I want to highlight something that bothers me about the entire idea of getting massive cost savings from emergency room diversions (via TPM):
The example Rep. Bill Huizenga (R-MI) gave in an interview with MLive.com was from his own experience when he waited until the morning after to take his youngest son to the doctor with an injured arm, because he did not want to waste money on an expensive emergency room visit. The arm, it turned out, was broken.
“We weren’t sure what was going on. It was in the evening, so I splinted it up and we wrapped it up, and the decision was, okay, do we go to the ER? We thought it was a sprain, but weren’t sure,” Huizenga said, adding that he and his wife “took every precaution and decided to go in the next morning.”
“When it [comes to] those type of things, do you keep your child home from school and take him the next morning to the doctor because of a cold or a flu, versus take him into the emergency room? If you don’t have a cost difference, you’ll make different decisions,” he said.
I hate this example for a lot of reasons including the fact that a broken bone is a legitimately good reason to go to the emergency room. It is a source of significant pain, significant impairment and over time a simple break left untreated can lead to a complex set of breaks that requires very expensive surgery. But that is besides the greater set of points why this is a bad story to tell.
Let’s go back to the most important graph in healthcare:
Why consumers won’t drive the #healthcare market. Most costs from high $ people who are beyond cost sharing. pic.twitter.com/buoAM00CPT
— (((Martin Gaynor))) (@MartinSGaynor) December 10, 2015
ER utilization can be broken into three components. True emergencies that lead to admissions. Here ER utilization is expensive but very valuable. Then there are acute emergencies that occur either off hours or can not be handled at the PCP or Urgent Care office due to the lack of equipment where the ER may not admit but they are an appropriate resource. Asthma attacks and broken bones are common pediatric examples of this case while unspecified chest pains and shortness of breath are good examples of older people. And then there are the cases where the ER is overkill. The problem is that ER overkill is a real problem but it is not a big driver of total medical spending. It might be a $5-$10 per member per month in the most aggressive modeling.
Marginal ER utilization for flip a coin decisions where having a large deductible could drive people to wait a day or two before getting a broken bone treated is not that big of a deal. Those are the cases on the left hand side of the graph. People who don’t use the ER a lot, who don’t use a lot of services a lot don’t cost the system a lot of money. Shifting a single in-network medium severity ER visit to a single in-network medium severity Urgent Care visit might lower the contract expenditure by $200 or $300. If the kid’s arm is broken and it needs surgery, that is 5% of the total episode of care cost. If there is nothing beyond an “oowie”, the shift might save 75% of the episode cost of care. The shopping paradigm is that it will change behaviors among people who are not driving most of the healthcare spending. It will save money but it is limited in what it saves as the people use a lot of medical resources will blow through any out of limit cap very quickly.
And this story only makes sense if there is a significant substitution effect between ER and Urgent Cares.
Having retail health clinics near hospitals does not reduce emergency department visits for minor health problems, a new study finds.
It was hoped that lower costs and increased convenience of clinics in drug stores or retail chains would curb emergency department visits, but these findings add to growing evidence that this is not the case, according to RAND Corp. researchers.
The investigators examined five years of data from more than 2,000 emergency departments in 23 states and found that the opening of retail medical clinics did not reduce emergency department visits for 11 non-urgent ailments, such as respiratory infections and earaches.
“One hope for retail clinics was that they might divert patients from making expensive visits to the emergency department for minor conditions such as bronchitis or urinary tract infections. But we found no evidence that this has been happening,” lead author Grant Martsolf said in a RAND news release. Martsolf is a policy researcher with RAND, a nonprofit research organization.
Urgent cares are either complements for ERs or merely time shifting substitutes for normal PCP visits. The evidence is showing that they are not particulary good substitutes for ERs
Third, I have major moral issues of subjecting kids to additional pain that they can not make an informed choice to accept or reject for cost reasons in order to marginally save fractions of a dollar per member per month. In my ideal world, every kid would have almost 100% actuarial value coverage. I am far more comfortable as a parent to take on risk and pain to save money than having my kids be in pain and at risk to save money on the premiums. And I want that risk and pain tolerance differentiation to drive public policy.
