Why the ER admits too many patients

Every player in the medical arena has found itself challenged by conflicts where one’s self-interest competes can skew what should be pure advice.   This issue is not restricted to the medical universe.  Every one of us has to navigate through similar circumstances throughout the journey of life.  If an attorney, for example, is paid by the hour, then there is an incentive for the legal task to take longer than it might if the client were paying a flat fee.

The fee-for-service (FFS) payment system that had been the standard reimbursement model in medicine has been challenged and is being dismantled because of obvious conflicts that were present.  (This is not the only reason that FFS is under attack, but it is the principal reason offered by FFS antagonists.)  Physicians who were paid for each procedure they performed , performed more procedures.   This has been well documented.  Of course many other professions and trades still operate under a FFS system, but they are left unmolested.   Consider dentists, auto mechanics and plumbers and contractors.

FFS is not inherently evil.  But, it depends upon a high level of personal integrity which, admittedly, is not always present.   In my own life, I often hope and pray that the individual who is offering me goods or services is thinking of my interests exclusively.  Am I living in fantasy land?

The Rand Corporation released a study in May 2013 that demonstrated that emergency rooms accounted for about 50% of hospital admissions during the study period from 2003-2009.  When I have posted on emergency medicine in the past, it has stimulated a high volume of responses, some good, some bad and some ugly.

I think it is inarguable that emergency room (ER) care wastes health care dollars by performing unnecessary medical care.  As a gastroenterologist, I affirm that the threshold for obtaining a CT scan of the abdomen in the ER is much lower than it should be.   And, so it is with other radiology tests, labs, cardiac testing, etc.

I understand why this is happening.  If I were an ER physician, I would behave similarly facing the same pressures that they do.  They face huge legal risks.   They are in a culture of overtreatment and overtesting because they feel more than other physicians that they cannot miss anything.  They argue that they have only one chance to get it right, unlike internists and others who can see their patients again in a follow-up visit.  If an ER physician holds back on a CT scan of the abdomen on a patient who has a stomach ache, and directs the patient to see his doctor in 48 hours, what is the ER physician’s legal exposure if the patient skips this appointment and ends up having appendicitis?

Keep in mind that we should expect that ERs to have higher hospitalization rates of their patients, since their patients are much more likely to be acutely ill.

But even accounting for the sick patients in the ER, I think there is a significant percentage of ER patients who should be sent home and are sent upstairs instead. This would be an easy study to perform.  Compare the intensity of testing between the emergency room and a primary care office with regard to common medical conditions.  I would wager handsomely that the ER testing intensity and admission rate would be several fold higher than compared to doctors’ offices.  Want to challenge me on this point?

Even though I understand why ER docs do what they do, it is a bleeding point in the health care system that needs a tourniquet.

It is clear that ER physicians are incentivized to admit their patients to the hospital.  Of course, they might be “encouraged” to do this by their hospitals who stand to gain financially when the house is full.  Leaving the financial conflict aside, when an ER physician admits a patient, he is completely free of the risk of sending a patient home who may have a serious medical issue. I am not referring here to patients who clearly should be admitted, but to the large group of patients who most likely have a benign medical complaint, but the ER physician advises hospitalization “just to be on the safe side.” These same patients if seen in their own doctors’ offices would never be sent to the hospital to be admitted.

Where’s the foul here?  Here are some of the side effects of unnecessary hospitalizations.

  • wastes gazillions of dollars
  • loss of productivity by confining folks who should be working
  • departure from sound medical practice which diminished the profession
  • emotional costs to the individuals and their families
  • unnecessary exposure to the risks of hospital life

How can this runaway train be brought under control?   First, let’s try a little tort reform.   Second, pay a flat rate for an ER visit.  Under this model, if the ER physician orders an MRI on a patient with a back strain, the hospital swallows the cost.  Finally, when hospitals are penalized financially for hospitalizing folks who should have been sent home, we will witness the miracle of a runaway train performing a U-turn on the tracks.

While the Rand Corporation’s results are not earth shaking on its face, my intuition, insider’s knowledge and a tincture of cynicism all converge on the conclusion that for too many patients the ER has become a portal of entry in the hospital.  Is the greater good served if the ER is a revolving door or barricade?

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower

Comments are moderated before they are published. Please read the comment policy.

