Cole illustrates why emergency room visits should not be adjudicated based on final diagnosis instead of presenting symptoms.
John had a bit of a scare earlier in the week:
Just got back from a relaxing seven hour visit to the ER. For the past couple of days I’ve had a little pain in my chest, but it felt like the pain I had when I had an ulcer a decade ago, so I dismissed it. Today it got worse and I could feel it in my shoulder and back, so I decided to go check my blood pressure. Checked my BP, and it was through the roof (200/100 normally about 135/75) and my heart rate was 84 bpm and it is normally about 55-65… so I decided I should probably go seek medical attention….
What do we know about Cole? We know he is a klutz. We know that he is middle aged. We know that he is carrying a couple extra pounds. We also know that he lives in the middle of nowhere and the closest hospital in Wheeling or Weirton is probably 30 minutes away once the vehicle leaves his driveway.
And we also know that he is having chest pains that were spreading and unusual cardiac measurements.
That to me sounds like a damn good reason to get checked out even if the eventual diagnosis is that there is not much happening. It sounds like a damn good reason because Cole is not a doctor but he knows his body and knows that something strange may be happening. It is prudent for someone with his demographics and chest pains to get a doctor to say “Okay” or “Oh Shit”. The cost of thinking he would be okay while he was actually going into an Oh Shit scenario is higher than the opposite way of being wrong.
The ACA requires insurers to use the prudent layperson standard to determine whether an ER visit a priori is an emergency. Using post-facto diagnosis codes imposes a knowledge requirement on the prudent layperson that they can’t meet.
Seth Trueger, an ER physician explains:
The ACA made the prudent layperson standard federal law (ACEP piece). The prudent layperson standard is exactly what it sounds like: the definition of a medical emergency is that a normal person with an average knowledge of medicine thinks is an emergency -– the patient’s symptoms make it an emergency, not the final diagnosis. So severe abdominal pain that turns out to be “just” an ovarian cyst is, by definition, an emergency….
If the patient is acting like a “prudent layperson” and thinks they are having an emergency, then it is an emergency and the insurer has to cover the ER visit. Full stop.
This is really important because there is a huge overlap in symptoms between simple benign problems (ovarian cyst) and serious life threatening problems (appendicitis) — see this fantastic paper by Maria Raven et al….
Tons of patients end up with final diagnoses like “acute viral bronchitis” which sound simple. Except when the patient is 80 and has CHF and COPD and it could easily be flu or pneumonia or a serious COPD or CHF exacerbation any or all of which could kill them.
We’re not medical experts. We know what does not feel right in our own body, that is a hyper valuable expertise but the layperson can’t self diagnose themselves and only go to the hospital when the chest pains are an actual heart attack instead of something else.
Years ago, I was driving a Toyota MR2 when it was rear-ended by a tractor-trailer rig. I was OK (although I had blacked out for a few seconds), but some anonymous observer who called 911 indicated that an EMT crew come out to the scene as well as the police and fire department. I told the EMTs that I was fine, but they, along with literally everybody else at the accident scene (cops, witnesses, the other drivers), insisted that I go to the ER and get checked out in case I’d suffered a whiplash injury. I did so, and the EMTs took me to the nearest hospital, and sure enough, I was fine.
However, when I submitted the claim to my insurance company, it was rejected because the hospital was out-of-network and it wasn’t an emergency. No big deal, because the truck driver’s insurance picked up the tab, but ever since I thought it was strange, as the only way to determine whether it was an emergency was to assume it was that it was, and a layperson (heck, with a whiplash injury, not even a neurologist could self-diagnose) is incapable of making such a determination.
Twice I ended up at the er with chest pains. The second time I was able to call the doctor before going (the first was a Sunday) and was told you never wait around with chest pain and get the hell off the phone and to the hospital, probably not in so many words. Both times there was no cardiac issue. After a good bit of fiddling about they determined -a year later- gallstones, which can closely mimic heart attack symptoms. Not an emergency but you can’t know it isn’t until they look. And ev n knowing this the Doctor says if chest pain presents again DO NOT ASSUME it’s gallstones again. I’m getting the thing yanked out soon and the possibility of confusing something more serious for something less will be reduced.
