$11,000 hospital bill from the emergency department

by Steve Sanders, DO

“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.

Steve Sanders is a primary care physician (Twitter @spsanders).

On Labor Day Costs of Care, a Boston-based nonprofit, offered $1000 prizes for the best anecdotes from doctors and patients that illustrate the importance of cost-awareness in medicine. 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. To learn more about the contest and read more of our stories please visit www.CostsOfCare.org (Twitter: @CostsOfCare).

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  • http://www.heartbeat-coaching.com Janet

    There must be something they can do. Can you follow up? At minimum, I should think they’d be able to get this bill drastically reduced. Not that they should have to pay more than $100 for being stuck in a hospital while the staff scares the poor guy into staying put!

    • Vox Rusticus

      He needs to work out a payment plan with the hospital.

  • http://fastsurgeon.blogspot.com JF Sucher, MD FACS

    “Surely we can do better”….

    How? How do you “do better”? This is a function of our societal demands. That is to say, our society has demanded that we make no mistakes. It has demanded that we “do everything”. It has demanded that we fix them immediately despite their decades of unhealthy lifestyles.

    To say “we need to do better” honestly is going after the symptom and ignoring the cause. WE (the American society) need to make some really hard changes in lifestyle. We will also need to make changes in our expectations of what the medical system can deliver. If we start now… it may actually start to get better in 20 or so years.

    This isn’t a rant. It is meant as an honest observation. The “medical community” wants to do everything it can to “be better”. Improving patient safety and outcomes are constant challenges that are at the top of my list everyday. But the road to healing starts at home.

    • Dave

      One thing that needs to change is that PCP’s need to be compensated for email/phone conversations. Such would make them much more available. If Mike had been able to contact/call Dr. Sanders or one of his associates it is likely he wouldn’t have called the ambulance, though I suspect Dr. Sanders would have still sent him to the ER to have his cardiac enzymes tested. Further, if Mike had contacted Dr. Sanders he likely would have been reassured that he didn’t need a stress test then and there (or even at all they aren’t all that great, CT calcium score, etc. might be better) and perhaps have went home (and saved thousands of dollars).

      I don’t think Mike wanted “everything done.” Heart attacks can be weird and, once he got anxious, his symptoms probably got a lot more “heart attack” -like. Lots of people just need reassurance. I know that without “Dr. Grandma” (a retired pediatrician), my wife would be taken in our newborn for every little thing. However for PCP’s to do this 2 things need to happen. 1. They have to no longer be afraid of liability. 2. They actually need to get paid for answering a phone call/email.

    • Diora

      I missed it, where exactly in the article does it mention anything about the guy’s lifestyle healthy or not? For all we know he was a slim non-smoking athlete…

  • http://www.google.com Guest

    Liability is the bottom line. If they hadn’t run lets say a chest pain evaluation and stress test 6 hrs later and he ended up dying. His wife would have sued, the hospital would have settled as opposed to going to court and cost would be driven up yet again to pay for all of it.

    The fact that they called an ambulance vs driving to the ER clearly demonstrates that people want top of the line care regardless of cost. I can understand calling an ambulance if you chopped a major artery while chopping wood but for indigestion??? Come on! People should associate healthcare with cost and not just expect the Rolls Royce treatment on a Kia budget.

    • Brian

      Guest,

      That’s easy to say with the benefit of hindsight. They didn’t call the ambulance for indigestion.

  • ErnieG

    This is a difficult situation. I am not sure how we can do better, or what you suggest we do.

    ER care is expensive, and the standard of care is very high. I am not sure the ER did anything “wrong”. It is easy to look back and say that this man had indigestion, that we did not need to spend 11K on his ER adventure, that the ER docs should have used clinicial judgement, that reassurance was need…but what if he did have an acute cardiac syndrome? Or what if he did get “reassurance”, and it ends up his next ER presentation is sudden death? These are not theoretical worries. I am sure any physician having spent any time in the ED or medical floors will give you stories of significant cardiac disease masquerading as indigestion. And trying to use clinical judgement or re-assurance to manage chest pain without objective laboratory or radiographic data confirming benign non-cardiac disease is looking for an eventual lawsuit they can’t win- coronary disease is too common and atypical presentations occur everyday.

  • Mark

    Sorry, Mike. You came in by EMS complaining of chest pain. Yeah, the doctors think it is just indigestion, but what if you’re the 1 in a million where it is not. They have to discharge you in a way so that you can’t sue them later, appearing to do everything possible. Unfortunately you didn’t take the hint and leave, so you got the full workup. Yeah, all the doctors think it is stupid too, but if they said so and then by just plain dumb luck something bad did happen they they’d lose everything. So, here is your bill.