And finally, a very good take on the practicalities of judgement and justice:
Wonder what would happen to a poor black single mom who admitted she put off getting her kid’s broken arm seen by doctor to save $$?
— emptywheel (@emptywheel) December 21, 2016
Gretchen
I broke my arm a few years ago and yelled at my son for taking too long to get ready to take me to the er. I had trouble waiting an extra 5 minutes to get to some pain meds. And I delivered 3 children without medication. Broken bones a f- ing painful, and it’s unconscionable to make a poor little kid suffer all night without relief to make a political point, or because you’re too lazy to take him.
rikyrah
Not only does the ER NOT save money..
Read that story of his…the man is a sociopath doing that to a CHILD.
Mike J
There are also examples like Alex Chilton who had chest pains while mowing his lawn. Indie musicians generally don’t have good health insurance, and he put off going to the emergency room because it’s expensive. And now he’s dead.
SP
Another problem with chain store clinics- they’re total shit. I got a flu shot at CVS because I was traveling during our flu clinic at work and my PCP didn’t have available appointments at the times I was in my home area. I reserved a time online, showed up to check in at that time, was told I had to wait an hour until my appointed time (seems the online system gave me a slot that fell during the regularly scheduled RN lunch hours), then waited 2 more hours after my “appointment” time. Other people there for other issues said they’d been waiting between two hours and all day since 9am.
Maybe it’s just CVS that sucks at managing their queue, but I got the sense from other patients that this was pretty typical of non-medical practice affiliated “urgent” clinics.
ETA- Follow-up story- my kid broke his wrist in foreign country, got to an ER, X-ray, splinted, about 90 minutes arrival to departure. No copay no cost (we have insurance as ex-pats in that country, our unsubsidized premiums are about the same as the employee 20% contribution at my US job.)
Mnemosyne
@Mike J:
Let’s face it, from an actuarial point of view, that was an ideal outcome since no medical dollars had to be spent. Not so ideal for his family and friends, however.
Yarrow
Republicans are sadists. Understand that and everything they do makes more sense. Of course he wanted his child to suffer. Why did the child make the mistake of doing something wrong so as to end up with a broken arm? Suffering is the penance he must pay for his mistakes.
Barbara
Great post. Within the “high utilizer” categories, you would also likely find that a significant percentage of cost is associated with end of life treatment. You don’t always KNOW treatment is an end of life event — you are trying to avoid the end of life. But many hospitals act as if life never ends when they go about deciding to treat people.
As to consumer demand for services, my local ER long ago (like many others) shifted to a two-tier system where “urgent care +” situations were routed through a team of PAs who triage visits that are unlikely to result in an admission. It also set up a walk-in clinic that has lab and x-ray on-site. (Not all services are offered during all hours.) The point being that it has long been the case that most people going to the ER don’t have emergencies but they need medical attention and doctors have some of the most consumer unfriendly hours of any profession. It is the height of irony to wring one’s hands about needing market solutions to keep people out of the ER — how about changing the accessibility of non-ER necessary services so that people have somewhere else to go? My last three ER visits: (1) My husband fell down the steps and injured his back. We did wait until the next morning and when he was still in significant pain, we went to the ER. (2) My daughter gashed her forehead right above her eye — same drill — when we could not stop bleeding, we went to the ER. (3) My other daughter tripped and fell on her arm. It needed an x-ray to rule out a break. My PCP doesn’t have x-ray and lab in their office and might or might not be available at night or on a weekend. The whole reason Steve Case started investing in urgent care centers was because he spent too much time at ERs with his kids. If even Steve Case can’t get after hours access, surely, it’s dawned on people that the medical profession has some accessibility issues.