There is a big mismatch between what we think ERs are for and what hospitals and insurers think they are for. It really should be beyond question that medical attention is reasonable for someone who was just been in a car accident. It’s not your fault that American health care is so expensive and devotes so many resources to the treatment of what are mostly outlier events, leaving everyone else mostly without recourse for seemingly “lesser” symptoms.
We just had a similar incident. Last week, Ohio Dad felt very lousy, and was afraid his heart had gone back into fibbing or fluttering. He could tell his heart rate was way up.
He called the cardiologist, spoke to the nurse, who tried to get him in with another nurse who has an office EKG. But that nurse said No, go to the emergency room (apparently, all the doctors were somewhere else that day, maybe the hospital).
So off to the ER he went, where they did an EKG, told him he was fine, probably just exhausted — getting over heart surgery isn’t as quick as Ohio Dad would like, and he should be taking it a little easier.
Now we wait and see if the insurance balks. It’s a little background stress that you might say is contraindicated for a recovering surgical patient.
On a related issue, I wish screening colonoscopies were paid for based on their intended purpose a priori, not the diagnostic code afterwards. I went in the other day for preventive care I thought would be without cost to me, but ended up paying nearly a thousand bucks because the doctor snared a polyp. So much for people who say the prep is the worst part. I don’t think this is nearly as big an issue as emergency department reimbursement, but it can be a nasty surprise if you aren’t warned, and even worse, it could discourage some who are warned from getting screened. People find enough reasons to talk themselves out of colonoscopies without the prospect of an unexpected bill.
“sorry, but ‘being hit by a big rig’ isn’t an emergency”. what a country.
@Ohio Mom: If the proper standard is what a “prudent layperson” would do, I would certainly hope Ohio Dad is in the clear. What could be more prudent than seeking emergency care when your cardiologist’s staff tells you to?
Ugh. It does take a long time to feel better. My dad was given a tablet that was connected to various equipment like a pulse/ox reader, BP cuff, etc. The results went straight to some place with a nurse 24/7 and she would call if she wanted him to be seen either by his doctor or at the ER. They could also call this center if they needed to.
Do they have something like that where you are?
Big Ole Hound
I’m 75 and have been to an emergency room about a dozen times with everything from broken bones in my youth to heart attack to gall bladder attack and my insurance, Aetna, has never failed to pay. I did have to argue with them about an ambulance ride once for appendicitus but it was speedily resolve.The cost has gone from 250 to 850 a month in the last 50 years. It is what it is.
I also don’t understand the reasoning behind the ER co-pay that is waived if one is admitted. About 3 years ago I had a miscarriage (my 2nd) that came with much more severe bleeding that my first one, which I dealt with at home. Finally, under the advice of the midwife who’d delivered my son, we went to the ER, because it was a lot, a lot of blood. I ended up being able to go home some hours later, and it sucks to be grieving the loss of a pregnancy while sitting in a bursar’s office because you still have to pony up a $100 co-pay since I guess it wasn’t enough of an emergency for ER.
Thanks for this. Tokyokie’s story should be included in the regulations as well. If experts say to go to the ER, then that should be covered – no questions asked – as well.
This reminds me of one of my childhood adventures. There was a TV ad for some new “HandiWipes” competitor. Some tall kid showed how strong they were by grabbing both ends, looping it over the top of a door, and gently hanging from it. Of course, I had to try it, and of course I wasn’t tall enough. So I jumped up to loop the cloth over the top of the door, and as I was falling back down to earth, the cloth tore, and I hit my jaw on the doorknob.
It hurt like hell, so I started crying and my mom took me to the ER to get me checked out (to see if I had dislocated or broken my jaw or something).
I figure I wasn’t the only one who did that because they took that commercial off the air not too long afterwards… :-/
A couple of years ago I had similar sympton: breathless, racing heart. Decided to stick it out because I needed to take care of my 90 year old dad in a few hours, and didn’t want to spend eight hours in the ER while they triaged me to the back of the line.
Husband took me to urgent care when I collapsed on the kitchen floor. Same fear of ER: die in triage if I didn’t have an active gunshot wound. They called an ambulance. Ambulance took it seriously.
