二狗娘

About once a month or so we have someone start a thread about their recent visit to an emergency department. The post usually revolves around the bill being surprisingly high. They all kind of end up the same way. I get lots of PMs on the forum asking similar questions. Since this is a relatively common situation, I thought it might be useful to do a post for forum members about how to minimize their emergency care expenses。

First, a few comments about our health care system.
# 1 - It is screwed up, broken, and embarrassing to be a part of. 
# 2 - Solutions are to either quit pretending it is a real market or to make it a real market. Depending on your political persuasion, you likely lean one way or the other on this.
# 3 - In order to have a functioning market, most/all of the market participants need to have skin in the game and there must be transparency of prices. Neither of those exists in our current health care "market." Especially transparency of prices.
# 4 - The health care system is unlikely to provide transparency of prices because it is so darn profitable not to have transparent prices. It is also an extremely difficult thing to do in any sort of exact manner, but it would be nice to see even in vague terms. 
# 5 - Doctors and nurses generally aren't in control of what's on your bill(s) nor does most of the money paid toward your bill(s) go toward doctors and nurses, so no sense in taking it out on them. 

Next, it is important to understand EMTALA- The Emergency Medical Treatment And Labor Act. This requires a hospital (particularly Labor and Delivery and the Emergency Department) and physicians working there to identify and stabilize any emergent medical conditions or labor without first ascertaining whether the patient can or will pay for it. The penalty to not do so is a personal penalty of $50,000. Malpractice insurance does not cover this penalty. A penalty can also be assessed to the hospital. 

As an example, if you come in with severe shortness of breath due to your chest being full of fluid from a lung tumor, the hospital must drain the fluid before it can ask you to pay, but it does not need to provide you chemotherapy or surgery to cut out the tumor. 

Once an emergent condition has been ruled out or stabilized, the hospital can then ask you to pay before proceeding with any further treatment. In practicality, by the time the emergent condition has been ruled out, the emergency doctor or OB/GYN has pretty much done all her work, so the whole "go charge the patient after the medical screening exam has been completed if they want to continue to get care" gets pretty silly. 

In addition, "emergent medical condition" is a very gray area. What is emergent to one person might not be emergent to another. Plus, sometimes the complaint is emergent (such as chest pain) but the final diagnosis (GERD) is not. So it becomes an incredibly difficult law to navigate around. The easiest and most common thing to do for those working in the emergency department is to just take care of anyone who walks in the door as best you can, pretend everything is an emergency, and let the coders, billers, insurance companies, and patients sort it out later. 

While the hospital and associated physicians are required to provide this care without first ascertaining ability to pay, they are not required to do it for free. They are allowed to bill the patient and/or their insurance company afterward. Many people that do not have insurance do not pay these bills. The typical reimbursement rate for uninsured patients is less than 10%. For some hospitals, the percentage of uninsured patients can be as high as 50%. In my particular practice, it is closer to 20%. Even in states that expanded Medicaid the number is still often close to 10% because people are either incapable or unwilling to sign-up for Medicaid or a PPACA plan. Many people who have good insurance do not pay their portion of the bill. Given the increasing use of high deductible health plans and health savings accounts, this is happening more and more often. Nevertheless, a bill is sent and if not paid, the account is eventually turned over to collections with the expected effects on the patient's credit score. 

Third, hospital and physician billing is seriously screwed up by something called "Chargemaster Pricing." This is where the price on the initial bill is some astronomical amount. These are purposely set high in an effort to maximize profits. The idea is to have it so high that no payor is ever going to be willing to pay more than that. A typical health insurance company will negotiate much lower rates with hospitals and doctors. These negotiated rates are usually pretty fair rates for every one involved. Some payors just pay the chargemaster prices -- auto insurance or liability insurers for instance, since they aren't in the same business as a health insurance company. Some patients just pay the chargemaster price too, although not very many despite typically being offered a 20-25% discount from them for paying promptly (like within 30 days.) One of the best benefits of having an insurance policy, even if your deductible is so high you basically pay everything, is getting the benefit of the insurance company's negotiations with hospitals and doctors. 

Fourth, when you go to the ED, you generally get multiple bills, although these are sometimes consolidated if the doctors involved are hospital employees. 

Bill # 1 - From the hospital. This usually includes an emergency department charge which varies based on the complexity of your visit. These range from level 1 (perhaps a suture removal) to a level 2 (a wound check on sutures done the day before or an abscessed that was incised and drained 2 days ago) to a level 3 (a cold or back injury for which no medications were administered in the ED and no tests were done) to a level 4 (perhaps a UTI that was given IV antibiotics in the ED) to a level 5 (a work-up for chest pain, belly pain, shortness of breath, or altered mental status.) If you are really ill, there is an additional "critical care" charge. There are additional charges for procedures such as CPR, intubation, or suturing. This charge does not include the services of the doctor, but does include the IV tubing, placing the IV, drawing blood, nursing observations, respiratory therapists, monitors, housekeeping, linens, electricity, heating, crackers and juice, warm blankets, etc etc etc.

