tort reform, but I think I need to clarify that the docs who wish there is no oversight at all are probably a minority only. In fact, I would say that the majority of docs just thinks that “sthg has to happen” but has no idea what. IMHO, health courts and specific legislation protecting judgment calls are the most important. In the US, tort reform did not yet happen, in any state (I practise in a supposedly reformed state); caps just don’t matter for defensive medicine as I explained above. The threat of litigation is by far the highest in the US compared to any other country.
    Tort reform is not the only thing we need to do in order to curb overutilization (patient expectations and our impatient, technology centered medical culture and, most importantly, profit aspects need to be addressed as well) – but it is a prerequisite. In other words: no cost efficient medicine without tort reform. Practising in the US climate is just too scary in that regard.

  19. “This statement reveals that you are, in fact, in favor of a battery of tests.”
    No, it reveals that instead of the doc trying to look like he is concerned for the patient (which he also is) or that he uses scare possibilities giving the uneducated patient no real informed choice, the doc is at least being honest.
    “I believe a thing that you don’t realize is that evryone, presumably including yourself, committs cognitive errors and judgment calls that (now or maybe only in retrospect) look bad.”
    Yes, and I can be sued if those bad calls hurt someone. rbar, it would be great if all docs were as reasonable as yourself when it comes to malpractice issues and I could agree on some halfway measures, but that’s not the reality of U.S. organized medicine. Most docs think they don’t need anyone looking over their shoulder.
    “While there may be bad people among physicians, when you stereotype the entire group as incompetent professionals who only care about money, you are trivializing the problem and not helping your cause.”
    I’m not saying the entire group is incompetent, all the time. Could it be that for a moment a good doc can be incompetent and make an error? If that happens would his defense be that he’s right most of the time? And if that momentary error hurt someone how should we determine how much that is worth? And who should pay? If an engineer makes a wrong load calculation could his valid defense be that it’s his first mistake in 20 years? If your loved one was hurt because of it where would you want to go for recompense? I do have strong opinions on malpractice “reform” and get tied when docs try to say they’re going to save us all this money if we absolve them. I have not seen the results in tort reform states, and patients are paying the price. If we remove oversight, decisions will get lazy(er).

  20. “bar, docs working for a profit hospital (even on salary) that does in house testing do have a financial stake in keeping the billings rate of that hospital up.”
    Um, no. If an incentive is not a personal incentive, it is not an incentive. Human nature 101.
    The standard of care in the office is not the standard of care in the ER. In the office, the goal is to find the right diagnosis, observed over time, with trial and error, and judicious testing. In the ER, the goal is to rule out possible serious/fatal conditions. After you rule out the bad stuff, then you look for the right one. But proving a negative is always much more difficult and expensive than proving a positive. Not only do we have to prove negatives in the ER, we have to prove them to 100% certainty. This is where society starts to hemorrhage bucks. This is true if you are for-profit doc in a for-profit hospital, or a salaried doc in a government-owned hospital (like me).

  21. Peter – You do appear to be angry at the medical establishment. While there may be bad people among physicians, when you stereotype the entire group as incompetent professionals who only care about money, you are trivializing the problem and not helping your cause.
    Every physician on this thread, from socialist Quack to reactionary MDasHell are essentially saying the same thing. To me, that’s an indication that they are saying the truth.

  22. @Peter,
    “Why didn’t the doc just say, “Hey Mike, I don’t think anything is wrong with you, but given my unrealistic fear of medical malpractice I’m going the have to order all these expensive tests to cover my ass, not because I think you have some thing serious, but because there’s a .5% chance that I might miss something that you’ll sue me for. You see I don’t really have any confidence in my diagnostic training and medical experience, and besides we make more money the more tests we do.”
    This statement reveals that you are, in fact, in favor of a battery of tests. In medical practice in general, and in ER practice in particular, it has to be 100% sure. All the time. If I was sure even within 10-20%, (based on one encounter) then my diagnostic skills are pretty good. The sad fact is, medical judgment means nothing any more. Our society demands 100% surety, when there is none in life. We spend money proving things are NOT there, which is far more expensive, and not cost effective. Many diseases declare themselves only in time. In our society, we are not willing to wait that time. And thus, everything has to be done in one shot. This has nothing to with diagnostic skills, or lack thereof.
    Why would any physician even try to cut costs, if there was no reward and only overwhelming punishment, if we do? Again, you get the result you incentivize. We have exactly the heath care system we want, not the one we say we want.