    • Primary Care Internist

      not “1 in a million”, probably more like 1 in 20. Especially in diabetics, atypical chest pain is pretty typical.

  • ER Doc

    2 comments:

    1) The title of this article is really misleading. I doubt that the bill from the emergency department was any more that $1500 including facilities charge and doctor bill. Still a lot but not 11k.

    2) I completely agree with both Dr Sucher and the guest. I can’t afford to miss anything. Missed MI is still the #1 payout in emergency medicine.

    • JoAnne

      Are you kidding me? You can barely get the CT for $1,500.

  • Anon EM doc

    He “forgot” to add himself to his wife’s policy and she overreacted to a newspaper article… Yet paying for it is society’s responsibility?

    In their defense I doubt I’d do an inpatient stress chest for some epigastric burning pain on a 29 y/o after I’d already ruled out a PE.

  • Vox Rusticus

    This is what happens when you allow a system of liability to evolve that tolerates no bad outcomes, no matter how unlikely. And don’t tell me differently: this patient was 29 years old. I have known cases where even younger patients who were presenting with clearly musculoskeletal signs, were evaluated (in the pre-enzyme in the ED era), discharged and had the incredible bad luck to die suddenly after discharge, surely an extremely unlikely event in someone so young. Didn’t matter, there were still plenty of people who wanted to hang the doctor.

    Under the circumstances, i don’t blame the ED one bit. This is why we have huge insurance premiums. And yes, when you don’t buy insurance, you risk bankruptcy with one visit to the ED.

    You cannot hac=ve a system that covers all risk, does so on demand (or tries to) and isn’t going to cost.

  • http://wingspouse.com Kathi

    Our family has experienced similar situations (and bills) and you really capture how fear stops common sense from prevailing. Part of the problem is that the medical staff doesn’t see considering cost as their responsibility, and the patient trusts that the tests are ordered because the professional has good reason to.

    I always ask how much a procedure will cost and only one time the staff could tell me. I have even received written quotes from hospitals/labs that ended up being wrong — and no apology or adjustment. The explanation is frequently either “we don’t handle the billing” or “that was a cash-only quote and a health savings acct is a form of insurance so that’s a different price.”

    • Justin

      I think the bottom line is the doctor’s liability if everything is not done. We can hand wave about physicians not knowing what something costs, but when the “standard of care” is serial enzymes + stress test that is what you do.

      If the patient is the 1 in a million who leaves and dies of a heart attack, no jury is going to say: oh, geeze doc, 29 year old, healthy guy, it was a really low risk, you’re not liable. The doc is on the hook, court case, liability premium increase, stress, etc etc.

      And you have to ask the patient if the cost is worth it after the fact. Would he trade the $11,000 bill for the peace of mind that his heart is actually ok? Would he (or his wife) trade the $11,000 bill if he was instead dead from a heart attack?

      • JoAnne

        I just hope his bankruptcy and divorce don’t lead to an actual heart attack.

  • Vox Rusticus

    This is what happens when you allow a system of liability to evolve that tolerates no bad outcomes, no matter how unlikely. And don’t tell me differently: this patient was 29 years old. I have known cases where even younger patients who were presenting with clearly musculoskeletal signs, were evaluated (in the pre-enzyme in the ED era), discharged and had the incredible bad luck to die suddenly after discharge, surely an extremely unlikely event in someone so young. Didn’t matter, there were still plenty of people who wanted to hang the doctor.

    Under the circumstances, i don’t blame the ED one bit. This is why we have huge insurance premiums. And yes, when you don’t buy insurance, you risk bankruptcy with one visit to the ED.

    You cannot have a system that covers all risk, does so on demand (or tries to) and isn’t going to cost.

    • Matt

      “This is what happens when you allow a system of liability to evolve that tolerates no bad outcomes, no matter how unlikely”

      We don’t have that system. In fact, in our current system, bad outcomes are tolerated extensively. At trial alone, physicians win 3-1.

      “This is why we have huge insurance premiums.”

      We also have huge insurance premiums because physicians sue health insurers for hundreds of millions. Perhaps we should reform the system that allows that to happen!

      • pj

        You overlook the fact that ours is perhaps the only nation where the loser of a suit doesn’t bear the legal costs- ask any Doc who “won at trial” if the legal expenses, time/lost income, and forever having to disclose the lawsuit to state boards, hospitals, employers, insurers, etc. if they feel whole. Other nations have “loser pays” laws.

        Also, how common is it for Docs to sue for “hundreds of millions?” That would be 1 in a million, compared to malpractice suits against Docs.

        • JoAnne

          This has nothing to do with the original comment. The original comment was about how our supposed zero tolerance legal system raises insurance rates. You’re talking about doctors paying legal fees.