raven
@SP: My wife fell and broke her wrist during our November vacay at the beach. We knew it wasn’t life threatening but that it needed to be addressed quickly. I badly cut a finger a couple of years ago and we got the $200 ER copay because I couldn’t find an Urgent Care late on a Sunday so I walked the 100 yards to the ER at the hospital around the corner. We decided to go the Urgent Care route wanting to save ourselves and BCSBGA money. We found a place, a PA took a look and said we needed X-rays and there was a “facility” in the same building. We got the X-rays and the PA determined that it was fractured and needed to be looked at by an orthopod. We felt lucky that we got it to see one in about an hour and luckier that they had a hand surgeon that could do the plate insertion the next day. All this while I was trying to reach BCBSGA but they have a really stupid phone answering system so I didn’t get them. I emailed or HR person and she some how got the insurance rep to call us that evening. The rep was very clear that our policy, an HMO, did not allow for us to have our of network surgery and the were not going to pay for it. We decided we had no choice but to truncate our vacation and come home. We were lucky here and got the surgery taken care of the following Monday. We then started to get the bills on our BCBSGA account and I could see that they were denying all the Urgent Care, X-ray and ortho chargers. The X-ray outfit billed us $2000 for the X-rays. I spent a good bit of time on the horn with the Urgent Care folks and they finally were able to get the X-ray people to reduce the charges from $2k to $200! Now I have to appeal the $800 or so that is still in the denial stage. I don’t know if things would have been easier had we gone to an ER but I’m going to find out.
SP
Here’s a funny look I got into the emergency care system in the US- Another of my kids (5 y.o.) was at hockey lessons, I went across the street to get him some snacks at the supermarket. I got a text to come back right away, he was lying in the middle of the rink not moving. They had already called an ambulance thinking he had some spinal injury even though no one had seen what exactly had happened. Turned out he had a cramp in his neck and didn’t want to move. They carted him off to the ambulance, but as I talked to him more I figured out that he was totally fine. In the ambulance we discussed this, he sat up and moved totally normally and ended up walking out on his own with no problems. There was no charge for the ambulance- apparently the response is covered by municipal budgets, but as soon as they move 1 foot with you in the ambulance it becomes a medical expense. Typically something like $800 for the first foot, $80 for each additional mile. So because he walked out fine I and my insurance company never saw a bill.
tarragon
I’ve had more Urgent Care visits where they directed me to the ER than I have had visits where they were the end of the chain. Now maybe it’s just me making bad choices or maybe it’s just not possible for wide swaths of humanity to make these decision well.
Russ
Sounds to me like someone had a few pops and wary of DUI did the usual it’ll be fine thing drunks do and went to the hospital the next day.
artem1s
Sadistic asshole. anyone notice how this is similar to the story about Mitt and poor Seamus on the car roof or Todd Aiken ‘her body just shuts that down’?. Privileged narcissistic sadist tells ‘amusing’ or ‘instructive’ anecdote and then fails to understand why his audience is appalled. I’m expecting a lot of this in the coming few years.
sigaba
@raven: Why is it when I pay for chest rads of my dog, it’s like $150, but human arm rads are $2000?
I mean I know WHY, they’re using cash payers to subsidize the reaming they’re getting from poverty and medicare reimbursement. But the principle still stands, a rad is a rad and my vet is absolutely making a good margin on her imaging.
sigaba
@sigaba: I would add that veterinarian radiologists are trained just as profusely as human ones, have a college degree, plus medical degree, plus internship, plus specialty internship, plus specialty residency, plus boards.
DBaker
Another issue with Mr. Huizenga’s anecdote is the fact that this kind of thinking prohibits proper care of general public health issues. For example, what if a person has a cough/fever that turns out to be TB, Ebola, etc. related. You want that person going to the doctor/ED/clinic right away because you don’t want other people getting sick and don’t want them thinking – let’s go and treat it when I have saved enough money up. You especially don’t want that person out in the general public and, say, flipping burgers and serving them to an unsuspecting public.
The GOP’s policies can often be summarized in totally selfish terms, that is, we don’t want to share with those icky other people. With healthcare, this simply does not work.
Barbara
I can tell you. I filed an amicus brief on behalf of an undocumented worker who lost her kids after a hospital that had treated one of them for a respiratory infection called the police when its doctor noticed that she had not returned for follow up care. The issues were somewhat complex because they involved the interface of immigration and child protective services, but the point is, they got CPS involved when they thought she was not taking her child’s medical condition seriously enough. The mother didn’t go back because the child was better. The hospital hadn’t provided a translator and she did not understand she needed to go back regardless of whether the child had improved.