  23. Peter,
    If you include me with your question “what do you guys want”, read my previous post and my detailed reply to Dr. Wachter’s last THCB post. I agree that some docs want to get rid of almost all oversight, while I think that the medicolegal threat should be used constructively, separating truly negligent (or incompetent) docs from the acceptable rest.
    I believe a thing that you don’t realize is that evryone, presumably including yourself, committs cognitive errors and judgment calls that (now or maybe only in retrospect) look bad.
    Docs have probably the highest numbers of decisions to make compared to any other profession (every patient means at least one if not several decisions), and all these decisions are connected to the patients well being and life, at least obscurely and indirectly (if not directly in someone who is really sick). Therefore, judgment errors are part of life. Your car mechanic or your lawyer may have given you bad advice/work the last time you have seen them, but their work is rarely connected with a client’s physical demise.
    Now again, I am not talking about doctors having freedom to practicse whatever they want. But most doctors feel unfarly threatened by lawsuits for reasonable work that they did in their best intent and best effort.

  24. “And yet, family of pt X is still pressing for answers, nearly 2 years after this unfortunate event.”
    Pressing how, through the courts? We can’t fix every patient/family event, but we don’t need to flush legitimate cases along with the not so legitimate ones because you guys don’t like the hassle. We can all come up with individual examples of wrong on both sides, but trying to con the country that stopping malpractice suits will solve our medical overspending is just false. If lawyers are taking these cases on contingency that means they have to spend their own dollars doing the research, which is very expensive. That in itself tends to weed out the illegitimate cases. Barry wants special medical courts that don’t use juries because he believes they are only swayed by emotion, would you agree to that, or is that even too much for docs to stomach? What do you guys want?

  25. OK, Peter, if I missed your point per the comment I responded to prior, then fine and my mistake. But, I don’t fully buy that I missed your point, I think you are an MD basher until proven otherwise.
    What is your response to this real life event that happened to a colleague two years ago that seems to still have reverberations, NOT suit, YET? Pt X came to his PCP for his 50yo battery of tests that showed no real disease process, including a completely normal EKG, and then pt X died of an MI 2 weeks later that was confirmed by autopsy, but no real coronary artery disease process of significance was seen in pathology findings.
    And yet, family of pt X is still pressing for answers, nearly 2 years after this unfortunate event. The MD is getting very frustrated that there are still calls, and I fully agree with this MD that the family needs to “let it go”.
    Hey, a moment of candor and honesty from you, sir, and hope if you do respond it will be direct as well, isn’t it easy to scapegoat MDs versus, what, natural causes?
    People die, and it sucks. Watch the M*A*S*H episode when Hawkeye’s friend dies on the operating table and then Colonel Blake reminds him of the 2 laws of Medicine:
    1. People die, and 2, Doctors can’t change rule #1.
    Why do we have to remind people of this nearly every day? Oh, yeah, someone needs to be blamed! The rules of life do not apply to this culture of narcissism run amok!!!

  26. rbar, docs working for a profit hospital (even on salary) that does in house testing do have a financial stake in keeping the billings rate of that hospital up. As in earlier posts here by hospital medical administrators their well intentioned and reasoned attempts to reduce billings (increase efficiency) are stalled when the hospital sees it’s income reduced. Tort reform is NOT a solution to the cost of medical care, it is a solution for docs and hospitals and insurance companies. In Texas, as a trade off for tort reform, the medical board was given broader powers to oversee docs. They did just that, and now docs are screaming about too much oversight there as well. Docs want patients to absorb the costs of their mistakes/omissions/good intentioned misses.
    Determined and “Quack”, it appears you think I’m (hypocritically) in favor of, “a battery of tests”, I am not, as you missed my point completely. If malpractice fear drives tests then what patient complaint, no matter how small, would not drive a hospital to do a complete and unnecessary array of tests?

