I won’t come back to the ER for glasses again

He was a 24-year-old African American man with no history of medical or eye problems.   On an ordinary Thursday evening at 8 p.m., he arrived into the emergency department complaining of a sudden loss of vision in both eyes.

“He couldn’t see a thing on our chart.  Vitals are fine, pupils are equal and reactive, and the rest of the neuro exam is unremarkable,” the emergency room attending briefly explained.  “Can you see him?”

As the first year ophthalmology resident on call that night, I certainly could.

“Great.  I’ll put in for a CT of the head and orbits.  It’ll be done by the time you …”

“Hold on that CT,” I interrupted.  “Let me see him first.”

Not a half hour later, I had whisked my new patient to the eye clinic, settled him in the exam chair, and asked him to read the chart with one eye covered.

“E.”  He correctly stated the 20/400 letter after just a moment’s hesitation.

We got down to 20/200 in each eye, and then he struggled.  I didn’t expect such a poor visual acuity from a young and otherwise healthy man.  I confirmed the normal pupils and as I swung the slit lamp before him, I wondered what pathologies I would find.

But there were none.  His eyes appeared perfectly healthy, if not slightly myopic.  We were discouraged from performing refractions on emergency visits, but I wanted to ascertain a diagnosis, so I went ahead.

After we corrected a moderate amount of myopia, he easily read the 20/20 line with each eye.   I turned on the room light and lifted the phoropter away from his face.  He looked at me with a sheepish smile and shrugged.

“The good news is your eyes look healthy, you just need a simple pair of glasses,” I told him.

I paused.  He looked at his hands.

“But,” I continued. “Something tells me you already knew that.”

He sighed.  “You got me.  I knew I needed glasses.  I’ve needed them for a while.  So much for sudden loss of vision.  Sorry, doc.”  He chuckled.  “But I lost my insurance.  It didn’t cover glasses anyway, and glasses are so expensive.  And eye exams are so expensive.  So I figured if I came to the emergency room, maybe I could get both for free.”

My heart sank.  It’s a common misconception that emergency care is free of cost.  I explained to him that emergency rooms are mandated to provide emergency care regardless of a person’s ability to pay, but patients will often still get billed. His little white lie would likely turn into a big invoice.

“I had no idea,” he said, looking forlorn.  “Oh, man.”

It was hard to blame him.  Most glasses were ridiculously expensive.   One company controls a large majority of the frame manufacturing and prescription glasses retail in the United States, and sets prices at an enormous markup.   It explains why one can get simple over the counter plus lenses, or reading glasses, relatively cheaply, but simple minus lenses to correct myopia are only available by prescription and therefore cost several orders of magnitude greater.

I gave my patient a spectacle prescription and pointed him in the direction of a few new online spectacle retailers, who were reliable and much more affordable.

“Thanks doc,” he told me.  “I won’t come back to the ER for glasses again.”

As I signed the patient back over to the emergency room for discharge, the attending told me he would do his best to minimize the patient’s bill.  We were lucky to avoid the CT scan, and we agreed to discuss the decision to image ophthalmologic cases before the tests were actually ordered.  “Communicating,” the attending surmised.  “Patient to doctor, doctor to patient, doctor to doctor.  It goes a long way, doesn’t it?”

I had to agree.

Sriranjani Padmanabhan is an ophthalmology resident.

I won’t come back to the ER for glasses again

This post originally appeared on the Costs of Care Blog. Costs of Care is a 501c3 nonprofit that is transforming American health care delivery by empowering patients and their caregivers to deflate medical bills. Follow us on Twitter @costsofcare.

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  • Dr. Drake Ramoray

    This article outlines the misperception that ER healthcare is free and looks at a business controlling a major part of the market, but the elephant in the room, and the point not stressed in the article, is what happens if ER healthcare is actually free or exceedingly low cost for some patients. Not surpsingly some actions aren’t very different than the above article.

    South Carolina woman on Medicaid uses the ambulance service as her personal taxi.

    http://www.live5news.com/story/22075845/live-5-news-investigates-woman-accused-of-using-ambulance-for-taxi-service

    The over use of services when they are perceived as “free” is one of the reasons why increasing the number of Medicaid recipients is unlikely to reduce healthcare costs. In fact, Medicaid expenditures are expected to increase in growth even more quickly with the changes implemented in the ACA. Without an increase in the number of docs taking Medicaid, and an increase in the number of Medicaid benefiiciaries it isn’t hard to imaging that there will be an increase in usage of the ER. Dramatic examples like the above SC woman aside, increased Medicaid costs through ER visits is a real problem.