  • http://drwhitecoat.com/ White Coat

    What is it with people who have little or no knowledge of emergency medicine thinking that they have the insight to comment on all the factors that influence emergency medical care? You have “insider’s knowledge”? Puhleeze. Sounds more like a case of megalomania to me. Many of the assertions in your little “insider’s” revelation have no basis and are flat out wrong.

    “Inarguable” that the emergency department performs unnecessary medical care? OK, doc. Tell me what tests that ED physicians regularly perform that are “unnecessary.” I’m sure that you have tomes of instances of inappropriate care just waiting to be published on your blog. Blow the whistle, why don’t you?

    You “think” that there are more patients who are admitted who should instead be sent home? What’s the basis for your “thought”? I’m guessing that you don’t admit patients personally. You’re a consultant. You have no basis for making that statement. On the outside chance that you practice general medicine, here’s an idea if you’re inundated with “inappropriate” admits: Drag your whining buttocks to the emergency department and evaluate the patient yourself. Then YOU write the discharge orders. Think of all the “inappropriate” admits you could prevent! In twenty years, I’ve seen exactly two doctors ever do that. While we’re at it, here’s a little more “insider’s knowledge”: Emergency physicians don’t admit patients, the hospitalists and primary care docs do. Emergency docs don’t have admitting privileges. So if you’re so concerned with all of the “inappropriate” admissions, point the blame where it belongs. Emergency physicians can’t admit a patient without another physician willing to accept the admit. Ooooh. Stop the presses. Maybe emergency physicians and hospitalists are conspiring to defraud the government. Of course, it wouldn’t be politically correct to piss off your primary care docs and hospitalists by alleging that they’re committing fraud. If you did so, they wouldn’t refer patients to you.

    In your little study about intensity of service and admission rates, make sure that you count all the patients sent to the ED from their doctors’ offices with specific instructions to have the testing performed, and also make sure you count all of the patients who have been to their doctors offices several times with the same problem and who get little or no testing done. Those should count as one visit, not multiple visits. And to compare apples with apples, make sure that you compare ED testing with office testing on NEW patients as opposed to established patients since emergency physicians have little or no prior knowledge about the histories of pretty much every patient they evaluate.

    Alleging that emergency physicians engage in widespread healthcare fraud by colluding with hospital administrators to fill hospital beds with patients who don’t really need to be admitted (wink wink) borders on being libelous. First, if patients are admitted and being held in the ED for beds (a frequent occurrence), then ED throughput is diminished. That makes emergency departments less efficient, not more profitable. Second, emergency physicians get paid based on intensity of service, not on hospital admissions. Just another example of your utter lack of understanding of the economics of emergency medicine. Maybe you haven’t heard about RAC audits. Maybe you don’t know about the two midnight rule and its implications. If you don’t know about these things, you need to educate yourself before pontificating about a specialty you obviously know little about.

    Stick to commenting about your own specialty and stop demeaning yourself by creating these uninformed linkbait posts.

    By the way, have you ever written anything about how often gastroenterologists perform unnecessary endoscopies, Dr. Insider?

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Not sure I understand why we are comparing ER visits to primary care visits. Isn’t there a difference between calling a doctor’s office and asking for a lunchtime appointment for a tummy ache, and showing up with a stomach ache at the Emergency room at 2 am? People don’t do this stuff for fun, do they? Is it possible that the patient feels a different sense of urgency in these two situations, and shouldn’t that be brought into account in a patient-centered, participatory, and whatever, post-fee-for-service world? And if the patient’s perception is given consideration, that may cause one to err on the side of caution and perhaps order a few more tests, or even admit someone needlessly, which is best ascertained after the fact…. I would think….

    As to paying a flat fee for each ER visit, that’s fee for service too, only calculated differently. This flat fee will have to be set high enough to cover the current case mix, or maybe a bit lower to get some “savings”. So now we pay lots of money for simple stuff, and hospitals will be perversely incentivized to attract as many simple cases as they can, get rid of urgent cares, and ramp up advertising. And then, people will start to die…. Question is how many deaths per each dollar saved are acceptable in the this pay-for-value system… this complex math is way above my humble non-linear tensor analysis proficiency….

  • Traderjohn

    White Coat makes some excellent points. The author simply has no idea of what he speaks (er, writes). The admission criteria is getting increasingly stringent on Emergency Physicians (EPs) and more often than not I’m ‘selling’ the patient to the Hospitalist in order to obtain a SAFE disposition. I get no financial reward one way or the other.