          • pj

            JoAnne, Your post is unclear. By “original comment,” I presume you refer to the article, not Matt’s comment? I was pointing out to Matt that his assertions about physicians “winning at trial 3-1″ ignore the fact that any Doc who wins at trial still suffers, in most cases, tremendously.

            I respectfully disagree my comment had nothing to do with the article/post. If more people knew what Docs go thru when we get sued, they might alter their perceptions of the cost/liability issue, or understand why these huge hospital bills occur. Just because a Doc wins at trial, in the USA they almost never get reimbursed for the items I mentioned.

            If you haven’t read Brian Nash’s posts on med mal in this blog, I suggest you do- very insightful.

  • http://emergency-room-nurse-blogspot.com girlvet

    And there you have it. Modern healthcare at its finest. Screw the patient so you can CYA. EKG normal, troponin normal, even frickin’ chest CT normal. I think the guy could have taken his chances and had an outpatient stress test or something. Its really shameful.

    • Vox Rusticus

      He could have left AMA. He didn’t.

      He went to the ED with indigestion signs. He didn’t try antacids. He called an ambulance to go there, no less.
      A 29-year-old who just ate a pizza.

      He “forgot” to add himself to his spouse’s medical insurance policy. Had he not gone to the hospital, he probably would have stayed ahead financially, taking that chance he did of going without insurance.

      He behaved as if costs were no object all of the way.

      Now he is surprised that a visit to the ED with chest pain costs real money, especially when the ED visit is followed by an admission as a rule-out.

      Yes, it is really shameful, but not in the sense that you think.

    • Justin

      Condeming CYA is much easier said than done when you’re not the one on the chopping block if something bad happens.

  • Vox Rusticus

    This was not just an ED visit; it was a three-day admission through the ED for a chest pain workup. Fortunately, there was no cardiac cause. Would the patient have been happier if there was?

    Not buying health insurance when you have the opportunity is foolish, even if you are young. What if the presentation was for an MVA, with imaging, admission, surgery or just observation? Would you object just as much to the cost?

  • http://www.heartbeat-coaching.com Janet

    I’m with girlvet. I can see the points raised here, certainly. But the ER scared the guy into staying. This happened to my mom once. She had Alzheimer’s and would have been better off staying at her assisted living center, but they scared me into keeping her there for a stress test. It was not the healthiest option for her.

    Had they given sound medical advice – not to mention sound financial advice – rather than covering their butts, they would have been liable for a more reasonable amount of money.

    What if they had said to him, “look, it’s possible that this is a heart issue, but that doesn’t seem likely. We can’t give you a 100% guarantee, but we think it’s safe for you to go home. We do recommend a stress test to be on the safe side.

    “But without insurance, and without any compelling reason to keep you here, we think you should go home and make an appointment with your doctor. Besides, the stress of the bill you’ll get if you stay is more likely to give you a heart attack than anything that happened to day.

    “And for Pete’s sake, get on your wife’s health insurance!”

    • pj

      The big problem with your argument is, an ED Doc can’t do it both ways – if they advise anything less than what was done, they are risking their livelihood….

  • family doc

    “I think the guy could have taken his chances and had an outpatient stress test or something.”

    Yes, but the point is that he decided that he wouldn’t take his chances. He and his wife came in requesting the docs to rule out serious disease, making them liable. In the current liability climate, that means a big expensive workup.

    • Primary Care Internist

      not only that, but they felt it was serious enough to not just walk into the ER, but to call 911??? and then they second guess the rule-out-MI protocol???

      For all you posters out there who criticize “the system” for these costs being passed onto an uninsured patient, give us your office contact info, and I will gladly refer my “atypical low-risk” chest pain patients to you instead of the ER, so you can assume liability when that odd patient actually has an MI and you told them “look, it’s possible that this is a heart issue, but that doesn’t seem likely…. we think it’s safe for you to go home”.

      monday morning quarterbacking doesn’t fly with the current medicolegal environment.

  • HJ

    I find it interesting how the patient was supposed to make his own diagnosis…and go against medical advice. Is that what doctors expect of patients. Why would I even see a doctor in the end, I have to make the final diagnosis?

    Mike should have saved himself a lot of money and done consulted Dr. Google.

    • Anon EM doc

      He wasn’t told to make his own diagnosis. His doctor did a sufficient job of confirming that he wasn’t immediately dying. The patient was given the choice of leaving with the condition that he was releasing the doctor of any responsibility in the extremely low chance that his symptoms WERE due to an immediately life-threatening cause. He chose to stay.

      Yes, he should have Googled his symptoms and tried some Tums before dialing 911.

  • http://www.google.com Guest

    Why do people still continue to blame the doctors and the hospital for driving health care costs? They don’t understand that THEIR actions as patients has influenced and continues to mold our current health care climate. Docs, big hospitals and big bad pharma are easy scapegoats for those who don’t understand the real issues.

