Late last week, my little guy woke up having trouble breathing. He got his inhaler, and we sent him to daycare as they were supposed to jump in muddy puddles, and he really enjoys jumping in muddy puddles. I got called mid-day by the day care. The teacher was concerned as he was in the middle of a massive asthma attack, and every time he jumped in more than two puddles, he needed to sit down for five minutes to catch his breath. He had been given his rescue inhaler and it helped for 15 minutes and that was it before he reverted back to his baseline.
I closed out my project, stuck my head into my boss’s door and told her that I was out for the rest of the day. I hopped on the next bus. I decided to be proactive so I called the pediatrician’s office and told them the situation, they agreed to see him in about an hour. When I got to day care, my little guy had his kitty and blankie waiting for me to pick him up.
“We go to doctor now Daddy?”
“Yep”
So we went to the doctor, and they pumped him full of steroids and albuteral. He stabilized but his blood oxygen levels still sucked and he was working his ass off to breathe. The pediatrician decided that her office was not equipped to do more, so she sent us down to the pediatric ER. As we were leaving, I was told that they would bill the sick visit co-pay to my account.
At the ER, they pumped him full of more albuteral, put him on oxygen for an hour, and gave him another pill to relax his breathing. By the end of the treatment series, he was attempting to perform pratfalls and pirouettes for the nurses. He was back to himself. We left the ER, and I paid the co-payment which is five times the standard PCP sick visit c0-pay. We drove to the pharmacy to drop off his steroid prescription and went to find ice cream.
As we were eating our ice cream, I started to get angry. I paid six co-pay units instead of the five co-pay units that I would have been responsible for if I just went straight to the ER with my little guy. I attempted to go to the lowest level of appropriate care, his primary care provider (PCP), but once it was obvious that level of care was insufficient, we escalated to the ER. The purpose of the high ER co-payment is to deter people from using the ER as a first resort. The low PCP co-payment is designed to entice people to the PCP as a first choice, or more realistically as a second choice after a phone call to the free nurse line.
I asked around Mayhew Insurance as well as other insurers and my buddies in benefits or claims confirmed that they would also collect two co-payments for that day of service as services were rendered at two different locations and with two very different set of billing codes. I understand the plumbing of the system, as I’ve plumbed things like this before, but the incentive is screwy. The incentive should be to present a patient at the lowest level of appropriate care and if there is an escalation of care during the course of treatment, co-pays should not apply for the escalation. Co-insurance and deductibles still should apply, but co-pays lose their incentive function once a person is already under care.
WereBear
Glad the little guy is doing okay.
We don’t have an integreted system of care. We have a Rube Goldberg system of care.
It’s really a middle-man problem.
WereBear
@WereBear: By which I mean the persistent notion that if some people would just stop consuming health care, other people would have more money.
raven
A month ago I fell and sliced my pinky open at the base. I was bleeding like a stuck pig but I wrapped it up and tried to find an urgent care online place I could go to at 5pm on a Sunday. After about 5 tries I bailed and went to the ER that is about 100 yards from my house. I have pretty decent BCBS but it still cost $200 copay and, when they determined my ulnar nerve was severed, a $200 copay on the surgery. Interestingly the hospital called to get the surgery co-pay and without any resistance the person on the phone offered me a $40 discount. I took it.
ThresherK
@raven: Shopping for emergency healthcare. Only in America!
JPL
Wasn’t the role of the PCP increased when Congress tanked health care during the Clinton years?
The Supremes will be issuing opinions today.
Kay (not the front-pager)
It’s been a few years (over ten) since my family has had to use the emergency room so I don’t know the protocol my current insurance uses. Back then, the co-pay was $200 if we went straight to the emergency room, but only $25 if we were referred by the PCP or were admitted to the hospital.This seems like an appropriate incentive to use lowest appropriate level of care. I wonder why it isn’t used more?
Omnes Omnibus
The little dude is okay, right? That’s the big thing.
Punchy
Any word on whether SCOTUS guts ObambiCare today or they give peeps one more week to get their doc visits in before pulling the plug?