    My main concerns are 1) making a legally defensible disposition, 2) ensuring the safety of the patient, and 3) preventing the all too numerous bounce backs we frequently receive from repeat EMS transfers (want to talk about waste of healthcare dollars!!).

    The article completely avoids, likely out of naiveté, the reasoning for a good percentage of my admissions: social work. We have case managers and social workers during the day in our medium-sized ED. But this doesn’t come close to addressing the problem, Without boring readers with the details, here a few representative examples:

    1) The psychiatric hold that isn’t cleared to go to the County crisis center. This could be as ridiculous as a blood alcohol over 80 or tachycardia of 101.

    2) The elderly patient who uses a walker, had a fall and lives alone. We can’t get rehab or SNF level of care set up after business hours.

    3) The homeless person who has an urgent but not emergent medical issue with no resources to get adequate care as an outpatient (again, especially after business hours and on weekends – our busiest times). A few that to mind are the patient with a small DVT or PE but no money for anticoagulants; hyperglycemia just short of DKA with no resources for insulin; or the patient claiming they want to stop drinking and already in early withdrawal with too high an SAS score (Californias EtOH w/d severity scoring system) to discharge to the street.

    I could go into many more examples, but I think this makes the point that the author simply has no idea what he is talking about.

    • Steven Reznick

      Trader John made great points. EMS arrivals especially the frail elderly from SNFs and ALFs are impossible to discharge. Their multiple chronic problems plus poly pharmacy make correcting an acute problem complicating chronic issues difficult. Couple that with no one available to help them at home and no one to receive them at facilities after hours and you realize how impossible the ER docs job is. Couple that with CMS mandates and patient satisfaction requirements necessitating a disposition in under three hours and the job gets even tougher.
      I think an impact can be made in younger healthy adults who received little or no health literacy training in school and get most of their data from the internet and from sales people. Things like cuts, scrapes, abrasions , trauma without fractures, simple viral upper respiratory tract infections, self limited viral gastroenteritis all end up in ERs or the urgent care centers because no one has a personal physician anymore and they are too health illiterate to care for illness and injury that there parents and grandparents routinely cared for. When they go to these facilities defensive medicine rules in ERs with good reason, while profit motive rules in private walk in facilities.

    • John L

      Note that #2 will not be eligible for rehab under Medicare rules, as simply falling without a fracture requiring surgery or some other acute medical illness will not merit a full inpatient admission. Not saying that you should send the person home, but I see a number of people admitted and told they will need to go to rehab by ED docs who are (at my institution) wholly unaware of whether that is even possible.

  • Thomas D Guastavino

    In 1983 I spent my last two months of my surgical internship year on the internal medicine service at a VA hospital. By June we noticed an almost three fold increase in the number of ER admissions, most for relatively minimal complaints. We found out later that the reason. Apparently the hospital reimbursement by mid year was tied to the number of beds filled. So the ER was given its marching orders, admit everyone so as to fill the beds.
    The moral. No reimbursement system is perfect. you go with the system that has the least margin for error and the most self correctable. In medicine that is-wait for it- fee for service. In any human endeavor the model that works the best is the one where there is the most freedom of choice between the parties with the least amount of outside interference. The ER is no exception. The big complaint against FFS, that it encourages over testing and over proceduring (Call it OTOP) is controlled in the following ways:
    1) OTOP damages a physicians reputation
    2) Patients can question a physicians decisions and if not satisfied seek counsel elsewhere
    Not enough? How about this. If an insurance carrier feels the need to question a physicians decisions then expand the second opinion system. Create a random rotating list of willing like specialist physicians
    who are willing to participate. The patient is asked to go to the is physician who is paid solely to review the records and provide an opinion as to the necessity of the care. No liability, no opportunity to take over then care.

  • Eric Strong

    Agree with White Coat and Trader John below. As a hospitalist, the majority of unnecessary (or more appropriately termed, avoidable) admissions are for social issues. A minority of them is because a subspecialist chooses not to come in to the ER after hours, and instead tells the ER or admitting medical service to admit the patient and they’ll be seen in the morning. It’s uncommon for a ER doc to admit a patient for a primary medical reason which is unnecessary, particularly as pointed out elsewhere, an admitting physician must be willing to accept the new admission – and the many such admitting physicians are either salaried hospitalists or housestaff, who get 0 (or close to 0) compensation per admission (i.e. it is in our personal best interest to not admit patients). I also can’t imagine how a hospital would incentivize ER docs to admit more patients as the author claims.