  27. Tom Leith,
    You know as well as I that a 29 y/o most likely is not having a heart attack. Your billboards are ginning up fear. This patient’s wife was ginning up fear. All the TSA BS is driven by fear. There is no end to testing if fear is the driver.
    Scott,
    My ED is the same as yours. My area is less litigious than some. Some cultures are less litigious than others. Can’t a 29 y/o with normal everything and resolved pain be discharged to outpatient follow-up? Rhetorical question: answer is he cannot if he is still afraid he is having a heart attack. He can be discharged if he is ready and willing to be discharged.

  28. Peter, you seem to be a reasonable and very well informed individual based on your other posts, but I am always surprised about the mixture of ignorance and outrage when tort reform is brought up. I believe you know that fact, but let me remind you that docs do not share one unified opinion (that’s why there’s no bigger association than the AMA that represents less then 20%) on anything (maybe that medicaid rates are too low). A great majority (I would estimate about 90% or more) would say that the current system is bad, but what to do about it is debated. There are still many who believe that nonsolutions such as caps on damages would work (I think it would bring down premiums but that’s all it’d do, it will not address defensive medicine and fear of litigation), other proposed solutions are health courts, and some might just want to raise the hurdles for lawsuits. I have my own opinion that I laid out as reply to Dr. Wachter’s recent post.
    And once again, most doctors (there are certainly important exceptions to that, such as docs owning imaging facilities/equipment) DO NOT HAVE A FINANCIAL INCENTIVE from ordering too many tests. If you order labs, pathologists, techs and probably the lab owner will get paid, but not the referring doc – and same applies for imaging studies. My position requires a lot of imaging requests – I don’t care whether my (academic) HC system has 50 radiologists or 20, and I do have financial incentives of any kind to order more (same applied when I worked for a large, aggressively expanding nonprofit MSG). I am the first to admit that docs have a huge incentive to order procedures that they perform themselves (such as surgery, certain injections, angioplasties) and that is a huge problem. But that’s not what we are talking about here (well, maybe the stress test is, depends on who did it).
    “Is there any condition that does not warrant a complete battery of tests?” What do you mean, is that sarcasm or an actual question?

  29. I’m with Dr Vickstrom re Peter’s comment: what is the two faced agenda here, sir?! People come to see doctors and expect, hey, let’s be honest, a sizeable percentage demand treatment and full resolution of symptoms, if not expecting that dreaded “C” word, cure!
    And if you as the doctor even hint there could be something missed, just watch TV ads and in the course of a couple of hours you’ll see the law firm of Money, Due, & Now tell you to call if you had a bad day at the doctor’s office, and the risk of being sued is there.
    So, you’re damned if you do, and damned if you don’t. I learned in med school go the mile as much as able, and make sure the patient understands the journey is to help, not harm. And yet now we are vilified for going the mile.
    Makes you wonder why less Americans are interested in going to medical school of late? Talk about thankless jobs!!!
    Again, where is the outrage what the hospital is billing, and specifically from the states!?

  30. @Peter,
    “Is there any condition that does not warrant a complete battery of tests?”
    Apparently not, to you.

  31. “The legal system has to do a better job separating reasonable from bad docs.”
    Docs need to do a better job at separating bad docs. What if anything will docs accept except complete absolution from all errors/mistakes/bad diagnosis and how then will they voluntarily reduce their (and their hospital’s) income? Is there any condition that does not warrant a complete battery of tests?

  32. This couple “forget” (more likely, “made the choice”) to drop their insurance coverage. Being upset that they are being asked to pay when they WENT TO THE HOSPITAL WITH NO INSURANCE –in an ambulance, no less– is beyond sympathy.
    What about a situation where the same couple declined homeowners’ insurance. They call 911 for a fire, fire is put out, but there’s 10k in damage. Whoops.
    Now, the hospital does not get away cleanly: there was clearly defensive medicine at play, hunting down this illusive chest pain.
    And, the fact that those paying cash pay a premium is also unacceptable. But I’m guessing that the couple in question would be equally enraged if given a bill for the hospital that matched what would have been the insurance company’s cost.