My drycleaner’s wife had similar situation. Went to ER. They sent him home with aspirin. He died in bed that night of a heart attack.
Maybe in DC and upscale parts of NYC we have the best medical treatment in the world. In the boondocks, not so much.
Very glad John survived.
The problem with heart attacks is that until you have the attack and the dying heart muscle releases cardiac enzymes there is no way (in the ER) they can tell that you may be about to have a heart attack. Even so, the most reliable indicator of a heart attack, troponin, isn’t released until 2-6 hours after the attack.
Anonymous At Work
What about the Vox story on Anthem rejecting that standard?
Gin & Tonic
Last time I went to the ER, the triage nurse asked me what the presenting complaint was. I replied “I broke my arm.” Her response will remain etched in my mind: “How can you be sure?”
The diagnosis when I left was unsurprising.
A resounding “yes” to that last paragraph.
And the thing is that even a “benign ovarian cyst” could turn into a less common but quite serious medical event wherein a large benign cyst ruptures, causing internal bleeding that can require transfusion and a surgical repair. There is just no way for a layperson to know, and sometimes only imaging, not just a cursory exam at a “Quick Clinic”, can determine with certainty whether or not that severe pain is being caused by something life threatening.
Or, in the case of an acquaintance who is a practicing physician, what feels like intense ovarian cyst pain in a patient with a history of benign ovarian cysts can turn out to be something different but even more dangerous: an ectopic pregnancy.
She got told to “go lie down, take Tylenol according to the dosage instructions on the bottle, and use a heating pad for the cramping discomfort, since there’s a long history of painful cysts resolving on their own with basic home care” when she called her insurance’s patient assistance line to get the nod of approval for her middle of the night ER visit.
Thank goodness she paid attention to her body and to her medical training, and made the decision an hour later to disregard the assistance line rep’s instructions and go to the nearest ER when the pain did not abate. She ended up requiring immediate emergency surgery for a ruptured fallopian tube and internal bleeding, and a it took a three day hospital stay before she was stabilized enough to be discharged.
Other than cancer, even death certificate diagnoses are off half the time.
How about this, any insurer who wants to reject ER claims has to offer 24/7 triage clinics and accept the attendant liability for making the wrong call. ERs have to make these calls on a daily basis and frequently get it wrong. Case in point is a friend who went in with drooping face and other indicators of stroke, got sent home with no scan. Next morning had to have his apartment door busted down after his daughter couldn’t reach him. Severe stroke with loss of speech and movement on one side. Hospital and physician being sued.
@TriassicSands: Problem was with that ER. They sent my 85 year old disabled mother home abrubtly. My mother had breathing problems. The ER nurse and doctor didn’t like her attitude. Rolled her out into the parking lot without even givi g me time to get the car. Radiology called us later that night to say yes there was a problem. Drove her back to the hospital. ER admitting said she would have to wait through the whole triage thing again. We took her home, and she died of pneumonia the next morning. Medical incompetence. Irony is her husband worked for that hospital for 35 years. We didn’t sue. Just took our business elsewhere, and told everyone we know.6752276″>TriassicSands:
My ER story: a while back there was a morning when I ate some gravlax that had been out of the fridge too long. I started feeling queasy by midday, and just as I had to get in the car to pick up the spawn from pre-school, I started feeling really gross. But the kid was stuck, and my spouse was thirty miles away, so off I went for what was no more than a 20 minute drive.
Seven minutes in I am feeling wretched at both ends and have to pull the car over. As I lean over a fence to attempt to vomit, I notice that I’m preparing to growl at the grass of a cemetery. Short commute, I think.
I dry heave, and then slowly collapse to a sitting position, leaning on the fence. Some very kind person sees me from across the street, and walks me over to his house. I disappear into the bathroom while he, unbeknownst to me, dials 911.
By the time I emerge from the seat of ease, shaky but somewhat improved, the EMTs, a cop and the fire dept. are all there. I say I’m feeling better and I’m ready to go home. They basically keep me sitting there until I surrender and they pop me in the ambulance for the one mile hop to the nearest hospital. This is the one day in living memory when I forgot my phone back at the house, so I borrow someone’s to call the pre-school and let them know my bundle of joy is on his own for a while. They’re great and handle that part. I forget to call my wife and tell her what’s going on, and, as I don’t know yet, I don’t tell the school which hospital I’m going to.