ArchTeryx
@DBaker: And that absolutely does not stop them from constantly stating that Healthcare is and should always be a privilege of wealth and employment. It’s just another tool of control to them.
Too bad viruses don’t read your party registration before infecting you.
Hitless
I’m going to go ahead and say that people going to the ER because they can’t tell the difference between minor injuries and emergencies isn’t the primary driver of health care cost in the US. It isn’t even the primary driver of ER overuse.
Roger Moore
@Mnemosyne:
I’m not sure that’s really true even from an actuarial standpoint. If he didn’t have insurance, he would have had to pay all his costs out of pocket, which is a goldmine if he can pay. If he did have insurance, then the company lost out on all his future premium payments, which might well be more money than the cost of saving his life. And that’s ignoring the actuarial value of a QALY.
Yarrow
Urgent Cares have sprung up like mushrooms. I have to think there’s some scam going with them. Maybe a bubble?
hovercraft
This man is a monster, I had a hairline fracture in my foot, and it was excruciating. How you could do this to a child, and his wife is just as bad as he is, is unconscionable. I can’t imagine the pain he went through needlessly. I wish they had asked if they gave him any medication to deal with the pain, and if so how much, did they have a stash of leftover prescription strength painkillers in the house? How the hell did that kid not howl the house down and force them to the ER? If not, what have they done to him to make him docile enough to endure that type of pain silently?
Yarrow
@hovercraft: He’s a Republican. They’re sadists. Of course they let their child suffer. They want to bring back child labor so even more kids can suffer. It’s what they do.
Starfish
@SP: This varies based on the CVS. We had one CVS in Baltimore that was pretty good. But the structure around the CVS is insane. I got the impression that they just prescribe cough suppressors all day long without having any idea of what is going on with the patient. They have to prescribe antibiotics in some company specified order. They can’t treat animal bites.
It’s like whoever said that they wound up getting diverted from urgent care a lot.
Alex
@tarragon: Exactly. That’s why we have medical professionals to do diagnosis. My dad has some fairly complex medical conditions, and he’s given up on urgent care because they send him to the ER every time. Once he waited to go to the regular doctor for a respiratory infection (listed as an example in the OP as a condition that usually isn’t one for the ER), and the doctor called an ambulance to take him to the hospital. Health care simply involves too much information asymmetry to be an efficient market.
hovercraft
@Yarrow:
No sane person wants to go to the ER, it usually involves waiting for hours in a packed waiting room. The vultures saw an opportunity to siphon off some of that ‘business’, by offering people who needed care, but didn’t think they were in danger of imminent death a place to go, they were sold as cheaper and faster, and the market would make a nice wad of cash at the same time. Win win. My personal experience has been that I should have just gone to the ER, in the long run it saves time, and at least it’s a one stop shop. Twice after sitting in the urgent care center, they’ve ended up sending me to the ER anyway. The market is always looking for new ways to separate us from our money, why allow hospitals a monopoly, in the market completion is always good, the Randians told me so.
raven
@sigaba: Well, we’ll see. The Bohdi has come up lame and he’s at the vet right now!
Soprano2
It’s anecdotal, but I’ve had terrible experiences with urgent care clinics, such that I will no longer use any that aren’t also connected to my primary care providing network. One urgent care clinic diagnosed my mother with diverticulitis, based on the fact that she had that same diagnosis ten years previous. It turned out she had an almost total intestinal obstruction that required surgery! I might go to urgent care after hours if I thought I had strep throat, but otherwise I’d either go to the emergency room or wait to see my primary care doc.
? Martin
I’m not so eager to jump on this guy. His rationalizations are fair game, but broken bones can be difficult to identify. Happened with both my mom and I.
For me, a soccer injury when I was a teenager. Thought it was a bad sprain – even ran (limped) on it for the last 10 minutes of the game. Pain and swelling got progressively worse as the evening wore on, went to ER to learn that I broke something. Was in no way obvious that something was broken. ER was 45 minutes away (and a 4-5 hour wait to be seen) which probably contributed a bit to the ‘wait and see’ approach.