  • White Coat Investor

    A flat rate for emergency visits is a terrible idea. If there is anything worse than being incentivized to order more tests on a patient, it is being incentivized to do fewer. Remember the 90s and managed care and capitation? That worked well.

    Right now I’m often in the position of talking patients OUT of tests that they want. It’s far easier to just order the test. The hospital loves it when I order tests, but I know it’s not the right thing to do for the patient’s health and the patient’s pocketbook. So I’m usually able to talk them out of it with a little education instead of having to “be a wall.”

    You also use a straw man argument with your comment that EPs order more tests “on the same complaint as a primary care doctor in his clinic.” It’s a different population of patients. The primary care doctor is seeing patients with private insurance, who have demonstrated they can and will follow-up in an outpatient clinic, who the doctor has met many times before, and who have been able to wait several days for their appointment. In the ED, the patient feels he is having an emergency, has only been having symptoms for minutes or hours, may not have insurance, hasn’t demonstrated that he will actually follow-up, may be high or drunk, and has neither been seen before nor will ever be seen again by the emergency physician. Totally different.

    Last, emergency care only accounts for 2% of health care spending. Even if you cut it by 50%, it isn’t going to fix the problem. As long as we’re pointing fingers at other specialties, I wonder how much could be saved by avoiding all these unnecessary colonoscopies and endoscopies….

  • HJ

    My spouse was SOB and sought the advice of his primary care physician. After evaluating the situation, the PCP sent him to the emergency room to be admitted to the hospital.

    There are no primary care physicians in my area that provide hospital care and I would guess every one of them would send patients to the ER to be admitted.

  • MKirschMD

    I have read the comments to my post on this blog and
    elsewhere. Regrettably, some have
    resorted to vituperative language and demonization, rather than to engage in
    civil discourse and debate. If I have
    made factual errors regarding the reimbursement of ED physicians, then I am
    prepared to stand down from these comments.
    The fact that one commenter above who was particularly critical of me
    wrote, “the hospital loves it when I order tests”, suggests that there do exist
    economic incentives. I am not prepared
    to retreat, however, from my belief that over-diagnosis and over-treatment are
    embedded in American medical culture.
    This is an undeniable fact. If
    some commenters wish to opine that their specialty is somehow not part of this
    reality, then they are free to do so. I
    think they have a tough case, but they are free to make it. Regarding my own specialty, I have written
    more than once under my own name, and expressed elsewhere, that my specialty
    and me personally are part of the problem.
    A fair minded reader of my own blog would already know this.

    To write and circulate throughout the internet that I am an ‘ER
    basher’ may have some red meat appeal, but it is false and defamatory. I write in my post that “If I were an ER
    physician I would behave similarly facing the same pressures that they do”. I continue for several sentences offering a
    sympathetic view of emergency medicine physicians. Not quite my definition of a ‘basher’.

    Regarding my NY colleague’s assertion that
    gastroenterologists are not qualified to evaluate acute abdominal pain, I
    believe that the other physician readers will agree that this claim has no
    basis. In my experience, we are the
    specialists who are first responders to acute abdominal pain.

    Responding to the claim that emergency room physicians do
    not admit patients, this needs some context.
    While ED doctors may not sign the admission order, they have often
    advised patients and later the admitting doctors that the patient needs
    admission. How many times have
    emergency physicians called primary care physicians or consultants telling us, “this
    guy needs to come in”? This is a proper
    exercise of their role, in my view. It
    is somewhat disingenuous to claim that “Emergency physicians don’t admit
    patients”, which may be only technically true.

    Finally, personal attacks only demean the attacker and
    provide little opportunity for a dialogue that could offer all participants the
    chance for a civil airing of divergent views.
    We can do better than this and we should.

    • Page

      I’m an EM resident and the idea of calling a GI doc to evaluate a patient with acute abdominal pain is simply absurd to me. There is very little a GI doc has to add that a surgeon or internist can’t offer. I literally cannot think of a single time that I’ve called GI doc to the ED for acute abdominal pain.

      I’ll concede that an ERCP can be useful in acute abdominal pain, but that’s usually upstairs after the surgeon says “hey, we need to call GI.”