  • Taylor

    I want to know where he went where the hospital bill was only $11k! I had surgery June 09 and the bill was $33k. That didn’t even include anesthesia. Now I have insurance so it was reduced to $20k, but I still owed $3,000 as part of my coinsurance. I was shocked that the bill was $33k for a little over a day in the hospital and I shared a room with an elderly woman who would not shut up all night and day.

  • http://humanfactorinmedicineandlife.blogspot.com/ Syed Ali, MD.

    You are right on the mark. I once had a patient who was seen in the ER for a bee sting, he got a bill later on for $5000. His treatment included one dose of solumedrol $47, one benadryl $5 and one naprosyn 50 cents….. heart attack after seeing a bill….. priceless.

  • Jack

    Perfect example of DEFENSIVE MEDICINE that people complain about.

    Lawyers would have a field day if this guy actually had an MI. Who said TORT reform isn’t needed?!

  • Rick

    Google Missed Diagnosis and the Sokolove law firms wants to be your friend. This guy needed everything done. DO NOT miss an MI on young patients. You here hoof beats at that age think Zebra. Doctors are not paid to pat you on your back and send you home but to find the unlikely diagnosis.

  • paul

    this patient dialed 911 with chest pain to make sure he wasn’t having a heart attack. please enlighten me as to how one can accomplish that with certainty with anything short of provocative testing.

    the patients here need to tell us docs what the acceptable miss rate for heart attacks is for this society. if the number is “zero” you have no right to complain about “unnecessary” admissions.

    the docs here, including the author, who claim that this gentlemen needed none of this testing because it was “just heartburn” need to either show me some evidence that any aspect of the history, physical, or ancillary testing that can be obtained in the initial ed workup can guarantee a noncardiac etiology to chest pain, or shut their pie holes.

    i admittedly run chest pain in 29 year olds differently than this case was run but will never criticize someone else for feeling uncomfortable releasing a chest pain patient, up to and including admitting everyone with chest pain (the only known way to never send home an mi). and my opinion on this will not change until more realistic expectations are outlined and we are appropriately protected from the cases that inevitably will slip through the cracks.

  • Guest

    I have a unique perspective into a patient like this. I currently work on both sides of the border. (The US and Canada). I see exactly this patient all the time. And in most cases, I treat the exact same patient.
    The likelihood of serious in this patient is probably than 1%. In Canada, assuming normal EKG, I can take this risk and after a single troponin, send him home with a diagnosis “atypical chest pain”
    Exact same patient in the U.S. I cannot miss coronary ischemia in this patient. Although I may go an entire career without one of these low risk, atypical chest pains turning out to have real disease, it’s not a risk I’m willing to take as I could lose my life savings if I am wrong.
    We are allowed a Zero percent miss rate. Why should I risk my house for this?

    • weakanddizzy

      Buy this Guest a Beer!!

      • pj

        HERE HERE! Why in the world won’t we (politically) consider modeling the Canadian system? I mean really evaluate it, not dismiss out of hand just because of a rumor that they “wait longer for surgeries.”

        I don’t think that can be blamed primarily on trial lawyers.

  • Guest

    I was trying to say “I treat the exact same patient 100% differently”.

  • solo dr

    That bill likely included the stress test, three days of a hospital stay, the CT scan, and a bunch of other stat labs/studies. With insurance the bill likely would have been reduced by 50-75%. Many patients do not want insuracne but then they only want to pay a copay or small deductible for care. I carry a high deductible, $5,000 insurance policy, and in my 30s, and pay $870 a year for this BC PPO insurance. It is worth having the insurance, as one ER visit/admission would wipe out my deductible, but I save thousands annually with the deductible.

  • Hally

    11,000? I would have expected MUCH MUCH more. I don’t mean to be heartless, but I would have expected somewhere around 25k for 4 days in the hospital and all those tests. I hope he can work out a deal since he’ll be paying cash.

  • xyz

    i would have done nothing different. i would continue testing him until i could safely say there is no coronary disease. serial troponins, ekgs, telemetry, stress test, ct for pe. some of my ed colleagues even put nitro paste on, along with dose of aspirin lovenox, and a call to on call cardiologist and document their name in the chart, ………….not taking any chances…………this is US medicine…………….you pay for what you wish…………..no mistakes come with a price………………you will have to pay……………………and add yourself to your wife’s insurance…………….before next heart burn…………………and pizza……………..

  • Drashish

    It upsets me greatly where I read comments by girlveg and others who agree with her POV/perspective. First, I do feel sorry for the guy. Honestly, I don’t fault him. He’s young and grew up in this uniquely American “model of healthcare deliervy”.