    http://www.usnews.com/news/articles/2014/01/04/study-er-visits-increase-40-percent-with-expanded-medicaid

    The CBO sees the writing on the wall and is already proposing caps on federal spending for Medicaid.

    http://www.cbo.gov/budget-options/2013/44889

  • sj0

    This is not a new problem, but it will get worse. 25 years ago, I was a high school student volunteering at my local ER. One patient had come in by ambulance for “chest pain” and the workup was completely normal. Afterwards she confided in me that she didn’t really have chest pain; she was flying to Hawaii the next day and just thought she should get a checkup before that. Her primary care physician could not squeeze her in. She actually sounded a little smug, like she taking pleasure in teaching a candy striper how to game the system.

  • Mike Henderson

    My wife was working at an ER in a rural area. The hospital was giving away free bicycle helmets. Someone called for an ambulance – they didn’t have a car to go to the hospital to get a free helmet.

    • Patient Kit

      And about 25% of 911 calls are not emergencies. People call 911 to ask what channel a TV show they want to watch is on or to complain that their cable went out while they were watching a playoff game. Seriously. Misuse and abuse of ambulances and our 911 system should be punishable. It’s a waste of money and services but, more importantly, it puts other people at risk who might really need that ambulance or 911 operator. Other people. What a concept!. I swear, if Big Pharma made a pill that cured people of narcissism, I might think more highly of the pharmaceutical industry. ;-)

      • Mike Henderson

        If it is possible to make a lot of money off such a pill, I am sure they are all over it. However, if they actually took their own medicine and treated their narcissism, they would stop acting like pharmaceutical companies – then they would stop developing further medications. Quite the conundrum ;)

        Narcissism – pervasive pattern of grandiosity, need for admiration and lack of empathy for others.

        • Patient Kit

          It wouldn’t solve all problems, of course, but a widespread epidemic of suddenly empathetic people would go a long way toward making the world a better place. Instead we seem to have far too many people who feel abused by the world and seem intent on taking it out on someone else as if that is the whole purpose of “others”. It’s a vicious cycle.

      • Suzi Q 38

        Ridiculous.

    • Suzi Q 38

      Our tax dollars at work…….

  • Patient Kit

    I’m really amazed at how many people are under the false impression that the ER is free for anyone who is uninsured. For some reason, they think that because they must be seen and treated if they enter an ER with a medical complaint that it somehow translates into the idea that they cannot be billed. Where did this myth come from? And why does it persist?

    I hear it a lot from relatively young, healthy people who really seem to believe that they don’t need health insurance because, if they ever need any medical care, minor or serious, they can always just go to one of the many free ERs. So, why pay for health insurance?

    Misuse/abuse of ERs by Medicaid patients is one serious issue, but the surprisingly widespread belief that insurance isn’t necessary because you can get anything you need or want in any ER for free is a whole other head-shaking issue. It’s like they think they know some secret that people who have or want insurance are too stupid to figure out. Free ERs!!! Who knew?

    • southerndoc1

      “the surprisingly widespread belief that insurance isn’t necessary because you can get anything you need or want in any ER”

      Isn’t that what GWB told us?

      • Lisa

        I thought it was Romney…

      • http://www.mightycasey.com/ MightyCasey

        Mitt Romney, although I’m sure GWB was in full agreement with him.

  • Lisa

    My son just got glasses in this manner. I think exam and glasses were about $130. But that was a lot of money for him, at this point in time.

    • Suzi Q 38

      Is there any reason why you could not help him with this fee? I am working, and work only part time, but I would have paid this necessary item for my son, even if he is an adult.
      I would have made him clean my house, or garage, paint a room or two in order to clear the debt.

      I then would have given him the lecture that not all things in life are free….this is why it is important to get an education and work.

      Off my soapbox, as I don’t know you or your family’s life.
      My apologies if you both have no money at all and are disabled.

      • Lisa

        Suzi, my son got the glasses. What I said that $130 was a lot of money for my son, at this time.

        You are right: you don’t know anything about my life (beyond what I say here) or my son’s life and I don’t think my comment about the cost of gives you the right to ask the questions you did. Geeze….

        • Suzi Q 38

          True.
          My apologies.

  • guest

    But, if he bought glasses how would he afford his cell phone bill?

    • Lisa

      Phones are necessary if you are to function economically in this country. Many people I know use cells phones as their only phone; they don’t have land lines and consider the cell phone to be a necessity, as much or more than medical care.

      • SarahJ89

        Africans in particular. I live part time in another country. Cell phones in the US are a rip off, which may be why you think of them as a luxury. In nearly every other country Africans go to work internet access and mobile phones are their lifeline to home.