      Note, I’m not saying that I don’t think GI docs are exceptionally important, just not for acute abdominal pain. Chronic abd pain? Of course. GI bleed? Who else am I going to call!? Acute abd pain? No way.

    • Graham Walker

      I’d really like to hear your responses to Movin’ Meat and WhiteCoat’s comments, as well as everyone else in this forum.

      According to my back of the envelope calculation, I see somewhere between 500 and 1000 patients per year with abdominal pain, most of them acute. I can think of two, maybe three indications for calling GI (which is still usually done by the hospitalist, and not as an ED consult): choledocholithiasis and cholangitis. When I call an ED consult for acute abdominal pain, I consult surgery most commonly, then OB-Gyn, then the hospitalist for admission (pancreatitis, usually, although we send most of those home as well), then pediatrics for admission (for serial exams). I probably consult radiology (intusseception evaluations) as often as I consult GI for acute abdominal pain. I’d guess I call GI 3-5 times a year.

      I think the other problem is you’ve chosen to pick on emergency physicians, and we’re a little more than familiar with the magical retrospectoscope that other physicians love to apply to our care, especially when they have no knowledge, experience, or training in our field.

      If you’re so convinced that patients are being inappropriately admitted to the hospital, are you sending these cases to your hospital’s QA committee? Are you immediately discharging them from the hospital? I’m amazed at how many patients get “reluctantly admitted” by a consultant, eyes rolled, who are still in-house 4 days later.

      You cannot compare testing from a primary care physician’s office to that of an emergency department; the pre-test probability of disease is much higher in an ED, the standard of care is arguably quite different, and the patients are complete strangers to us. If we have no way of knowing that “Mrs. Jones’s daily headache” is always sudden onset and thunderclap in origin, are you really going to fault us for doing a workup for subarachnoid hemorrhage?

    • http://drwhitecoat.com/ White Coat

      You do little to address the issues that were raised and you continue to make assertions of fact without any basis, but I’ll put up a response on my own blog so my comments don’t get deleted again.

    • dbr1

      I think the problem is that your piece is founded on a falsehood: that ER MDs have financial incentives to overtest and overadmit. This is in almost every case inaccurate, and is defamatory to a whole group of providers. Of course it provoked an angry response, although things should not be made personal.

      If you had simply said that in US healthcare there is a culture of overtesting and excessive caution largely because of fear of malpractice, and that this effect is very strong in Emergency Medicine you would have been much more accurate.

      No matter how much you say you empathize with ER MDs, you still come off as a consultant who is aggravated by the personal inconveniences of dealing with phone calls and consultations from the ER and has found a way to understand the reason for those inconveniences as based on the worst of motives.

    • Steve

      We can argue back and forth about admission criteria and costs but this comment is stupefying to me:
      “In my experience, we (gastroenterologists) are the specialists who are first responders to acute abdominal pain.”
      Is that a joke? While technically acute abdominal pain can last for up to 12 weeks- what patient sees you without having been to the ED or their PCP’s office? Providers in the ED and PCP offices are the ones who see these patients first in the first hours to days to even weeks of their illness. It’s only after an evaluation by one of us that they make it to your office. By that time, we have triaged and treated those that don’t need your services. This is a large percentage of patients whom never enter your consciousness because we took care of their issue without your services.
      Your follow-up comments did little to un-disturb the hornet’s nest. I see little value in a gastroenterologist who has no experience working in EM commenting on how we should fix our system. The ED always seems to be the easy target for these rants but most come to the table with very little hard data to back up their arguments. The reality is that we are the ones seeing that truly acute abdominal pain at zero dark thirty and making that decision of whether or not to do a CT while the rest of the world sleeps.
      As shadowfax pointed out in another post, we are making great strides towards avoid admissions in conditions that used to be a “slam dunk” and are managing disease in the outpatient realm that would have been considered ludicrous 10 years ago. We are closing in on a solid literature base that will allow us to discharge low risk chest pain with rapid troponin and EKG rule outs in only 2 hours. Some are already practicing this way- I predict an official ACEP clinical policy within the next 2-3 years.
      If we are serious about fixing healthcare costs we should refrain from casting stones at other specialties when we have no clue about how they actually operate. Let’s have productive conversations within our own specialty and start fixing what we can personally control.
      -Steve Carroll, DO
      @embasic
      steve At embasic.org

      • Steve

        I would also like to go on record that I completely agreed with one of your previous posts regarding whether GI docs should do ACLS. I posted a comment supporting your assertion because I agree with it. That blog post was well thought out and written and its topic was something that you are familiar with. This post- not so much.