Last year my mom was getting off the sofa and turned her ankle. Heard a pop. Knew something bad happened, but the pain wasn’t terrible. She could walk on it, but it hurt. I referenced my injury 35 years earlier, wondering if she could have broken something. She waved it off. 3 hours later we were at urgent care getting an xray confirming it was a broken bone. Even the prior experience didn’t immediate cause us to act differently. What’s more, her husband was a C-level exec for an insurance company and she actively volunteers to help patients navigate Medicare/Medicaid. Short of having a physician in the house, you could not have a better set of circumstances to inform when to go to the ER, and yet we still got it wrong. On the upside, the urgent care was a minute from my house (I have 3 in walking distance plus 2 hospitals) and she waited no more than 10 minutes to get the xray at a nearby shared facility. The out of network billing was a PITA, but the service and treatment was pleasantly outstanding.
My only point being – don’t go too hard on a dad trying to make decisions in an emotional situation. Go hard on a congressman trying to score political points off of the event.
amygdala
@? Martin: Yeah, the politicizing is noxious, but I couldn’t help thinking that a single AA mom making the same decision may well have had Child Protective Services knocking on her door the next day.
? Martin
@amygdala: And that’s a perfectly fair policy point that should be raised. But that didn’t inform his personal decision.
randy khan
I’m kind of stunned that nobody has pointed out that his anecdote actually contradicts his argument – they misdiagnosed the kid’s problem, and they actually should have gone to the hospital right away, given the potential impacts of an untreated broken bone.
I mean, obviously, he’s a terrible person (and I would be entirely unsurprised if the *real* story is that his wife wanted to take the kid to the ER right away and he said they shouldn’t go), and reasoning by anecdote is stupid, and ER costs are a minor part of health care costs overall, but on top of all that he can’t even offer an example that is consistent with his position.
Roger Moore
@Yarrow:
I think there’s a real need for something between an ER and a regular doctor’s visit. I think the main thing that’s driving the whole thing is EMTALA, which said ERs couldn’t turn patients away because of ability to pay. The net result is that ERs tend to be big money losers, because indigent patients who can’t get care any other way will use the ER. That means a lot of places have shut down their ERs and replaced them with Urgent Care, which doesn’t have the same requirement to treat anyone who comes through the door.
Barbara
@? Martin: I waited to take my child to the ER because I wasn’t sure the bone was broken. When it became clear how much pain she was in after a few hours, I went to the ER and, yes, it was broken. I would note that the current practice for simple fractures is to wait for the swelling to recede to put on a cast, so we did have to wait for that but we had some pain medication. The same happened when I was a kid with my ankle and it turned out not to be broken. I don’t think waiting to go to an ER to see if time gives you further clarity is a bad thing, but the idea that you would have to wait just to save the system a few bucks is obnoxious.
hovercraft
@randy khan:
The republican “policy”, prescriptions for reforming the healthcare system is built on bullshit. Tort reform would have a negligible impact, because it is not a huge driver. The ER is used as primary care for millions, but it is also not the biggest driver of costs, HSA would work only for people who have money, for the majority of Americans living paycheck to paycheck they would never be able to have enough money to make them really useful. The big kahuna no one will talk about is the end of life. From what I’ve read the vast, vast majority of health care costs come from the last 18 months of life, and when you drill down further the very last months of life take up the bulk of that. Just the concept of discussing end of life decisions was distorted into “death panels”. Imagine if there really was a serious discussion about how the desire to cling to life, regardless of the quality of that life, is what is driving the cost of healthcare up. The cost of drugs and the middleman’s (insurance co.) are barely part of the conversation for republicans, except when they are accusing democrats of cozying up to them while the GOP shields their profits at every turn.
The GOP lies about every damn thing.
hovercraft
@Barbara:
THIS.