        I’ve noticed that homeless people in the US absolutely require a cell phone. If you are homeless a cell is not a luxury, it’s a necessity. You cannot look for work or a place to live without one. I have a landline and a job and car and home. For me a cell is a luxury. If I were homeless, this would not be so. A cell would be my de facto home base.

        • Lisa

          I agree; I never said a cell phone is a luxury only that a phone is necessary to function economically in this country.

          • SarahJ89

            Lisa,
            I was responding to guest. It’s hard to tell sometimes where a reply will end up.

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

    Instead of blaming the kid for trying to get away with a pair of glasses, why not look up Luxottica and place the blame where it belongs?

    • Patient Kit

      At least, Luxottica doesn’t own the mind’s eye, “I spy with my little eye” or wine glasses. Yet. ;-)

    • jon

      The major networks(and Forbes) have featured stories about Warby Parker,a startup company that took on Luxottica.Their glasses cost about $95.They have UV protection,anti-scratch and anti-reflective lenses.They donate 1 pair for every one they sell.

    • SarahJ89

      Margalit,
      What is Luxottica?

  • Lisa

    I think you are overestimating the financial resources of many people. Getting dental work or glasses without the ability to pay cash at the time of service is difficult. Yes, most providers will agree to accept a credit card, and may even agree to charge your credit card a certain amount every month. But what if you don’t have a credit card? If your credit card is maxed out?

    That is why people try and get glasses and dental care at health fairs. I am certain most people would rather not stand in line and wait long hours to get glasses or dental care. You would have to be pretty desperate to sign up for that, imo.

  • guest

    You might want to read a terrific book by Barbara Ehrenreich: “Nickled and Dimed.” It’s about her adventures (and misadventures) trying to live on what she made with minimum wage jobs during a year-long break from her regular job as a journalist..

    Those of us who have a hard time believing that there are people who really don’t have $200 for glasses have clearly never walked a mile in their shoes.

  • Suzi Q 38

    I know where this thinking comes from.
    The gazillions of people who flood the ERs with minor illnesses.
    A slight fever…..a productive cough….etc.
    They don’t pay. If you sent them a bill, they would throw it in the trash.
    They don’t own any property and have no money, so good luck collecting.
    They talk amongst themselves and tell each other how easy it is.

    • SarahJ89

      And you know the politicians promulgate this belief amongst middle class voters. My friend who lost his job had to go to the ER for stitches. Could he pay the bill? No. Was he cavalier about it? No. It weighed on him, but there was nothing he could do about it. Meanwhile he had to listen to every politician running for office talk about how we don’t need health care because “you can get free care at the ER.” You can lay that right at their feet.

      • Suzi Q 38

        Your friend’s case has merit, but there are so many others that could have gone to the urgent care or doctor’s office.
        I have seen this practice close ER’s in hospitals. The hospitals turn their heads and don’t do anything about it because they get to bill the government for services.

        How many of these cases are for the homeless, who in reality just needed a clean bed, a couple of meals, and a shower?

        • SarahJ89

          Our local “nonprofit” hospital closed down the urgent care unit they had in the ER because they make more money charging ER prices for the same services. Or lack thereof. The last time I was there (broken bone) the place was like a parking garage full of people in serious pain sitting for hours on plastic chairs. These folks weren’t there for the sniffles.

  • Lisa

    I don’t know who paid for the patient’s bills. Did he have insurance? Or was he so poor the hospital would have to write off the charges. In my experience, hospitals play hard ball when it comes to collections. That said, I agree with you that the patient was stupid and the whole thing was wasteful. But I don’t blame the doctor for this one. The system – probably.

    In Canada, dental insurance and vision care are often covered by supplemental insurance policies provided by employers. And I think dental care is generally cheaper than here in the US, based on the number of ads I saw for dental tourism in Canada. No idea about the cost of glasses. In England, the NHS does pay for dental care for people with low incomes. I am not sure about vision care.

    I do think dental care and vision care covered by medicaid in this country. If you are low income enough to get medicaid, you are unlikely to have enough money to cover these things. Walk around in a poor area and you will see a lot of rotten teeth. My sister is an optomitrist and when she worked in practices in poor areas she saw lots of kids who needed glasses but didn’t get them until they were having problems with reading. She also saw a lot of adults with advanced cataracts and case where glacoma wasn’t diagnosed until they were having vision problems.

    • SarahJ89

      The only dental care provided for by Medicaid in my state is to pull teeth. Nice.
      The agency I worked for had a horror of paying for dental care because the need is so great in the US they were afraid of being flooded with requests. So… we’d spend several years rehabilitating someone. Then send them out the door to job interviews with no teeth. Brilliant.