    • Lynne Flaherty

      As someone who has practiced in the ED for over 20 years, I think you have some good points in your original essay. It is much easier on my blood pressure to admit a patient than to send them home. There is, however, no financial incentive to do so — I am paid by the hour, regardless of the patients I admit or the tests I order.

      Having recently been through a horrible experience, where a totally unexpected bad outcome led to three years of misery and financial hemorrhage, I will tell you that my threshold for testing and admission has definitely changed. I learned, through my trials, that it is far more difficult to criticize a physician for tests he ordered that may or may not have been required, than to crucify a physician for trying to use common sense, experience, and evidence to eschew testing. It’s the same with admission. I know that over 90% of the chest pain admissions result in the uneventful discharge of the patient in 24 hours, but the literature simply won’t support me in sending more patients home. I’m not allowed a 4% error rate; I’m not allowed ANY error rate.

      Add in the pernicious effect of “patient satisfaction scores”, and you have a heavy incentive (none of it really financial to me) to give patients what they want. As I characterize my job to non-medical folks, it is to make people happy without causing any trouble. If, in the middle of all of that, I actually provide some good medical care, that’s a nice extra. But nobody really cares.

    • wva88

      I have yet to meet a GI physician who would even touch acute abdominal pain. They will come in for an intervention only after they have been seen by a general surgeon and there is a definitive imaging study showing an indication for intervention.

      The same thing on the outpatient side. GIs will accept a patient visit only after they have seen their primary care physician several times, have had a complete battery of imaging and laboratory exams, and still have not had resolution of symptoms. There are two in my area who will only accept patients if they have previously seen a general surgeon.

      So the idea that GI are the “specialists who are first responders to acute abdominal pain” is ludicrous. For this to be true, you must be saying that you are the FIRST physician to see a patient with an abdominal complaint. That is demonstrably false. Even a referral for ACUTE abdominal pain from a PCP will always be met with a “send them to the ED.”

      As mentioned, no GI physician I know will accept a patient for an outpatient visit “off the street.” A referral from a primary care specialist is necessary. Then, imaging is almost always demanded, which means the patient has been seen by another specialist – a radiologist. Then, a great majority of GIs demand a general surgery consult before they actually see the patient. In the meantime the patient has been sent to the ED (on GI orders) where this is all evaluated.

      Before any patient with ACUTE abdominal pain is ever seen by a GI, they have been seen and evaluated by at least 3 other specialists.

    • JR

      You aren’t able to have an opinion on police brutality unless you are a police officer. You aren’t allowed to have an opinion on the TSA unless you work for them. You aren’t allowed to have opinions on anything outside your direct experience. (/Sarcasm)

      I’ve seen over the past few weeks a knee jerk “no one can discuss this unless it’s inside their expertise” response to many posts. I’ve also noticed that moderation has been a bit lax… there are many comments that seem to be personal attacks. Those used to be filtered out.

  • medicontheedge

    In our hospital, ED admissions are ordered by the ED MD, but they have to be “approved” by the hospitalist service. So there is more than one player involved. And let’s not diminish the fact that the ED is more often than not the the quickest and easiest way for a Doctor to get their patent admitted. I am sure all of you here who actually work in an ED hear this every day: my Doctor told me come to the ED, instead of going to the office.

  • IHateHospitals

    It would be great for a flat fee when you are in the ER. I ended up in the ER a few times due to a racing heart. Each time I received a statement, they costs varied from $2,000 to $4500. But for each visit they did the same thing. Blood work, etc. Then released me and said if it continues come back. It’s a racket!

    • Some dude

      That’s the hospital charging you, not the physician. ED physician charges are usually $100-$250. The rest of those charges are from your hospital. If you saw another physician, you’d get another charge from them. Confused yet? Now you know why our American System is so Messed up. Hospitals charge on the order 10-20x as much as the physicians. True, the physicians make the orders, but we don’t get reimburesed for those orders, b/c in the US, it is illegal to for physicians to own hospitals.
      They can, however, own outpatient surgery centers, where they get all the profit from the colonoscopies or back surgeries you probably don’t need.