The typical amount for a level 4-5 visit that is freely negotiated between the hospital and a good insurance company is probably something around $2K.

The hospital bill also usually includes a charge for any x-rays, CT scans, ultrasounds, or MRIs, a charge for any labs done, and a charge for any medications given. This could easily be another $1-3K, more for an extensive evaluation like multiple CT scans. This does not include the services of a radiologist or pathologist if required. 

Emergency care is expensive to provide. There are a great deal of compliance and legal issues, highly trained staff, expensive equipment, consultants, and 24/7/365 availability of all that. 

Bill # 2 - From the emergency physician. First there is an emergency visit charge using the same level 1-5 + critical care levels. This includes the doctor's history and physical, counseling, recommendations, prescriptions, work notes, charting, calling consultants, transferring you to other hospitals, talking to your primary doctor, reviewing old records calling an admitting physician etc. About 25% of the work I do for a given patient is visible to the patient so sometimes it feels like "all they did for me was give me a prescription for ibuprofen." If there was a billable procedure done (sutures, intubation, cardioversion, fracture reduction, abscess I&D, CPR, etc) there is an additional charge. Sometimes, the procedure charge is more than the visit charge. A typical level 5 physician bill might be $200-300 after insurance company negotiation. It's $175-200 for Medicare. Procedures are highly variable. Putting a breathing tube in to save your life is $146 when Medicare is paying. A little laceration on your scalp might be $100 when Medicare is paying. 

Bill # 3 - From the radiologist. The hospital charges for the tech and machine. The radiologist charges for her expertise reading it. A typical fee to read a single CT might be $250 (Medicare) and up to twice that with a private insurance company. 

Bill # 4 - If you were seen by another physician in the ED (a consultant) they will also send you a bill for their consultation and possibly any procedures they do. 

As you can see, it doesn't take much to get the bill for a single ED visit into the $5K range for something where there wasn't even anything serious going on. Just like a single hospital admission, surgery, or delivery will hit the max out of pocket for the year on many insurance plans, so will a single emergency department visit. It's just really expensive stuff. 

Fifth, nobody you interact with at the hospital at the time of your visit has any idea how much anything costs. Part of that is the whole price transparency thing. Those who know the price don't want the front line workers to know it. Part of it is the fact that there are so many moving parts. Medicine gets inappropriately compared to aviation a lot, but it really isn't a fair comparison. Every one getting on a flight is basically getting the same thing. Medicine is like an airline flight where every row has its own flight attendant, every one on the plane is going somewhere different, and they all get a different movie and meal hand delivered to them. Imagine how much that flight would cost? Finally, despite the fact that there are hundreds of different products and services being sold, everybody pays a different price for them. This is due to dozens of different insurance plans each of which has negotiated a different price for every product and service, co-insurance plans, government plans, and various different levels of deductibles and co-insurance and different amounts of previously consumed care already in the year. 

Bottom line, don't expect to be able to "shop" while you're at the ED. It's impossible. We can't even tell you the chargemaster price, much less your price. 

Now, let's get to the meat of this post- what you can do to minimize the costs of your emergency care.

# 1 Buy health insurance

When you go to the ED with a truly emergent condition, you're not going to be in any sort of position to negotiate prices. Far better to be associated with someone who has already done that for you and has far more pricing power than you do.

If you can't afford health insurance, apply for Medicaid. If you don't qualify, try to buy through a PPACA exchange. If you have a very low income, the subsidies are typically quite large and most of the middle class qualifies for a subsidy of some type. Even a family of 4 making $80K might be able to buy health insurance at a 50% discount after the tax subsidy.

If that still doesn't work for you, consider a health sharing plan. While these do not provide as comprehensive coverage as a PPACA plan, the "share" might be half as much as health insurance premiums. 

Health insurance is expensive stuff because it gets used all the time and health care is expensive stuff. If you think you're only going to pay 2% of your household budget on health care while the nation as a whole spends nearly 20%, you need to reset your expectations. You're doing well if you're only spending 10% of your income on health insurance and health care. 

Another option, assuming you can work, is to get a job where health insurance is offered as a benefit. If you can't afford health insurance, and your job doesn't offer it, you should continually be in the job market looking for a better job.

# 2 Expect to pay your maximum out of pocket costs

If your maximum out of pocket cost is $10,000, expect to pay that and be pleasantly surprised if it doesn't get that high. If that is too much for you to afford, buy an insurance policy with a lower deductible/out of pocket cost. The total cost of your ED visit is generally going to be a four figure amount, between $1,000 and $10,000. 