Barbara
@Roger Moore: @Roger Moore: EMTALA probably explains some of this. Doctors hate EMTALA. It interferes with their self-determination to see particular patients at particular times. When people talk about this issue it reminds me of the way they talk about SSDI — that too many people who might not technically be totally disabled get it, and what is really happening is that they were laid off and can’t find another job and they are old and lo and behold they can get a doctor to certify a disability. To those people, I always want to ask: What do you think they should do? Most ERs are still operated by not-for-profit tax-exempt organizations that receive millions if not billions of dollars in taxpayer outlays. If they are not set up to take care of people who don’t have real emergencies when that is what is needed, then by God, set yourself up differently and stop complaining. It is as if medical practice exists to give health care providers interesting and well-compensated lives, and not to actually care for people who need health care services. Screw that. Most hospitals don’t have enough real emergencies to justify an ER department, and an awful lot of true emergencies involve indigent people as well (gunshots, automobile accidents, etc.).
Diana
@hovercraft: gotta reply to this.
Years ago, when I was 14 and in private school in New England in the early 80’s, I broke my leg.
I couldn’t walk on it, and my ankle and lower leg swelled up in a perfectly spherical way (it looked as if some large round fruit had somehow magically been lodged between the tibula and the fibula, if I remember those names correctly) but this was New England and it was decreed that it was only sprained.
I spent the night it with it. It hurt constantly and way too much for me to sleep at all but I wasn’t screaming. By morning, I still couldn’t walk on it, and the strange swelling made it sufficiently dissimilar from any sprained ankle anyone had ever seen, so I was duly trundled off to the hospital where it was decreed that my leg was broken and I got a big heavy plaster cast from mid-foot to knee.
That was my first all-nighter and my first broken bone. I’ve pulled a lot of all nighters since then, for work or pleasure but (knock on wood) I haven’t broken anything since.
liberal
@SP:
Comparing my kids’ visits to the ER vs my own, and comments from ER pediatric staff, I think kids have much less wait time than adults.
liberal
@hovercraft:
Yes, though sadly the problem is across the board. Liberal arguments that health insurance bureaucrats shouldn’t get between a doctor and patient easily translate into arguments against government bureaucrats doing the same.
AFAICT patients or their loved ones will raise political hell, demanding that a payor (private insurance or the government) give them access to very expensive drugs or procedures that will grant them only a few extra weeks or months, if that. Pretty sure this has happened a lot, recently, in the UK.
I would assume the right way to go about this is quality-of-life-adjusted-life-years, but that’s DEATH PANEL’S!!1!
liberal
@? Martin:
I call bullshit.
Have you ever had a child? If so, you’d know that they’re much, much worse than adults in terms of being able to introspectively examine their own medical condition, pinpoint sources of pain, etc. In which case it’s prudent to get it checked out, particularly if you’re doing things like applying a splint.
Most likely, in this case, the dad, a right-wing fucking douchenozzle, probably suffers terribly from the Dunning–Kruger effect, and arrogantly assumed he knows something about medicine and human physiology, when in fact all he knows is how to suck on rich people’s genitalia.
randy khan
@hovercraft:
All true.
And the HSA isn’t even that great a thing for people with money unless you have a lot of medical expenses. My wife and I use our HSA (which has a big chunk contributed by my pretty generous employer) largely as a way to get a discount on our long term care insurance, with some build-up of principal each year. That’s really only a strategy that makes any sense if you’re doing all right financially.
Ella in New Mexico
In all reality, what this guy did was not a grossly negligent or inappropriate thing to do–if the kid didn’t express a lot of pain and obvious injury (eg, severe swelling or malformation of the area involved) it wasn’t a terrible decision to wait and see how things were in the morning. I might have done that myself, but then, I’m a nurse so I would have felt like I had a better set of tools with with to judge the seriousness of the situation. ;-)
But I have to say, this story–the discussion of “ED Diversion” exemplifies a lot of whats wrong in American healthcare right now.
If you live in a major metro area, you might have lots of options other than a formal ED for minor emergencies. But for tons of people in rural and less wealthy areas of the country, you really don’t. Especially if you need X-rays or labs to diagnose what’s wrong with you. Also, if you’re not covered well by insurance and need to be billed for your co-insurance, hospitals MUST treat you regardless of ability to pay in an emergency thanks to EMTALA. So if you’re broke or need to be billed later, you go to the ED.