    But for those like girlvet, Janet, kathi, and HG. I just don’t see why your so blind to the obvious, especially if you post on KevinMD which should mean you actually read what providers are saying.

    This is another reason why I don’t buy the academics figure of $50-80$ fir defensive medicine. It has to represent into the hundreds. In my town alone, we must add up to hundreds

    Bottom line, I went to medical school to treat the probably. Now I spend much of my clinical day ruling out the improbable. Not by choice. But lawyers ad patients want that. So as a result unfortunate souls like the patient end up paying
    the bill

  • http://fertilityfile.com IVF-MD

    I’m filing this post away for the next time somebody tries to argue that “defensive medicine doesn’t add all that much to the cost of healthcare”.

  • http://wingspouse.com Kathi

    Tell me again why Tort reform wasn’t a part of the new healthcare bill?

    • Primary Care Internist

      because obama is a lawyer.

      almost all of congress are lawyers.

      the handful of MDs in congress are not practicing, and have NEVER practiced primary care.

      and kathleen sebelius (head of hhs) was the chief lobbyist for the kansas trial lawyers’ assocation. doesn’t everyone see just how nuts that is???

      • http://www.google.com Guest

        EXACTLY!!!!!

  • Marc Gorayeb, MD

    I sympathize with Kathi in post no. 14 above. There is no excuse for us not to be able to tell patients how much what we are proposing to do will cost. In the current system, I cannot get that information, and that’s not right.
    Had this patient been told straight up how much this adventure in defensive medicine was going to cost him, I believe he would have come to his senses.

  • Maggie

    It’s rather sad that his initial response was to declare bankruptcy, not ‘how do I work with the hospital on the charges I incurred?’.

    Says a lot about the mindset of this 29-year old – feels no responsibility for payment for the services rendered for the medical care he agreed to. He was not forced to stay, he was adviced of AMA, as ALL patients who go home when the doctor thinks it’s a good idea to stay even if for a remote problem – the doc is damned if he does, damned if he doesn’t.

    This young man should go to the hospital billing department, fill out the paperwork necessary to document his financial situation and work out a payment plan – he should NOT declare bankruptcy on what is, in fact, a small size debt…..it’s less than a good used car for goodnesss sake. He can have it paid off in a year or two and at least keep his dignity by taking responsibility for paying for the services he received – and he’ll likely have the total reduced by the hospital if he just does the necessary paperwork to have his bill reduced!

    • Primary Care Internist

      absolutely agreed.

      i would bet this guy pays his cable tv bill. i’ll bet he doesn’t get all generic “store brand” groceries. and probably has a monthly cellphone bill which he pays. he probably drives a car and has car payments, insurance, gas, and DMV fees. He might even have a mortgage.

      But “healthcare” is a right, right? so the hospital, and the treating doctors (likely unpaid voluntary attendings who will never see a dime from such a patient) will get screwed.

  • http://wingspouse.com Kathi

    I think an important point is getting overlooked.

    Our healthcare system incents physicians to run every test, even when it isn’t cost effective (or even justified) because one oversight or rare situation will cost someone their license. If a patient won’t let them run a test, they become “non-compliant.”

    At the same time, the patient has been continually told that only the experts should make healthcare decisions. AMA intimidates the patient, much like an attorney might tell a physician an action will open them up to legal trouble. How many of you physicians regularly skip a test before diagnosing the obvious, even though you know any attorney would recommend otherwise?

    I’m married to a physician, so I’m a bit more bold than most patients. I ask two questions: What will it cost? How will it change treatment? I don’t usually get an answer for the first question, but asking the second question sometimes helps me decide if I want a test. STILL, when I deny that urine sample at my yearly exam (bc I have no symptoms), or refuse an amniocentesis (bc I wd still carry the baby), I am given a raised eyebrow and warned that I am denying them information to make a correct diagnosis. When I leave that $50 tylenol on the tray, I’m charged for it anyway. When I get up and leave because the $300 quote for blood work is showing up as $500 on the screen, I am reprimanded and warned I may be billed for the visit.

    Physicians shouldn’t argue that patients aren’t informed enough to make their own healthcare decisions and then argue that patients have the right to make their own decisions if they don’t want to pay for the healthcare. Which is it?

    • http://www.heartbeat-coaching.com Janet

      Great comment.

      Let’s also keep in mind, we don’t know this couple. I would bet that they’re nice people who were scared. We don’t know whether or not he gets cable TV and if he does, that doesn’t make him a spoiled brat.

      To me, the point here is that the system is flawed. When it’s more important to cover your butt – at the patient’s expense – than to give sound medical advice, something is wrong.

      I’m not blaming the physicians for this or the patient.

      To me, the point is, there is a big problem here. And the answer isn’t to blame anyone but rather to address the problem.