Starfish
Oh man. I hate that. I took my little person, also with asthma, to the urgent care when he was just under three, and the urgent care said he was too young for urgent care so I attempted to take him to a pediatrician’s office in an unknown city. They do not take walk-ins even if your child is standing there having an asthma attack so we ended up in the ER. It took much longer to get the appropriate care due to all of the rules and regulations that are put above “HEY ANY OF YOU ASSHOLES CAN GIVE A NEBULIZER TREATMENT.”
Keith G
Reminder to Marc Maron fans and others: The interview with President Obama
Or use your favorite podcast app.
sharl
Glad to know your boy is OK.
{I’ll read again more carefully now for your view on your insurance experience related to this scary incident.}
Omnes Omnibus
@Punchy: My guess is that the ACA and gay marriage decisions come down the last week of the month.
Patricia Kayden
Sorry to hear about your son’s horrible asthma attacks. I used to have them too quite frequently when I was a kid with the last one being in 1995 where I was hospitalized after an allergic food reaction. Thankfully, it appears that I’ve mostly grown out of severe (or even minor) attacks.
So far, I’ve had good luck with Blue Cross — no co pays for hospital visits and I believe a very small one for doctor’s visits. Not sure if you can switch insurance coverage since you work for an insurance company.
mtiffany
Or at the very least (most?) the co-pay for each successive escalation of care should be billed out at the rate of the first level of care sought, i.e. the ER co-pay should have billed out at the rate of the PCP co-pay because you ‘did the right thing’ by going to the PCP first.
Howard Beale IV
Only with our healtchare system where there’s no price discovery or transparency-and forget about shopping around.
Glad your little one is OK
satby
Glad the little guy is OK, as a fellow asthma sufferer those things suck.
And yeah, the incentives are creepy and unfair. Especially on an escalation, if the incentive wasn’t there you might have ended up at the ER in the first place and gotten him better faster. But you tried to work within the system as designed. it is insane..
pseudonymous in nc
This is less of a problem in countries with actual healthcare systems where a) there’s no billing or nominal billing for emergency treatment; b) there’s a social understanding that you only seek emergency treatment in emergencies because alternatives are readily available.
(What makes it especially bizarre in the US is that you might see a doctor from the PCP in the hospital, wearing a hospital badge, who’ll bill separately.)
In short, the problem here is that the insurance/billing model is tied to corporate structures (billing entities) when an actual heathcare system reflects functional structures that are relevant to the patient and not the accountants.
It is curious that the acquisition/expansion policy of large hospitals only seems to work one way — you get charged outpatient rates for things at your PCP, rather than getting a discount if a PCP specifically refers you to a hospital because the PCP can’t provide the appropriate care.
divF
Same thing happened to me a couple of months ago. I was in respiratory distress, went to the PCP first, got escalated to the ER because it was a Friday afternoon and pulmonary embolism had to be ruled out (turned out to be an a pneumonia that was not picked up on an X-ray, only with at CT scan – props to Madame Dr. divF, who called it as pneumonia from the git-go). I got charged for both copays. This was Kaiser, so I stayed in the same facility, and the hand-off was smooth: the PCP called the ER, told them I was coming and why, and we were off. Plus it turns out that if you need to go to the ER, 3:30 PM is the ideal time to do it – things are slow at that hour, and you get attention quickly.
Richard: I’m glad it all turned out good for you. Your little guy sounds like a great little guy.
raven
@divF: I went at 5 the Sunday of a full moon. It was empty. When I came out 2 hours later it was packed!
SuperHrefna
@raven: I’m so glad you didn’t wrap your hand in a towel and try to flag down a police car for help….
SuperHrefna
And Richard, let me add to the chorus of people who are happy your little guy is ok!
JPL
I’m glued to Scotusblog even though opinions are not coming down until ten.
Jim
Those who say “USA! We have the best health system in the world!” obviously don’t use the system that you and I use.
raven
@SuperHrefna: Me too!
Don K
I always figured the structure and charging of copays was done this way to gouge a little more money out of customers, for the benefit of insurance companies or the sponsoring employers.Another example is charging higher copays for specialists. Let’s say you’ve had a heart attack and have been referred to a cardiologist. By charging a higher copay, is the insurance company trying to incent you not to see the cardiologist? Well, maybe they are, hoping that if you skip the cardiologist you’ll die quickly rather than stay alive and cost them lots of money. I guess I’m cynical that way.
divF
@raven:
Yup, same here – by the time we left at 7 PM the place was jumpin’.
shawn
glad your guy is ok.