  33. Peter, only very few (if any) ER docs profit from ordering more tests. Re. confidence in training and expertise – medicine often presents ambiguous, complex, nonstandardizable and confusing situations. In a trial, the typical question by the claimant’s lawyer is: did you have test y (or hospitalization) at your disposal? Why didn’t you use it? And for this particular case, the questions would be: isn’t chest pain the major symptom of CAD? Are you aware that MIs can go along with a normal EKG?
    As long as well meaning, well trained docs doing a reasonable effort regularly get into legal trouble (this includes settlements and patient complaints with compensation requests), defensive medicine will prevail. The legal system has to dio a better job separating reasonable from bad docs.

  34. Why didn’t the doc just say, “Hey Mike, I don’t think anything is wrong with you, but given my unrealistic fear of medical malpractice I’m going the have to order all these expensive tests to cover my ass, not because I think you have some thing serious, but because there’s a .5% chance that I might miss something that you’ll sue me for. You see I don’t really have any confidence in my diagnostic training and medical experience, and besides we make more money the more tests we do.”

  35. @Tom and MDasHell: My ED exists as a service to the community in time of need. Who determines that need is up to the public (and that fact is mandated by EMTALA and accompanying regulations). You think you are having an emergency, then I am OBLIGATED to see you and make sure you aren’t (before my staff asks to see your insurance card or lack thereof.) Given my one shot to see that patient, I will by definition do more than the patient’s PCP who will try to treat the most likely problem (indegestion) and then see how it goes by having them come back later or call if they don’t get better, etc.
    Having the patient see the PCP and chug some antacid is the IDEAL situation– that doesn’t exist anymore. Primary doctors (offices) routinely tell patients to “go to the ER” rather than make room for sick visits. Why? because they are overworked and underpaid and stuffed to the gills with chroic-disease management. They also don’t want the liability of missing something in their office with their limited diagnostic equipment.
    The ED has become, rightly or wrongly, the rapid diagonstic center for the entire health care system, and its design and cost structure is based upon chief complaint, not final diagnosis.
    Where else do you get that value and efficiency? What is it worth to the system? To you?
    @RTO: People make choices, sometimes not in their best interest (e.g.: “I can’t afford my medicine for HTN” (even the $4 copay at WalMart?)– but “where’s the outlet? I have to charge my iPhone while I wait.”)
    @Brett: The discounts you mentioned are clear examples of my comment above. Who can offer 75% off and stay in business? Those for whom the U&C charge is an 80% markup.
    Lastly, if the attending physician didn’t see the patient personally, s/he is committing fraud in Medicare cases, and most cases of commercial insurance. The resident can’t bill for anything. That the attending wasn’t involved in the case from the initial presentation of the H&P before diagnosic testing is started is a injustice to that resident’s training and that patient’s care.

  36. We all know that the only people who pay the retail price are the self-pays. The only reason these U&C charges are listed as so high is because payors insist on steep discounts off of U&C to be in their network… And worse is that they insist on ” most-favored nation” status and even steeper discounts when the dominant payor in the area. Thus, everyone plays 3-card Monte with rates so that a positive operating margin exists for the hospital– but of course the loser is the self-pay patient.
    Also note that the average EM doc provides $135k in free services a year (costs, not charges). That’s “average” and varies widely. Almost no uncompensated care in Beverly Hills or Boca, and massive free care here in Philly, where I am lucky to get a Medicaid patient (for whom the state pays less than the COST of care) because it is better than another free visit.

  37. “What does he do when they say “no” and offer the two year plan?”
    Ask for detailed bill and medical records, have it audited and start blasting them for every little test and procedure they did till they get feed up and agree to take the lower payment.
    Also force it to court and make them justify the charges comapred to what they report their cost to deliver the care was

  38. @MD as HELL & DeterminedMD
    Yeah, he should offer to settle reasonably and that range you two give sounds about right. What does he do when they say “no” and offer the two year plan?
    Reasonable middle class folks tend to pay their bills and the hospital uses this fact to say “We get our customary and reasonable fees from 5% of our patients. Those who can’t pay, we oh so charitably write off.” The outrageous, ooops! I mean customary and reasonable list prices then persist.
    @MD — around here (St. Louis) we see bloody billboards along the highways saying something like “Got Chest Pain? Get Thee to our ED. Better safe than dead.” But here you are saying “chug some antacid and call me (or not) in the morning.” What’s the guy supposed to believe or do? And who should be lobbying hardest to get those billboards taken down? It won’t be cardiologists, CT Surgeons or “Heart Hospital” admins, will it?
    @RTO I don’t buy the “I forgot” thing either.
    t