# 3 Don't go to the Emergency Department if you don't have to

Since emergency care is such expensive stuff, don't go there if you don't have to. This is a very expensive place for convenience care. If you're not having an emergency, exhaust all other options before turning to the ED. This includes nurse help lines, your cousin, your neighbor, your primary doctor, your cousin's primary doctor, telemedicine, and urgent cares. But if you're clearly having an emergency, for heaven's sake go to the ED. Far better to owe $10K than to lose life, limb, or eyesight. If you're not sure, do the best you can. Doctor's offices and urgent cares are good at quickly sending you to a higher level of care if needed. 

# 4 Don't take the ambulance if you don't have to

An ambulance ride costs $1500-2000. An Uber costs $20. If you need the ambulance, for heaven's sake call it. But if not, call an Uber. This also applies to interhospital transfers. "Doc, I don't want to go by ambulance because it's so expensive. I know there is the liability thing, but I'd be willing to sign all that Against Medical Advice paperwork if you think the chances of something happening to me en route are less than 10%." 

Just because the ambulance came to your house doesn't mean you have to ride with them to the hospital. Your taxes cover the trip to your house and the assessment by the medics. Your health insurance (and you) covers the trip from home to the hospital. Don't worry, you won't offend the medics. If they're really worried, they'll follow you there. That's a good sign that maybe you should have just gotten in the ambulance. 

# 5 When you go to the ED, consume as little care as possible

When you first meet your doctor in the ED, make two things very clear to your doctor. First, that you would like to avoid doing anything today that can safely be done later as an outpatient or not at all. Second, that you understand that there is a great deal of uncertainty in what they're doing today and that you're not going to sue her if something isn't identified on this visit. Repeat this multiple times during your visit. Use words like "I'm willing to share this risk with you if it can save me substantial amounts of money" and "What would you do if it was your wife or child?" "Can this be done safely later if I'm not getting better?" What are the downsides of not doing that test or treatment today?" "What do you think the chances are that this is actually something serious? I'd rather not get a huge work-up today if you think the chances are less than 10%." 

If you don't want a $10 tylenol or a $100 morphine shot, don't take any medication while you're in the ED. If you're writhing in pain with a kidney stone, you'll be more than glad to pay $100. If the pain or nausea isn't too bad, just let the doc or nurse know that you'll tough it out and wait until you get prescriptions to go home with to treat those symptoms. "Do you think it would be safe to skip the IV dose here if I go to the pharmacy right away afterward and start taking the antibiotic prescription?" "Is there a cheaper medication you can prescribe that would work? I don't mind a few more side effects or having to take it three times a day if it is 1/10th the cost."

If you've got something serious enough to admit you to the hospital you're definitely going to hit your max out of pocket, so might as well just get what your doc thinks you need done. 

By the way, it's important to understand that some admissions to the hospital are "observation admissions" and some are "inpatient admissions." Depending on your insurance, that may involve different amounts of co-pays or co-insurance from you. Medicare in particular is this way.

# 6 When the bills come, read them.

Take a look at the bills once they show up. After you get over the sticker shock, make sure they are reasonably accurate. Is there a pharmacy charge but you didn't get any medications while you were there? Is there lab charge but you didn't get labs? Bills are wrong all the time. Contest them if they are. Wait until it "runs through insurance." That first bill might be showing chargemaster prices, not the real prices. 

If you've gone to an out of network hospital, you might be "balance billed." That means your insurance and the hospital or doctor don't have a negotiated agreement and your insurance company refuses to pay the whole bill. This becomes particularly problematic so many people, including legislators, are working on solutions to this. The problem is just outlawing balance billing gives the insurer enormous negotiating power over the hospital/doctors (why should we negotiate with you when we can just pay you whatever we want). But other solutions basically put government in the position to set prices for a private transaction. It's a tricky problem to solve and is best when the hospitals/doctors and insurance companies just make a good faith effort to negotiate a fair price/payment. 

If you can't afford the bill, contact the hospital. They often have assistance programs that reduce the bill or allow you to pay interest-free over long periods of time. 

If you really can't pay the bill, realize that there is nothing to repossess. Medical bills are like credit card bills. Sure, your credit goes to pot but after it does you can often negotiate to pay pennies on the dollar to the collection agency. Food, shelter, transportation, and utilities first. 

If you're a Boglehead millionaire and hate paying $5K for your ED visit because there was nothing wrong with you anyway, but can easily afford it, pay your bill and realize that's why you saved up all that money in the first place. Problems that can be solved with money aren't problems when you have money. If you realize you screwed up and went to the ED when you shouldn't have, chalk it up to life experience and don't make that mistake again. Most of us (including me) have made that mistake.