U.S. Healthcare Trauma cost

[VentMedic]

Saw this article in San Francisco Chronicle. If the poor guy had just crashed a couple more miles down the road.

http://sfgate.com/cgi-bin/article.cgi?f=/c...UG1LOTC6T75.DTL

Uninsured patient billed more than $12,000 for broken rib

David Lazarus

Friday, March 30, 2007

There are 47 million people in this country without health insurance. Richmond resident Joey Palmer is one of them.

He learned how costly this can be after fracturing a rib in a relatively minor motorcycle accident and subsequently being hit with a bill for more than $12,000 from San Francisco General Hospital.

"There's no way I could pay something like that," Palmer, 32, told me. "I'm not a bum, but I'm not making a lot of money right now. How is anyone supposed to pay a bill like that?"

Iman Nazeeri-Simmons, director of administrative operations at San Francisco General, said she sympathizes with Palmer's situation.

"It's not us," she said. "It's the whole system, and the system is broken. We need to look closely at making changes and at how we can deliver care in a rational way."

Palmer's story illustrates the broader problem of runaway health care costs in the United States and a system that leaves millions of Americans to fend for themselves.

It also underlines the importance of universal coverage that guarantees affordable health care to anyone, anywhere -- a goal that's become a central issue in California and in the current presidential campaign.

"We are the only developed country that doesn't cover all its people," said Stan Dorn, a senior research associate at the nonpartisan Urban Institute. "We also spend a lot more than the rest of the developed world."

The United States spent an average of $6,102 per person on health care in 2004 (the latest year for which figures are available), according to the Organization for Economic Cooperation and Development.

Canada spent $3,165 per person, France $3,159, Australia $3,120 and Britain a mere $2,508. At the same time, life expectancy in the United States was lower than in each of these other countries and infant mortality was higher.

But those are just statistics. When you talk about America's health care crisis, you're really talking about people. And Palmer's experience speaks volumes.

He was riding his motorcycle through San Francisco's Presidio on Sept. 19. It was late afternoon. Palmer was heading toward the Golden Gate Bridge and then home to Richmond.

Suddenly his brakes locked, sending the motorcycle into a slide. Palmer slammed into a guardrail. He was pretty shaken up, but he could tell he wasn't badly hurt.

A passer-by saw the accident and called for help. An ambulance arrived within minutes.

Palmer said he told the paramedics that his ribs felt banged up, possibly broken, but that he was basically OK. He said he preferred to be treated in Contra Costa County, where he lives and would probably qualify for reduced hospital rates because of his income level.

Palmer is a woodworker who specializes in the decorative touches on wealthy people's yachts. He said he made only about $7,500 last year, getting by primarily with the assistance of relatives.

Palmer said the paramedics were concerned that he may have sustained internal injuries and insisted that he be treated immediately at a hospital. So he was driven by ambulance to San Francisco General, the only trauma center in the city.

Palmer got lucky here. The ambulance was from the Presidio Fire Department, which is run by the federal government and doesn't charge for ambulance service. Had the trip been made by a private ambulance company, it likely would have cost Palmer between $700 and $1,000.

On the other hand, what Palmer didn't know is that as soon as the paramedics radioed ahead to say they were bringing in an accident victim, San Francisco General, as per the hospital's procedures, issued a trauma alert to its staff.

Basically, that means a page was sent to doctors and anesthesiologists on call at the time. That page alone cost Palmer $4,659, and he hadn't even set foot yet inside the hospital.

The actual hospital experience was, to put it mildly, a nightmare. After blood was drawn for a variety of tests (the cheapest of which cost $44 and the priciest $107), some X-rays were taken ($423).

Then, Palmer said, he was left in a room ($2,070) with a junkie "who was having a real bad trip." He asked to be moved elsewhere but was told no other rooms were available. So Palmer ended up on a gurney in the hallway.

And he waited there for five hours.

Palmer's bill indicates that he was twice given Vicodin ($22) to ease his pain during this interval, but he insists he took no medication.

"I finally saw someone and asked if I could check myself out," he said. "The guy said they were still waiting for the results of my CT scans. I said that I hadn't had any CT scans. It turns out they forgot to put me on the list."

So Palmer was put on the list for CT scans. And he waited another hour.

At last the CT scans were taken ($3,334) and then another round of X-rays because, Palmer said, the first batch apparently hadn't been done correctly.