      Janet

      • Vox Rusticus

        The “system” isn’t “flawed” unless you count the unreasonable expectations of patients to consume costly care in the pursuit of impossible certainty as part of that “system.”

        The system delivered what was asked of it. Yes, expensive, and overkill as seen by the Monday-morning quarterbacks through their finely-focused retrospectoscopes.

        If the patient had been sent home after the initial ED visit without the admission and subsequent testing, and he died or just had a second event like an MI, the patient and family would likely blame the doctoras and hospital, looking for a payday.

        I am with the poster above that says you can plug your pieholes if you don’t have a way to deliver the same level of certainty in diagnosis in a simpler and cheaper way.

        • Matt

          “The “system” isn’t “flawed” unless you count the unreasonable expectations of patients to consume costly care in the pursuit of impossible certainty as part of that “system.”

          When they don’t pay for it and the providers have no incentive to care about the cost, and the providers market themselves as being able to do anything, what do you expect?

    • Vox Rusticus

      Re-read the story.The situation was that care was requested regardless of costs, and in the ED. The patient called an ambulance. He wasn’t price shopping. He was told by the resident of the low probability of a heart-related diagnosis and told he could leave if he wanted, but that would also be against medical advice He was told that if he left he would be responsible for that decision. Apparently he did not wish to assume that responsibility. He knew he didn’t have insurance–he hadn’t paid for any–yet he insisted on staying for admission and further testing. He appaerntly did not care about the cost of that choice. He was told, at least the story suggests, that further testing was only to cover the already small remaining risk of cardiac-related disease as a cause of his indigestion symptoms. Cost was apparently not a concern at the time. He was apparently not interested in knowing a cost/benefit analysis of his decision.

      Now he gets a bill for the whole adventure, and it is substantial (but payable in the usual process of working out a payment plan with the creditor). Instead, this 29-year-old now wants to entertain personal bankruptcy.

      This is not a tragedy. This is the consequence of poorly-considered risk-taking–not buying insurance when the opportunity is available, and demanding emergent care with no apparent concern for cost or necessity.

      • Jeff Taylor

        ‘He was told that if he left he would be responsible for that decision.’

        This shows the stupidity of the US ‘system’. In most developed countries an ER doc would take responsibility for telling the guy to go home, but to come back if certain symptoms appeared/became worse. This has little to do with tort reform and everything to do with being a physician.

        • Maggie

          He was seen by a RESIDENT….the guy didn’t even ask to see the ATTENDING.

          One of the biggest problems is that the above is a shining example of why discouraging clinical judgement, through fear and intimidation of malpractice suits if you don’t follow the standards of care to the letter, lead to higher costs.

          This RESIDENT didn’t want to take the leap and use clinical judgement – that the guys odds of dying, at 29, of a heart attack were less likely than being struck by lightning…..the guy was more likely to die in a car accident going home than keeling over from an MI.

          The 29 year old didn’t want to even use some common sense – didn’t ask, hey Doogie, what’s may odds or dying….no conversation of risk-benefit or odds or anything…..the RESIDENT didn’t want to make the wrong decision and the ATTENDING wasn’t brought in for further consultation.

          All in all though, the 29-year old is still responsible for the cost of services rendered.

    • Jack

      I agree with the post as well. However we live in a very litigious society with lawyers stirring the pot. Medicine is like a lottery ticket. Even if the patient “choose” not to under go the test despite given the information, he/she may still sue the practitioners for “not providing sufficient information for a lay person” or “I didn’t know better or didn’t completely understand the consequence”….”he is the doctor and SHOULD have STOPPED me”….

      Sure the lawsuit may get thrown out but just the thought or process of going through these lawsuits would make the doctors order the tests.

      • Matt

        ” Medicine is like a lottery ticket. ”

        Show me a med mal victim that feels like they won the lottery!

        • Primary Care Internist

          true, “victims” may not feel like lottery winners, but i know plenty of “1-800-lawyers” types who are rich from med mal. These guys were the bottom of the barrel students at mediocre law schools.

          my cohorts from undergrad (ivy league) who went on to law school universally stayed away from what they describe as “ambulance-chasing”.

        • pj

          Matt- pls see post 18 above.

  • Finn

    Seems to me that the real problem here is that both sides are operating out of fear: the patient, because his wife scared him, and the hospital, because it’s afraid of being sued.

    That said, I think the only thing wrong with the patient’s bill is the charge for the 3rd day. It’s not his fault that the hospital’s equipment was broken so he shouldn’t have to pay for the additional overnight stay that it required.

  • John

    A call to the 24 hr advice nurse might have prevented the trip to the hospital. In triage, she/he might have eliminated the heart attack potential and concluded with the same result. No $11,000 hosptial bill.