      • querywoman

        Ditto for Texas. And so called charity or low-income dental clinics only really serve children who have Chips and Medicaid.
        I think the low income dental clinics probably just hold onto the grant money in their kitties as long as they get enough children.

        • ninguem

          The Medicaid program in my area, offered dental service. So they claimed.

          Yet we physicians would be called, emergently, for dental problems, day and night. And with Medicaid, those ER visits were counted against OUR utilization, as physicians.It rankled.

          Then, one day, I got a call on Saturday morning, a patient needing help for dental pain. She had just seen the dentist a few days previously.

          So there was no doubt, there was an established dentist-patient relationship. The dentist had no excuse for not managing this after hours.

          “Why aren’t you calling your dentist for this? Why are you calling the doctor?”

          “The dentist won’t answer, there’s no dentist offering after-hours service.”

          “You need to call the 800-number, it’s on your Medicaid paper, there’s an 800-number for the doctor, another for mental health, another for the dentist……”

          “I know. I did. I called. I was told there’s no one covering.”

          All too often, you find yourself dealing with someone a few bricks short of a full load, but this lady knew what to do, did all she was supposed to do, and the system was letting her down.

          “Would you mind giving me all your information, name, phone, Medicaid number, and the 800-physician and mental health and dentist numbers. I want to look into this myself. I’ll get right back to you.”

          Basically, all the stuff on her Medicaid card. She gave me the info, and I called.

          I dialed that same Medicaid dentist 800-number. I got the operator, and said I was Mary whatever on the card, this was my number, I needed a dentist.

          Operator tapping on keyboard. You know how you can hear this on the phone. She’s clearly going from screen to screen. She gets to the specific Medicaid dental program covering this area.

          The operator gets a blank screen. She explains to me, it’s a blank screen. She had clicked the link for the after-hours covering dentist for Medicaid for that part of the state.

          Nothing. Blank screen. When she does it for other parts of the state, she gets a covering dentist. Just not my area.

          “Well, as you can imagine from my male voice, I’m not Mary whatever.”

          “I kinda wondered about that.”

          “I’m Mary whatever’s doctor (well, covering doctor, close enough). I was trying to figure out what was wrong with all this. The Medicaid card says call this number 24 hours a day, yet there’s no dentist. Do you think that’s right?”

          “No, I don’t think that’s right.”

          I was going to leave it at that. Not her fault, after all. But then she gives me the head of the Medicaid dental program.

          His home number.

          So, I call the dentist at home.

          He answered, and I told him the story. Who knows how long this had been going on, no one had checked. Months? Years?

          In fairness, the dentist apologized, said he would get to the bottom of it, and offered to open his personal dental office on a Saturday afternoon.

          I called Mary whatever back at her house.

          “Do you mind driving 80 miles one-way to see a dentist?”

          All too often, I get Medicaid recipients with a bad-looking tooth that really doesn’t hurt, but looks bad, milking the situation to get narcotics. They don’t care if the dentist is not available, they really just want the narcotics.

          This lady actually wanted to get better. It made my day.

          “I’ll be glad to drive 80 miles to see the dentist,” She arranged ride and some baby-sitting and all that. I called the dentist back, gave him the lady’s phone number, checked back later to make sure all was arranged. She was thrilled. Thanked me for cutting through all the red tape.

          And I had the home number of the head Medicaid dentist at that time, to make sure the problem stayed fixed.

          Graffiti on the toilet in the doctor’s lounge.

          “For a good filling, call………”

          I mean I’m just sayin’

          • querywoman

            Dental is a different game than eye care. It’s expensive and considered a luxury service.
            I like it that you got the dentist at home.
            That dentist should be turned into the dental board.
            Glad you contacted the head Medicaid dentist.
            ER’s get the real dental pain.

    • Lizi

      In the UK you can have free eye care and dental care up until 16 or 18 depending on when you finish full time education. If you leave school at 16 you will no longer be eligible because it is assumed that you will be working. If it is discovered that you need glasses, ophthalmology review etc that can all be done for free. There are standard frames that you can get for free, but aren’t necessarily ‘trendy’, so if you want cooler glasses then you will have to pay for the frames yourself, but the lenses are still free.

      Once you are over 18, unless you fulfil some specific criteria, you won’t be eligible for free eye care until retirement age. However, most opticians do comprehensive eye examinations for £10 (apparently that’s about 17USD), which makes them incredibly affordable.