Fast forward: several hours in the ER confirm I ate some bad fish. They did a bunch of stuff, including and EKG and a chest X-ray, but the real treatment was lying back for a while w. rehydrating IV bags coming and going. I got the prudential treatment from my insurance company. Had to pay the co-pay, but the some thousands bill went away.
The conversation with my partner that evening dwelt a lot on the importance of proper communication skills.
The moral of this story: don’t eat bad fish. And call one’s spouse.
@Hoodie: This. What a good idea. It will never happen as long as health insurance is a private for-profit enterprise. Single payer is the *real* solution. Again, not going to happen as long as there’s money to be made from sick people.
Edit function is completely fucked up. Edit keyboard covers the screen. Changes don’t happen.Been that way for days. Time to move on to other blogs. Embarrassing to comment here. Typos carved in stone, also mistakes not made that blog assumes.
@TriassicSands: I just had this issue – symptoms of heart problem, no personal history but family history of heart disease – so took an ambulance to ER, where they did tests that were negative, but admitted me (I thought) overnight for further tests. It turns out if it’s for a ‘monitoring’ it isn’t considered an admission until you’ve spent 2 midnights in the hospital. Medicare is saying it’ll pay $400 of the bill (currently at $7K, but that doesn’t include the doctors’ fees or the ambulance). My supplemental might cover some, but who knows? Of course, now I’ll be reluctant to go to an ER if it happens again.
Only slightly off-topic: Why is everyone so surprised this was going on?
BC in Illinois
I went to my doctor about two weeks ago. Chest pains. They didn’t stay more than 10 – 15 minutes, and had none of the other “shortness of breath / stabbing pains / extend to arm or neck / breaking out in sweat” symptoms. They didn’t even co-relate to the times I was doing strenuous stuff. Just chest pains. Once or twice a day.
The doctor did an EKG, took one look, and she sent me to the ER for a stress test. The ER did another EKG, looked at it and the bloodwork and never did the stress test. They admitted me to the hospital and scheduled a heart catheterization. Three hours from when I first saw the doctor. Heart cath on Thursday, two stents, and they sent me home — feeling fine — on Friday, February 2nd. A weird feeling. By some definitions I had a heart attack (or just avoided a heart attack), and I didn’t feel all that much different. Just take it easy, no chest pains. Mrs. BC and I watched “Groundhog Day” for the occasion.
The rule that I told son and sons-in-law, was that “If you have chest pains and they go away, fine. If they come back then get to the doctor. Don’t ignore them. Don’t wait for them to keep coming back for two weeks, as I did.”
@Tom Levenson: I can top you —
I had been married for three months. It is mid-December. My wife and I were going to fly from Pittsburgh to Boston the next morning to see my family for an early Christmas visit. My wife was working late and would not be home until 8:30 or so. I left work just after dark and started walking to the bus stop a couple of blocks away. I need to cross a five point intersection and then the main road to get to the bus stop. I am wearing a dark coat and a dark hat.
I have the walk signal and start walking across the street. At the same time, a car whips around the corner and makes a 135 degree turn. I see the car as I notice that I am about at the midpoint of the hood. It is one step away from me when I am aware. The strange and sudden thought that the reason why so many drunk drivers survive collisions is that they are relaxed at the point of contact goes through my head … so I jump, protect my head and relax the rest of my body. I go through the windshield shoulder and elbow first and land in the driver’s lap.
He’s pissed that a pedestrian hit his car. I’m somewhat in shock. I get up and out and I feel pretty decent all things considered. A cop witnessed the entire thing as he was in the convenience store along the intersection getting a cup of coffee. He writes the drive a citation and is surprised that I don’t want an ambulance.
I get myself a cup of coffee and proceed to walk to the bus stop. As I am waiting for the bus, I call my wife. Note to self — never use this line again:
“Hi honey, I’m fine, I just got hit by a car and I won….”
Not a recommended line.
She left work immediately and insisted that we go to the ER that evening. Second useful thing I learned that night is saying “I got hit by a car” will get you seen only slightly slower than a sucking chest wound or chest pains.