"Finally a doctor came to me -- it's now almost 2 in the morning -- and said, yes, I had a fractured rib and some bruised muscles," Palmer recalled. "That was that. End of conversation."

Shortly afterward, he said, a clerical staffer approached with discharge papers for Palmer to sign.

"She asked how I intended to pay for everything," Palmer said. "I told her I didn't have any insurance. She looked at me and then asked if there was anyone I could sue."

Several weeks later, he received a bill for $11,082 in hospital charges and a separate bill for $922 in doctors' fees.

Palmer's hospital visit was expensive and time consuming, but it wasn't unique. Many people could cite similar (and similarly costly) experiences in receiving "emergency" medical care at U.S. facilities.

"We view health care as a chance to make as much money as you can," said Dorn at the Urban Institute. "The goal of health care should be improving people's health."

San Francisco General's Nazeeri-Simmons was unable to comment on Palmer's lengthy hospital stay because she didn't have access to his medical records. But with Palmer's permission, she was able to examine his billing file.

"These charges are comparable to the entire health care market," Nazeeri-Simmons said. "They aren't out of line with what other hospitals are charging. They're actually lower."

Not always. Trauma activation charges, for example, typically range from about $2,000 at some Bay Area hospitals to $7,000. At Marin General Hospital, the charge can run as high as $12,636.

Nazeeri-Simmons said a sliding scale is offered for low-income San Francisco residents. But Palmer, as a resident of Contra Costa County, wasn't eligible for the program.

"If you were uninsured and making less than $10,000, you would pay nothing," Nazeeri-Simmons said. "But that's only if you live in the City and County of San Francisco."

After receiving his bill, Palmer complained to the hospital about how much he was being charged. Nazeeri-Simmons acknowledged that a second look was given to the bill at Palmer's request "and we decided to eliminate the trauma activation charge."

That reduced the amount due by $4,659. But Palmer still owes more than $7,000 for an eight-hour hospital visit that involved, by his estimate, only about 15 minutes of actual care.

"It's unfortunate that he's in the situation he's in," Nazeeri-Simmons said. "But what is an individual hospital to do? Are we supposed to eat the costs?"

She said a government-run program similar to systems in place in all other developed democracies would almost certainly keep costs in check while ensuring that everyone has access to treatment (without being impoverished in the process).

"Universal coverage would mean that a Joey Palmer doesn't get left out in the cold just because he was in the wrong county," Nazeeri-Simmons said.

For his part, Palmer said he'll try to pay off his hospital bill as best he can. And then, if he can swing it, he'll leave the country. He's thinking seriously about moving to France.

"If you get sick over there," Palmer mused, "you can go to any hospital and it won't cost a fortune."

He said that with a tone of quiet disbelief.

[CBEMT]

Palmer is a woodworker who specializes in the decorative touches on wealthy people's yachts. He said he made only about $7,500 last year, getting by primarily with the assistance of relatives.

He either doesn't get much business, or doesn't charge much. Both of which could be for a number of reasons.

"She asked how I intended to pay for everything," Palmer said. "I told her I didn't have any insurance. She looked at me and then asked if there was anyone I could sue."

Ah yes. The very thing that causes sky-high healthcare costs, being encouraged by a hospital.

But Palmer still owes more than $7,000 for an eight-hour hospital visit that involved, by his estimate, only about 15 minutes of actual care.

THAT, I tend to believe without question.

[JPINFV]

"It's unfortunate that he's in the situation he's in," Nazeeri-Simmons said. "But what is an individual hospital to do? Are we supposed to eat the costs?"

I just wanted to quote that to make sure that no one missed it.

In the end, this is a philosophical question more than anything else. We don't live in a perfect world and no one can claim that health care should be free [really, anyone here willing to work for free? Hmm, didn't think so. Supplies and technology isn't just magicked up either. When you need to use a CT-Scanner, for example, a whole range of people need to get "paid," from the scientist that invented/innovated that specific unit to the person who extracted the minerals to build it, to the person who transported those minerals, to the people who made it, etc. They all, no matter how small, get a chunk of that bill. Should they all work for free since their services are going to health care?] Should the government pay for it? He's using a motorcycle. Was maintainance up to date on it? Should he even be riding a motorcycle knowing that it offers much less protection than a car in an accident? Should I be responsible for his care when he picks a job that only pays 7k/year [hell, I make around 7k/year and I work part time]? How much taxes are we willing to pay to insure everyone? Who should pay? Is it fair that because you are able to make a product that almost EVERYONE uses [example, Microsoft and Bill Gates] that should pay a sizable chunk more then everyone else? Are business leaders not already contributing to society by the services that they offer and that we choose to use?