      The issue with UK dentists (both from general knowledge, and from having read those incredibly reliable and insightful Daily Mail articles) is that there are not enough of them either NHS or Private. It is not a clean-cut issue of ‘oh the NHS is sh*te’. There is simply not enough dentists in this country, and there are not enough young people choosing dentistry as a profession, so the problem will continue.

      Because there is a shortage of dentists, they can have relatively good incomes for their hours. Having said that, I wouldn’t become a dentist for any amount of money because I can’t think of many things worse than that as a job. Unfortunately many others feel the same, and the problem will continue unless dentists can get out there and advertise their trade to those of school age who may then start to consider it as a profession.

      • Lisa

        Thanks for the info.

        I don’t think we have such a severe shortage of dentists in this country; I certainly see lots of ads for dentists.

  • medicontheedge

    And then he comlained in the Pres-Ganey survey about your “lecture”, and you got reamed for poor customer service.

  • SarahJ89

    Wow. You seem to assume everyone has the extra cash you seem to have. You also appear to think the young man was making a poor choice, rather than not being in possession of all the facts.

    I’m terribly myopic. I work and am clinging to the bottom rung of the middle class. Buying glasses is a large purchase in our budget. When I was younger the only thing that saved my butt was the fact my landlord was an ophthamologist who gave me glasses at cost.

  • SarahJ89

    The young man did what he needed to do to survive. You would do the same or more if you suddenly lost your comfortable position in life.

  • Suzi Q 38

    I have students from other countries who have not been to a dentist for decades. Their teeth look so bad. I was concerned about their son, who is 10.
    They have very little income, because the parents do not have jobs. One has a good excuse, as he doesn’t speak English, but the mother speaks very good English.

    I have tried to explain to them that even if they worked for low pay at a decent company like Costco, they would get medical, dental, and vision coverage. It beats staying home all day and worrying about the future.

    They finally got their Medi-cal card last week and went to see the dentist.

    The man had 6 cavities and needed one root canal, the woman had 7 cavities and needed a root canal, and their son had 5 cavities.

    She said that they can not afford to have the work done…..I told her that if she didn’t try, she might loose her teeth in a few years and need dentures.
    Her gums are bleeding, and she is very sensitive to cold.
    She is only 40.

    • Lisa

      Susie, this story doesn’t add up: A $600,000 house, a $20,000 car, vacations, cell phones. But no income? Just saying…

      • Suzi Q 38

        I thought the same thing.
        It sounds farfetched, but it is true.
        They sold their house in another country, cashed out and bought one here, in cash.
        They could not qualify for a mortgage, because they both had no income.

        There are people who abuse our system and those who need it and use it wisely.
        I am curious to know why a person with assets can be on medical and not have to pay.
        Agreed they don’t have an income, but doesn’t the government check for property or bank accounts?

    • SarahJ89

      I wonder how much of the dental issues is cultural. I grew up in a time and place where people assumed they’d lose their teeth as they aged. For a woman it was when, not if, they’d have a hysterectomy. Most of them had no access to birth control (doctors routinely refused to tie a woman’s tubes until she’d had six or seven kids) so it was actually a relief to finally get rid of their uterus. Most small children of poor families had nothing but brown stubs in their mouths by the time they were four.

      Once people get used to stuff like this it’s hard to get them to take it seriously. It becomes part of the wallpaper of their lives.

  • Ava Marie Wensko George

    This goes to show that we need a massive campaign to discuss appropriate ER use with the public. This, however, is the elephant in the middle of the room. It seems that our politics in this nation get in the way of patient care and information about how to save costs.

    • http://www.mightycasey.com/ MightyCasey

      Too true. Particularly when someone at the top of one party’s ticket says stuff like “of course you can get healthcare without insurance – just go to the ER!”

  • querywoman

    Eyeglasses can be had cheaply, like at Wal-Mart, who guarantees ‘em. It’s easy to get a low cost eye exam in most cities. It’s not like costly dental care.
    Most people just don’t know where to go.

  • SarahJ89

    Here’s your statement that I was responding to:
    “Maybe the individual really is budgeted down to the last dollar, and one or two hundred bucks is truly unaffordable.

    I tend to doubt that, but hey it’s possible.”

    To me, that’s a rather blithe dismissal of someone else’s economic reality. One or two hundred dollars may be nothing to you, but it’s a big bite for some people. I come from a similar background as yours, but I don’t ever forget what it was like to be that up against the wall financially.

  • karen3

    Have you never heard of Zenni? Glasses are $9 + shipping. A walmart optician is about $40.

  • querywoman

    We minyons do not know the real cost of ER services. It’s bloated.

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