I am pretty sure you know this and it may have been a mistype but the insurance does not collect the co-pay (or deductible or coinsurance) – the health care provider does. “other insurers and my buddies in benefits or claims confirmed that they would also collect two co-payments” Yes, the insurance company would determine when a copay would be charged but the actual money goes to the porivder.
Is your PCP copay not (relatively) much lower than your ER copay? Maybe like $5 versus $250 as it is with some plans with the company I work for?
Richard Mayhew
@Omnes Omnibus: He is all good
WereBear
@divF: There’s something about the waning light… and facing the night ahead with this thing now getting worse… that makes one make the jump.
JPL
@Richard Mayhew: Poor guy.
Richard Mayhew
@shawn: My PCP co-pay for a sick child visit is 20% of what the ER co-pay is.
shawn
@pseudonymous in nc: we do not have social understanding here (Nor do I really believe any country truly has one – humans are the worst kind of people everywhere – @ssholicness is not an exclusively American trait) – companies have to cater to the lowest level of customer – its why we get sickeningly sweet and condescending customer service in some places – because some people will raise holy heck if they are not catered to in every little way possible no matter how unreasonable – also why the people giving the customer service are at the end of the day so beat down that they often take it out on the “good” customers
shawn
@Richard Mayhew: yeah $20 v $100 (or whatever your version is) is not a big enough difference
MPAVictoria
Fucking hell. In Canada you would have just gone wherever you wanted and never seen a bill. So depressing.
Richard Mayhew
@JPL: And nothing yet on the ACA; although on the other issues, seems like a decent day for the good guys (Patel, pre-trial detention etc)
shawn
@MPAVictoria: if Canada had the population (and yes the history) of the US they wouldn’t have the system they have now
Omnes Omnibus
@Richard Mayhew: Yeah, not a bad day at all. Especially from this Court.
Richard Mayhew
@Richard Mayhew: Another round of decisions on Thursday.
The Raven on the Hill
My experience of “urgent” “care” clinics is that they don’t deal with genuinely urgent problems, which are what are otherwise called emergencies. What they do is largely primary care.
But, hey, the insurance companies and the “urgent” “care” clinics make a tidy profit, which is what counts in the best health care system in the world, right?
My sympathies to you and your son and next time—just go to the ER, hunh?
James K. Polk, Esquire.
What maintenance inhaler besides albuterol is your little guy using?
If he’s not taking any maintenance ICS or ICS/LABA, I would ask your PCP for a low dose Dulera prescription (100mcg). Taking too much albuterol is a very bad idea, and since he’s so young you should avoid oral corticosteroids as much as possible!
Email me if you have questions, it’s possible to get the maintenance meds cheap if know how.
Interrobang
This is horrible. As bad as some of my experiences with the ER have been (mostly long waits because they were shorthanded, and once having the doctor become convinced I was just a drug-seeker — well, no shit I was seeking drugs; my abdomen was exploding with pain!), at least I don’t get a bill at the end of it all. Thank you Tommy Douglass. Were I a shrine-building type, I’d have a shrine to him.
Brachiator
@Richard Mayhew:
A wonderfully clear explanation of your family’s medical issues.
The basic problem here is that economic incentives don’t always have anything to do with the medical decisions that a person may have to take. And it appears some co-pay setups assume that the patient is making a decision without consulting his or her doctor.
Perhaps there should be some kind of automatic adjustment if the doctor directs a patient to the ER (or to an urgent care facility).
@The Raven on the Hill :
Isn’t there room for urgent care facilities? Some of them seem to be used by people who have insurance, but not a regular doctor. Or they couldn’t get an appointment with their doctor, and have a medical problem that is serious but not life threatening.
MPAVictoria
“if Canada had the population (and yes the history) of the US they wouldn’t have the system they have now”
And if my Cat were my Dog he would bark.