Interesting little tax information to ponder (2001 data). The top 1% of income (>270k/year) earners pay ~35% of all federal income tax in the US. The top 5% (>115k/year) pay ~54% of all federal income tax. The top 25% (>50.6k/year) pays ~82.6% of all federal income tax.

-http://www.house.gov/jec/news/2001/PRESS/2001/05-15-1.htm

[Ridryder 911]

There are as many reasons for extreme costs of health care (trauma included) as there are diagnosis.

First trauma never pays off. figure that was a cheap ER bill. The average traumatic brain inury (TBI) costs into the several hundred of thousands dollars; up to millions. So yes, it is usually is astronomical... but remember those that usually get stabbed, shot, clubbed and then have to have major surgeries, trauma ICU, rehab, etc.. usually do not carry Blue Cross and Blue Shield insurance.

As well, there are those (probably like that patient) that will never pay for their expenses. Now, multiply this by the several millions of patients that never will pay, one can see part of the problems. ER being used as "free clinics" has to be absorbed into the problems as well. Then as the story described.. " he was in a room with a junkie for five hours".. Do we think that junkie paid for his ER visit too ?

Now, part of our problem is we (EMS) do over triage. Read posts, that regards any type of significant trauma scenario. Most EMT's immediate reply is "send to a Level I trauma per chopper"... which is not always the most appropriate treatment in fact in majority of the time. Remember Level II's, Level III's can handle many of the trauma cases there has not been any proof helicopter transports decreasing mortality and actually saving lives (yes, even an old Flight-nurse/medic hates to admit it, but it is true) . As well, we need to get out of the "golden hour" mind set thinking that every trauma patient requires such services, as was exampled in the story. That error cost the patient several thousands of dollars calling a "trauma alert". when in fact it was not warranted... in the long run, EMS looked foolish.

More education in quick detailed assessment, the ability to utilize better judgement of those that do need Level I trauma services (surgical candidates) and those that can be treated successfully in other centers. More studies of accurate determination of trauma injuries that require surgical intervention, than standard protocols that have been handed down for decades to feed patients into trauma centers without scientific validation.

R/r 911

[VentMedic]

Nicely said Ridryder and you are right this is cheap. My neighbors' 9 y/o son fell skate boarding. A Pedi trauma alert was issued not by the medics but by the hospital(level II) staff. Reason for the alert; the child realized he might be in trouble and changed his story a little..."memory loss". By the end of the day the kid had a $23,000 band-aid. Of course better safe than sorry later, but...

On the other hand, what Palmer didn't know is that as soon as the paramedics radioed ahead to say they were bringing in an accident victim, San Francisco General, as per the hospital's procedures, issued a trauma alert to its staff.

The hospitals themselves are now calling the trauma alerts more not necessarily EMS. Are they seeing every MVC as a potential insured customer?

Basically, that means a page was sent to doctors and anesthesiologists on call at the time. That page alone cost Palmer $4,659, and he hadn't even set foot yet inside the hospital.

Trauma alert charge...entry fee into the ER.

This gives you an ER doc, anesthesiologist, surgeon, at least 2 RNs, RT, Rad. Tech etc. They disappear usually within 5 minutes of pt arrival if they see there is no need for their services. The trauma charge remains. I agree a more careful use of assessment, old habits and resources could be in order prior to activation. These players will still be inhouse with their beepers on if this is an accredited trauma center.

Not always. Trauma activation charges, for example, typically range from about $2,000 at some Bay Area hospitals to $7,000. At Marin General Hospital, the charge can run as high as $12,636.

Unfortunately our medical insurance policies aren't that great in covering everything. A lot of policies are now 80/20. 20% of $100,000 is still a lot. The care of a preemie will hit $1,000,000 in just a few months. Many insurance policies have that as their cap. The parents are forced into taking state and federal assistance for the baby. Plus, they too may not be covered by insurance themselves once the cap is reached.