In our community, for example, the medical community outside an acute care hospital still operates on bankers hours-8-5 M-F. We do have quite few a “Urgent Care” centers (none of which are 24 hours) that can’t do any of those things–you get referred to the ED for a baby with a high temperature or a possible broken bone.
One local hospital is in the stages of building a stand alone “ED”-so it will have some of the same diagnostic services like X-Rays, CT Scans, Ultrasound, Lab and Pharmacy services. THAT kind of “urgent care” will keep folks out of the “proper” ED who don’t need to be there, but I really wonder how much it will save anyone–someone’s gotta pay for all that infrastructure.
I’m also uncertain how the EMTALA laws will apply to these kinds of hybrid ED’s.
burnspbesq
Anecdote isn’t the same as data, but I’m a big fan of easy access to ER sevices because there’s a decent chance that I’m only alive because I had it.
The abdominal pain that I thought might be appendicitis turned out to be from a swollen lymph node that was swollen because of B-cell non-Hodgkins lymphoma. Six months and $150k worth of chemo drugs later (less than $8k out of pocket because I have bithchin’ insurance), I was good to go (although I still see my oncologist quarterly).
Dave in Dallas
I suspect Dad having a kidney stone would have qualified for an immediate ER visit.
Jay S
@liberal: I disagree, end of life costs are driven primarily by information asymmetry and oncologists that refuse to lose. In my experience with people facing end of life, having knowledge about the kind of treatment they are likely to get in a hospital tends to make hospice look a lot more attractive. At Group Health Coop in Washington, the oncologists actively resisted patient education on the type of treatment given in hospitals to revive someone who was dying anyway, for fear that it would only distress them. It took a great deal of pressure (including patient experience from surviving relatives) to convince them that this was actually good practice and made the decision making easier.
Not everyone wants to have everything possible done when it generally degrades the quality of what life you have left. Some do, but generally a look at the reality of how little they can expect to get for what is often painful and degrading treatment makes many people say no thanks.
Pogonip
Maybe this guy worked for an HMO. Some years ago, I slipped on the ice and broke my arm; this was back when the HMO gatekeeper doctor had to give you “pre-approval” to go to the ER. I arrogantly broke my arm after hours and the doc wasn’t pleased to be awakened; it was Thursday night and she told me to come to her office Monday and she’d look at it. Even more arrogantly, I went to the ER anyway. The surgeon pinned my arm back together and the HMO paid.
Steve LaBonne
@Jay S: Thank you for reminding me that I need to get off my ass and write a living will.
Barbara
@Jay S: Hospitals vary wildly in the referral of patients to hospice at the end of life. Ceders Sinai (UCLA) is notorious for not letting go. Someone who is or used to be one of the doctors in charge at one time had standing orders that no one was allowed to talk to his patients about hospice. Let that sink in. Some people really are chancers — my husband had a friend who was dying from a kind of lymphoma and she was willing to do anything because her children were still young. She didn’t want two months of hospice. She wanted years and was willing to undergo experimental treatments and anything else, and ultimately did probably shorten her life by a few months after having a toxic reaction to an experimental drug. People who study this phenomenon among the elderly find that adult children who have spent a lot of time with their parents perceive the decline over time and are more willing to let go, but that adult children who have not been around as much are often very resistant to accepting end of life decisions. Partly this is out of guilt that they have not done more and now never will.
Jay S
@Barbara: Yes I understand there are people who will fight to the end, and I’m fine with that if it is their choice. People really need to make advance directives to limit the meddling of relatives in these decisions. People need to inform themselves and not rely on doctors alone.
@Steve LaBonne: You might want a medical power of attorney as well as a living will, if you have someone you trust to enforce your wishes.