    • Primary Care Internist

      you are delusional if you think a “24 hr advice nurse” would tell ANYONE with chest pain anything short of “go to the ER” or “call your doctor right now”. They are not going to assume liability, and I’m sure their employer (insurance company generally) has schooled them extensively on punting anything and everything to a doctor/hospital.

      These types of programs are just purely for marketing purposes, and I have NEVER seen or heard of any actual clinical benefit to my patients, or my colleagues’ patients from this.

      • pj

        Ditto

  • http://www.myheartsisters.org Carolyn Thomas

    Hello from Canada, the commie-pinko land of socialized medicine, where all medical care during my heart attack (E.R. visits, all diagnostic tests, O.R. procedures, nursing care, all drugs while hospitalized, CCU post-op recovery bed, and all follow-up appointments with cardiologists and other doctors since then) has not cost me one dime.

    I was lucky to have made it that far, however, as I was also one of the many women who are misdiagnosed in mid-heart attack and sent home from the E.R. with an acid reflux diagnosis (women under the age of 55 are seven times more likely to be misdiagnosed like this) – despite presenting with textbook symptoms like crushing chest pain, nausea, sweating and pain radiating down my left arm. I left the E.R. that day feeling supremely embarrassed for having wasted their valuable time and because I’d made a fuss “over nothing”.

    Two weeks of increasingly debilitating symptoms ensued – but hey! at least I knew it wasn’t my heart, because a man with the letters M.D. after his name had clearly told me it was just indigestion! Finally, when the symptoms became unbearable, I returned, but this time taken directly from E.R. to O.R. with a 99% blocked coronary artery.

    Docs can’t win: if you send home a patient like me because the cardiac enzymes, EKG and treadmill stress tests are “normal” (also common in women with single-vessel disease) you risk missing a potentially fatal heart condition. If you keep them for observation or more tests, at least in the U.S., it can mean financial ruin for the patient.

  • gzuckier

    I’m with the folks who think brushing off a possible MI is a bad idea.Young healthy folks have MIs too. A low probability of a disastrous event is nothing to ignore. Expecting the guy to pay for a weekend of IP monitoring because nobody wants to do the necessary workup over a weekend is out of line, as is expecting him to pay for another day because the machine is broken, as a lawyer might be able to point out. I also agree that $11,000 seems pretty low. I wouldn’t be surprised if there are another slew of itemized claim lines in the pipeline which haven’t come forward yet.

    Note that in a case like this, the insurer would pay the bill without quibble (except for maybe that additional day’s stay for broken machinery), an indication that care was not overdone.

    The argument that this is just CYA medicine in case the patient goes home and dies with a heart attack after all takes the position that the patient going home and dying with a heart attack that could have been prevented is something to be shrugged about; hey, nobody’s perfect, some lawyer will just pick on this silly little thing. I find that attitude highly unacceptable. Saving $11,000 by risking the life of 29 year old because the odds were pretty good he wouldn’t die is the kind of thing that gets you on 60 Minutes answering embarrassing questions.

    As for the patient? Who “forgot” to sign up on his wife’s policy? Perhaps he should focus less on losing his house over a stomach ache than on what would have happened had this been an actual heart attack and just the beginning of a filing cabinet full of bills, and he having forgotten to get insurance. Our local court spends at least one morning a week on nothing but the lawyer for the local hospital presenting case after case of unpaid bills, for patients who are uninsured, underinsured, or insured but fallen through the cracks.

    This is why the insurance companies are so hardnosed about preexisting conditions, etc. and pressuring the administration into requiring that everybody buy insurance. They’re already trying to deal with enough people who try to work the system by signing up for healthcare when they’re already sick (maternity being an “illness” whose financial course over time is relatively predictable, for instance).

    The whole thing makes universal coverage sound pretty good, doesn’t it? Whether single payer, multiple providers via insurance exchange, government plan, private insurers, whatever.

  • Baldedoc

    Look I’m not even going to address the CYA/defensive medicine debate because I see no possible common ground between those who expect physicians to put their own families welfare above a patient’s medical bill but the whole “I have to go bankrupt” thing is utter BS.

    There is not a hospital billing department in the country that isn’t willing to give 30-50% off almost immediately if you are unable to pay followed by setting up a payment plan. Then, in the vast majority of states they are unable to take any legal action if you make a “good faith effort” to pay which is usually negligible (ie in GA that is defined as $1/MONTH). The most that will happen is that the most aggressive of hospitals will trash your credit rating but so what? It’s not like bankruptcy won’t. That’s why Dave Ramsey puts medical expenses behind all other bills including unsecured credit cards when you’re negotiating bad debt.

    And this is all moot if the hospital has some sort of indigent plan like all of those I’ve worked at which writes off the bill completely.