  39. The two hospitals I’ve had the privilege of visiting in California offer steep discounts for cash (in this case, the discounts were both 75%). That would put this bill at $2750. I’d offer that, and have them put him on a 6 month payment plan (also offered at both of these hospitals).

  40. How much would this case cost the hospital if it involved a patient with Blue Cross or another major insurer in his area?
    Bet not half that amount!
    So, why is it hospitals have this absurd notion that people who come in without insurance can pay “retail” price for care? And why is it we hear these stories FOR YEARS now and states aren’t clamping down on this extortion!?!?

  41. The total absence of common sense is present in all parties to this case.
    1. The patient should never have gone to the doctor without a chug of antacid. He never would have gone at all.
    2. The resident should have presented his attending with a case of reflux with normal EKG and enzymes rather than a chest pain.
    3. The attending should have seen the patient himself so he could have a relationship with this low risk (for MI) young man who did not know any better.
    4. The Congress should have reformed tort claims long ago to free us from stupid but sometimes necessary defensive medicine actions.
    He should offer to pay the hospital $3500 to settle his bill. That is what the hospital would get from insurance.

  42. Sorry, but like many of these stories there are to many holes left in what is given to really make conclusions about our system. When we look at why people are not covered by insurance it often goes back to their own choices. A simple “we forgot” is not excusable, and probably not the truth. I would guess they made a choice that they could not afford coverage, I see that often in healthy people, especially males. They also made the treatment decisions fully aware they had no coverage. We have a system that is flawed in many ways but to not acknowledge the role of our own choices as one of the issues is in itself flawed.
    A better conclusion to the problems might be found with a review of the decisions that the individuals involved made and not just those of the care providers.

  43. I agree with rbar’s assessment. This is clearly defensive medicine at its worst – with no real attention to the impact of care decisions on the patient’s financial well-being, and more than a little bit of fear-based decision-making.
    There’s a two-fold problem here around American low tolerance for medical errors: doctors feel they are being forced to prove they’ve done everything possible, and patients feeling like the medical establishment is trying to cover up errors they know are happening. The lack of trust between two parties who need one another as much as doctors and patients do, is tragic.
    Clearly the subject of tort reform and defensive medicine is an issue. Likewise the ability of any organization to adequately police the quality of medical care at a particular venue or by a particular individual. By all means let’s develop metrics that weigh in things like increased mortality rates due to increased skill levels/experience drawing a “sicker” patient demographic. Health care providers need some governing body to turn to when a peer or superior is clearly practicing unsafe or inappropriate medicine. Patients also need access to some kind of meaningful information around the philosophy and techniques preferred by a particular health care provider, the type of cases being treated, and the outcomes. This can all be done without revealing patient identities.
    One of the outstanding issues with the PPAA is what appears to be a lack of interest in resolving some of the more glaring problems with health care in America today. If we wait for the politicians to hash it out, we’ll never have the kind of radical care quality shift everyone knows we need.

  44. I am faced with stories of diagnostic overkill basically daily (when I am on call as aspecialty physician, or while reviewing OP charts).
    The story’s “analysis” (“a health system treating a disease and not the patient, trading a patient’s pain for financial poverty”) really falls short – it’s like a politician stating that he/she cares about “job creation”.
    The dysfunctional forces during these encounters are:
    -anxiety by the patient and/or by a friend/relative that often results in overly aggressive care (“doctor, it could be condition x which is dangerous – we have to do something – and some people may specify: test Y – STAT”)
    -more importantly, it’s defensive medicine. To my knowledge, ER docs have no financial incentive to order a lot of testing (there may be some exceptions to that). When they order tests, they know that they have that single encounter to rule out dangerous conditions, and that’s why they tend to err on the side of caution, and sometimes absurdly so.

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