This isn't just about the uninsured junkie, but also anyone who might be changing jobs especially in healthcare and think they can get by 30 - 90 days without coverage. The junkie as well as the knife and gun clubs are results of deeper society and political issues that have evolved over a long period of time. It was thought that if we don't mention them in the political arena they would go away just like the healthcare issues. A little "band-aid" here and there with a little talk and we're good to go until another election year. I'm not picking on any one political person, but many.

I also know an RN who was a traveler. He was between assignments and was going with another company. While flying to his next assignment, he developed a pulm emboli. Eleven days in the hospital and well over $100,000 in med bills. He negotiated the hospital to $95,000 which is a bargain.

Also, if you vacation in remote areas like the Florida Keys, there are hospitals but if you want transferred back to the mainland, keep an extra $7000 available on your credit card. Most insurances will not cover an inter-hospital transport(ground or helicopter) if the medical services aren't out of the scope of that hospital. If it is not trauma criteria, EMTALA guidelines will be strict. If it is your request, you'll be footing the bill.

And yes, people do use the ER instead of a clinic or doctor's ofc. But, the ERs keep advertising PDQ service...30 minutes or less.

But, if you know you need a CT scan and if you say the right words in the ER, persistent head pain, blurred vision, etc...you'll get the CT that you might otherwise not get without insurance. Even women with lumps in their breasts may have to wait months for an appointment to get a mammogram through a clinic. They too may have to resort to getting into the hospital system by way of the ER to get treatment earlier.

Don't have any answers, just opinions....

[ERDoc]

He either doesn't get much business, or doesn't charge much. Both of which could be for a number of reasons.

Ah yes. The very thing that causes sky-high healthcare costs, being encouraged by a hospital.

THAT, I tend to believe without question.

:x So much goes on behind the scenes that people don't see and don't understand. There is not one MD and RN to cater to each pt. I cover 5-12 pts at any given time depending on how busy the dept is. Each one is waiting for something. CT scans can take some time to read, especially trauma scans. I don't know what parts were scanned, but I'm assuming at minimum, his chest was scanned. It can take a while to read all of the images, sometimes several hundred per pt. There is also monitoring time. We like to watch trauma pts for a while to make sure they stay stable. It really makes your day go bad when you send someone home who dies. Labs also take a while. I'm not saying that 8 hours isn't excessive, but the ER isn't McDonalds. Good pt care can take some time and just because you don't see things happening doesn't mean they are not. It only takes about 15 minutes to do a thorough H&P, but it doesn't end there.

[MAGICFITZPATRICK]

This story makes me sick :oops:

[MAGICFITZPATRICK]

This story makes me sick :oops:

[CBEMT]

:x So much goes on behind the scenes that people don't see and don't understand. There is not one MD and RN to cater to each pt. I cover 5-12 pts at any given time depending on how busy the dept is. Each one is waiting for something. CT scans can take some time to read, especially trauma scans. I don't know what parts were scanned, but I'm assuming at minimum, his chest was scanned. It can take a while to read all of the images, sometimes several hundred per pt. There is also monitoring time. We like to watch trauma pts for a while to make sure they stay stable. It really makes your day go bad when you send someone home who dies. Labs also take a while. I'm not saying that 8 hours isn't excessive, but the ER isn't McDonalds. Good pt care can take some time and just because you don't see things happening doesn't mean they are not. It only takes about 15 minutes to do a thorough H&P, but it doesn't end there.

Sorry Doc, I guess I should've provided context for my statement. Basically I (like the general public, even if I'm more in-tune with the goings on than they tend to be), have to go one what I see. When I see patients in "Critical Care" rooms at the ER for upwards of 6/8/more hours when I know there's beds upstairs, it does make you wonder. I know that ERs often board patients during cruch times, but when there's beds waiting and it's 8 hours later, it can't possibly be an emergency anymore. The scans HAVE to be done by then, and not even the lab on "ER" takes that long to return results. There has to be a point where you can say "Ok, they're stable, we know there's nothing we didn't check for, the unit can do the rest." Isn't there? I mean, if I'm wrong tell me. I've taken patients home directly from the CC room. If it's been decided that they're going home, get them the hell out of the trauma room! They're literally taking up space at that point.

[scope2776]

i'm interested as to what you guys think about universal coverage?