  • http://healthtrain.blogspot.com Gary Levin MD

    This is another one of those obscene occurences that regularly occur. It is systemic and requires changes to the system. This is not, nor should not be the burden of a patient. In the ideal world the decision should not be made by an attending who has not interviewed nor seen the patient face to face. This will only get worse with the advent of telemedicine. A quick troponin level would answer the question of an AMI in several hours, not days. A further obscenity is created by the hospital employee stating that the stress test is not done on the weekend. (this is to save money by not having personell on scene to do the test. Perhaps a cardiologist on call should do an emergency stress test if there is a question one needs to be done in an acute situation why wait two or three days?
    A senior administrator or medical director should be avaialbe to review the charges before they are sent out. It is too easy for a bill like this to be generated by the hospital’s billing system adding up bottles of medications, IVs charges for tubings, etc. Any other business such as an automotiver repair shop would review expensive bills prior to sending them out to a customer. This patient should be righteously outraged at these charges. Too long has medicine hidden behind trite excuses for excessive charges. The whole incident could have been avoided by a triage nurse in person and/or a telephone call. It has nothing to do with the threat of being sued.

    • http://www.myheartsisters.org Carolyn Thomas

      Hi Dr. Levin – Loved your automotive repair shop analogy! Trouble is, I’m not going to drop dead if my mechanic misses my alternator problem.

      And that stress test idea may perhaps be true for male patients. However, treadmill stress tests are famous for NOT identifying heart disease in women, particularly for single-vessel or non-obstructive disease (twice as common for us as multi-vessel obstructions are). Most cardiac diagnostics for the past three decades have been developed and researched on male subjects, with women represented in statistically insignificant numbers, if at all. Cardiac enzymes like troponins, for example, peak far later in women than in men.

      Like many other women, I was sent home from the E.R. (after a five hour visit) in mid-heart attack despite “normal” troponin levels, EKG and treadmill results. The New England Journal of Medicine, reporting on misdiagnoses of women’s cardiac events in the E.R., concluded: “Women younger than 55 were SEVEN TIMES more likely to be misdiagnosed than men of the same age. The consequences of this were enormous: being sent away from the hospital doubled the chances of dying.” More on this at: “Heart Attack Misdiagnosis In Women” – http://myheartsisters.org/2009/05/28/heart-attack-misdiagnosis-women/

  • Tbabcock

    “15 minutes later he was on a gurney tolling through . . .”
    I guess I might have been more realisting in evaluating the risk. If a history and risk assessment indicated he was low risk I would tell him, go home for now and return in 6 hours for a repeat cardiac enzymes. Come back immediately if symptoms return, but here is a tablet of pepcid. And follow up with your doctor to decide if you need further evaluation. If i was wrong, and he had another “event, ” he is only 15 minutes away, and how long would it take for the hospital staff to react and get him to more urgent care? There is also the minor issue of the extra day because of equipment problems on Monday–shouldn’t the hospital be responsible for that part of the stay?
    Yes, he should have gotten on his wife’s insurance, or have taken aadvantage of the right to continue short term with the existing policy. But that does not really excuse lack of judgment by the physician. You pay a physician for his or her expertise, and should not have to be given an AMA (“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,”) form that can be presented in such as way as to coerce the patient into staying. Expertise should mean having a skill set suitable to make a reasonable assessment of risk, and a willingness to convey that risk effectively so that the patient can make an informed decision. And when a decision is made by the patient based on that risk assessment, there is nothing “against medical advice” about it.
    Let’s also be realistic about the risk of dying from a second cardiac event, having perhaps just survived the first. If that is going to happen, being in the hospital rather than 15 minutes away may provide very little real advantage in survivability.

  • chad

    i’m an er doc. i can assure you that there is no incentive to order less tests in the emergency department. and until us docs dont have to be lawyers too, that will not change. in fact, less and less kids are going to be encouraged to be docs because lawyers run medicine. it is a fact. i practice medicine LARGELY from a defensive standpoint. many would say that is a good thing for the patients. WRONG WRONG WRONG! common sense with good science is what i should get to use. instead we order CT scans on everyone and their brother because we aren’t allowed to miss anything. if i told you i should be allowed to miss 1/100 people with a heart attack who present with chest pain you would think i was crazy. yet in order to practice sound medicine that is true- otw you are ordering too many tests and admitting too many patients. yet i am not allowed to miss any!!!! and mind you these are ssi disability pts licking their chops to win the lottery off of me. it’s a ridiculous system and the only reason i comment on boards like this is to vent and walk away. i can’t wait to not practice this kind of medicine, which means i can’t wait to be done with medicine. also, i’m a normal young doc and most of us normal docs feel this way. we should strike lol.