Terry Schiavo was our wake up call in this household
Rusty
As a further example of the inability to know costs, our daughter fell ill at college in the middle of the night and was taken to the ER of the University owned hospital. They weren’t sure if there was a neurological issue so ended up running a CAT scan, EEG, spinal tap (possible meningitis concern), and consults with the neurologist, etc. Final diagnosis was severe migraine (family history of very severe migraines including loss of memory). We have health insurance from my job at a different university that covered her. They kept her in the ER 12 hours and smacked us with a $16,000 bill of which we owe $1,800 since it was out of plan. No way to avoid it, no negotiated rate and a complete screw job (just wait until they send me another letter asking if I would like to give to the university as a parent, they will really get my feelings on the subject).
Larkspur
@Barbara: I agree. When I was about 12 years old, I tripped and fell down hard, with my left arm hitting the ground first. It hurt and I felt nauseated. It was evening and we were at a relative’s house for dinner. There was nothing distorted-looking about my arm, and there were no other injuries like scrapes or cuts.
So it made sense that my parents took me home that night and not to the ER. What didn’t make sense was that for the next five days, they forced me to “exercise” my arm to work out the sprain or something. I cried each time and told them I really could not extend my arm all the way. They were frustrated because I was being such a baby. But after five days, they looked at each other and decided to take me to the ER. Before I saw the doctor and had the Xray, my parents told me to tell the doctor that I fell just a day ago “…for insurance purposes”. (I didn’t figure out till years later that they may have been afraid of being accused of neglect.)
And yes, I had a hairline fracture on my elbow, and the doc said to move it as little as possible and to go to the pediatrician for a half-cast and further instructions. We didn’t have a pediatrician, so they took me to my father’s chiropractor and he slapped together some kind of cast and it got better. My parents joked about it with their friends: “Well, we sure had our medical licenses revoked!” But I was raised to not question them. It wouldn’t have occurred to me to yell at them, “Mom, Dad, my arm won’t move past this point. Do something!” I didn’t know a kid could even do something that assertive.
Kinda OT, but I sure felt bad for that Huizenga kid when I read about it. I mean, if his dad splinted it, there had to have been some sign of displacement or just wrongness. I’m going to slap that dude if I ever see him.
NW Phil
I’ve usually gone to some type of clinic with late hours if it’s a bad cut or potential break. ER’s take forever; lot’s of experience waiting in those for family or my most serious health episodes which required an ambulance ride.
Steeplejack (phone)
@Larkspur:
That was child abuse. You might want to explore whether your lifelong problem with depression is really PTSD instead.
(Apologies if this is out of line.)
Tehanu
@Gretchen:
Not too lazy — too cheap. Here’s hoping that kid is the one who eventually makes all the decisions for his dad’s old age care.
@Yarrow:
You called it.
@Larkspur:
And that’s exactly what rightwingers think is the correct way to raise a child, never to show any independent thought, because their children are their property, goddammit, intended to be identical clones. (Now I come to think of it, it certainly worked for Il Douche’s kids, didn’t it?)
Barbara
@Larkspur: It could have been the times. My parents did something similar when my sister had a bad accident on her scooter. It was awful. I remember her crying all the time. They never did anything like that again, and generally showed good judgment later. I don’t think my sister broke anything but they definitely ignored that risk.
Larkspur
@Steeplejack (phone): Not out of line at all; kinda sorta directly on point.
@Barbara: Yes, it was definitely a 50’s/60s kind of thing, although my parents showed poor judgment a lot. It’s funny: I recall a friend of mine, a little older than I am, and she told me a similar story, only it involved her own daughter and how she’d scolded the girl for making a fuss and potentially wasting daddy’s hard-earned money – and then they found out the arm really was broken. My friend told me this and cried and laughed at the same time. It sounds dumb, but the point is, she made a mistake and was horrified by it, and recognized it as an example of Horrible Parenting. Everyone is going to screw up parenting over and over, but the response to it is what defines you. (For the record, I don’t have children, but I’m just saying.)
If any of you have ever read the book Little Heathens: Hard Times and High Spirits on an Iowa Farm During the Great Depression you’ll see that this “Oh, they’re kids; they’re resilient, they’ll get over it” attitude was really prevalent then. But they didn’t have antibiotics then, and no nearby ERs, and no money, and as great as that book is, it doesn’t make me wish for those simpler times. Those really were hard times.