The ER docs agreed that I won the collision.
Everyone’s different billing and outcome results proves my point. Best healthcare in the world if you are in DC or Manhattan. Totally fucked if you are elsewhere. Great doctors in the boondocks, but the admissions and billing is a mess, and possibly a danger to your survival.
@David Anderson: Your family is a walking medical emergency. If you keep posting, no one named Anderson will ever get insurance again. Good for me, since we have no Andersons in the immediate family.
Snarki, child of Loki
@chopper: “sorry, but ‘being hit by a big rig’ isn’t an emergency”. what a country.
I suggest hitting some “Big Insurance” CEOs with big rigs until they decide if it’s really an emergency or not.
@TriassicSands: So maybe they should have kept him for observation, instead of sending him home to die. They knew that. He and his wife didn” t. Well fuck them for not being experienced medical practitioners. Your defensive argument just proved my point.
Gin & Tonic
@glaukopis: I think once it hits 24 hours it’s an admission. At least that’s what my wife tells me, and she’s spent her working life in hospitals.
Better to be in debt and alive, but there is no excuse for that. Our health care system is a mess. When asked, I will not say I favor Medicare-for-all. No health insurance plan than requires a supplementary plan to achieve good coverage should be the model for universal health care.
@Sab: I was once in a Dr’s office and was fibbing. She insisted I go to ER via ambulance. This would result in a royal pain retrieving car from Dr.’s office. I wanted to drive to ER. She patiently explained that if the ambulance brought me, I would be seen hours sooner at the ER. And in fact, I was seen immediately, even though I was conscious, alert, and not bleeding.
It makes more sense when you realize the insurance companies’ standard is the “we get to say no whenever we feel like it” standard.
PSA: Women may experience a different set of heart attack symptoms. The American Heart Association has a list:
Villago Delenda Est
Let’s get one thing straight here: the care of the patient is totally secondary to the care of the profit of both the hospital and the insurance company.
Big Ole Hound
@Sab: Most of northern California has great healthcare and hospitals; UCSF, Stanford, John Muir plus at least 8 or 9 insurance companies. Living here is great for healthcare and weather of course.
@Gin & Tonic: My DIL is a doctor and says the rules have changed recently and even doctors are often unaware of what they are, but she’d heard the two midnights rule. They did get me out in just under 24 hours though.
OMG. I’m pretty sure the doctor in that case was my PCP for a number of years. At the very least, I live in Southern California and I had a PCP with that name. When I asked my new PCP why he wasn’t with Kaiser anymore, I got some bland answer about how he never really fit in with Kaiser’s way of doing things. One more point in Kaiser’s favor in my book.
@glaukopis: I’ll be working on a project this semester for school that involves finding triggers for a full admission earlier in the process rather than have patients go through nearly 48 hours of observation status. Because of the way payments are made through Medicare Parts A and B, the hospital gets less for an observation vs. an admission, and the patient pays more. And insurers often take their cues from CMS.
@Sab: Please let Alain the Site Fixer know via the Contact Form. It sounds like you’re using the “mobile” version of the site on your phone or table. Let him know all the details.
Alternatively, make note of it on the Issue Tracker on Github.
It won’t get fixed unless he’s told about it.
I’ve often wondered if that would work. My only impact with a car was being doored by a little old lady while riding my bicycle to class. Managed to get my chin just over the door did a dramatic flip up and over then caught the top of the door with my hands so I barely hit the pavement. Not a scratch. The street was full of students going to class who applauded when I stood up unharmed.
While we’ve seen plenty of evidence health care in the USA is too expensive it’s the casino aspect that puts my nerves on edge. Will the insurance pay?
@glaukopis: All of my clients say the threshold for when an outpatient (in ED or observation) becomes an inpatient is 24 hours.
@Sab: Yeah, healthcare outside of a major city is a dicey proposition. I will never live in a city that doesn’t have a Level 1 trauma center.
Seriously, even a trained doctor can’t generally know what a condition like chest or abdominal pain is without tests. Paying based on post-facto diagnosis is just a requirement for precognition.