/?
shawn
also, and again forgive me if i am nitpicking a mistype – but the situation you describes is not prevention, it is treatment
Roger Moore
@The Raven on the Hill:
They just define urgent a little bit different from the way you do. Their concept of urgent is something that needs looking at today, not something that can safely be postponed until the next time your PCP is available, while an emergency is something that could cause irreparable harm without medical attention. The bigger difference is that under EMTALA, an ER has to take anyone who comes in without checking for ability to pay, while an Urgent Care clinic can restrict itself to people who have the ability to pay.
Brachiator
@pseudonymous in nc: This is less of a problem in countries with actual healthcare systems where a) there’s no billing or nominal billing for emergency treatment; b) there’s a social understanding that you only seek emergency treatment in emergencies because alternatives are readily available.
I don’t know that this is actually the case. In the UK, there are apparently problems with the A&E service (accident and emergency) in various parts of the country, especially problems with overall costs and wait times.
http://www.kingsfund.org.uk/projects/urgent-emergency-care/urgent-and-emergency-care-mythbusters#treated
Some of the reasons for this may be related to common problems elsewhere, “Lack of access to GP appointments and Lack of access to out-of-hours care.”
Sidebar: some of the comments in one article I found on the net claims that a significant number of UK doctors are moving to Australia. I wonder what this is all about. In any event, it appears that even countries with good universal health care have adjustments that have to be made to keep everything working well.
brantl
Glad your munchkin is all right, Richard. I bet you just go to the ER next time, if he’s that bad off, as you will get the treatment sooner, and at less money.
batgirl
A few years ago I was experiencing fainting spells. I went to a urgent care facility the first time I hit my head. The doc came out to the waiting room and told me to go to the ER because of the head injury and I wasn’t charged.
Later that year, I fainted again, hit my head again, and went to see my primary care physician. She brought me back to the exam room to tell me to go to the ER. For a two minute conversation, I was charged the copay and my insurance was charged for an exam.
It turned out I did serious damage and was in the hospital for 10 days (in which a parade of doctors often stopped by for barely a minute while charging my insurance.)
Don’t you just love American healthcare?
fuckwit
Thanks again for your analysis and expertise. It’s so valuable. Your story helps make all the technical macinizations of the system more concrete and understandable. Glad your little one is OK.
ShadeTail
I’m getting the impression that this payment structure is something that comes from the insurance companies and/or the care providers, rather than being baked into the A.C.A. Am I correct with that? And either way, how could the A.C.A. be used to provide a fix?
bob
How you work in this kafkaesque nightmare amazes me. It might have been cheaper to drive to canada to get care.
Ohio Mom
A little off-topic but in the same ball park: Once you have been treated for breast cancer, mammograms are no longer considered “screening,” they are considered “diagnostic.” It’s the same machine, the tech does the same things, and the radiologist who reads the films isn’t any differently trained than the one reading the “screening” films.
“Screenings” are free under the ACA, “diagnostic” mammograms aren’t, and therefore come with hefty co-pays. The catch is, once you’ve already had breast cancer, your chances of having breast cancer again are much higher, so it is arguably more important that you go for mammograms regularly.
So here too, “prevention doesn’t pay,” unless of course you are the health care facility. I’m with Don K @25, it’s a racket, and that is all there is to it.
Southern Goth
@shawn:
The population argument on why Canada’s system would not work for the US is total bullshit.
Something that works for a population 35+ million doesn’t work for 300+ million? Where was the cutoff? 70 million?150 million? Why?
shawn
@Southern Goth: “works” being a relative term
pseudonymous in nc
@Brachiator:
In the UK, the problems are mostly down to squeezed funding, stealth privatisation and stupid internal markets, which, thanks to the English electorate’s selfishness, will continue unabated. If the NHS was funded at slightly higher levels with fewer artificial accounting requirements, it’d be on a much sounder footing.
And there are other countries beyond the US, Canada and UK, and the ones with functional healthcare systems all operate on the principle that you don’t extract massive amounts of money from people in emergencies, even though emergencies cost the most money. You fund that stuff collectively one way or another.
Anyway, Urgent Care in the US is mostly bullshit: it’s ‘Had a Boo-Boo Care’, where your PCP is booked up and can’t cope with boo-boos.
Pseudonym
*Albuterol, with an O. (Speaking from experience.)
Pseudonym
Or is “Albuteral” but spelled properly with an O at the end on the spam list?