Interesting. Medicare part A copay becomes covered after 48 hours. It’s why I’m irritated that my back procedure will cost me $250. Otherwise if I could stay two days it would cost next to nothing.
@David Anderson: your story worked out better than mine. I ended up hitting a windshield with my face when a driver in downtown Chicago decided he would avoid the six-way stop made by the intersection of three roads (Chicago is rife with these northwest-to-southeast corridors that cut thru’ the grid system) by taking a left-hand turn to cut thru’ the gas station lot. Unfortunately, he took his left-hand turn right into me on my bike. I’ll never forget that moment, even tho’ I blacked out on the impact and woke up in the ambulance wondering what the hell had just happened.
I was just about to start grad school – the next day, in fact – and I had purchased student health insurance. Unbeknownst to me at the time, I was still on my dad’s BC/BS insurance – and he must have been paying a fortune for it, because I was in my twenties and this was pre-Obamacare days. So my problem wasn’t a lack of insurance – it was *too much* insurance, which led to infighting between the insuance companies as to who was the “primary insurer” (each was determined that it was going to be the other), which led to me getting dunned during my recovery for a bunch of medical bills, because the insurance companies were playing chicken with each other. It was an exhausting and infuriating fight to get all the bills covered, to say nothing of all the reconstructive surgery, dental implants, etc. that the surgical team recommended – and don’t get me started on the weaselly attempts to get out of paying for dental implants to cover the teeth I lost because “that’s dental, not medical”.
Ugh. Bottom line is: if you get hit by a car, don’t get hit in the face. And don’t, for God’s sake, have more than one insurance policy in play, unless you are sure which is the primary and which is the secondary!
@Anonymous At Work: Anthem is currently reviewing my appeal because my sudden onset of dizziness after 48 hours of epigastric pain didn’t turn out to be an acutely bleeding ulcer after all. If anyone knows any attorneys who want to take a crack at Anthem for abandoning the prudent layperson standard in favor of final diagnoses, I’m happy to be a test case, and I’m sure I’m not the only one. I’m a healthcare provider who spoke with a friend & colleague for advice before going in–an NP with GI speciality experience–and if we can be fooled, I’m pretty sure anyone can be.
Alain the site fixer
@Sab: What browser and device are you using? The edit comment function seems to work fine but some users have issues with it, so please let me know!
I’ve never heard of such a thing and wish we’d been given one.
Ohio Dad was sent home from surgery with instructions to take his own pulse. He wasn’t getting consistent results so we sprung for an oximeter at CVS. Pro tip: don’t buy medical equipment at CVS, their markup is astronomical.
@Anonymous At Work: Our new carrier is Anthem and while we aren’t in one of their targeted states for punishing people who go to the ER “mistakenly,” the welcome package we received had a lot of material on what symptoms merit the ER and which ones don’t. Hence our anxiety about being denied.
The Midnight Lurker
It was the pressure of getting all our damn calendars in the mail a month-and-half after the year started. Take the rest of the year off, Sarge.
@David Anderson: Similar thing (about relaxing) when my car went out of control on a turn. (I think one low-pressure tire unbalanced the car and then burst.) It spun 180 into the other lane, seemed to pause, then went off the embankment, rolling over two full times.
As it started to tip over the first time, I thought of a story briefly mentioned in a small Japanese aikido book by my teacher’s teacher. It was meant to illustrate the most basic principle, and was about his beginning student (I think) in a car accident.
So I thought I would willingly make the roll with the car. I wasn’t hurt, and got out on my own.
(Was made to wait for the ambulance people. I said I was fine. They mentioned that effects of shock can postpone pain, a reasonable point, and insisted I go to the ER to be checked. I spent hours lying still in a brace in a bed in the hall, but that’s OK. Eventually I flagged a doctor down, they looked at my test result and released me.)
I was lucky. And the Subaru performed well, totaling itself but protecting me. I also think that relaxing and going into the roll (as if following in a dance) helped a lot, at least for these particular conditions in this one accident.
Went to the ER the day after Thanksgiving 2017 with abdominal pains. They diagnosed ovarian cyst, which I’ve had before. Two days later, I still felt awful, and had an emergency appendectomy that evening. Yes, the appendix had ruptured. The author’s choice of examples above are thus poignantly memorable!