Emergency Room Abuse and the Taxes You Pay

First of all I want to make it clear that I am liberal, want a social medicine system, and do believe that everyone deserves quality healthcare. That is my disclaimer.

Emergency Room Abuse and the Taxes You Pay

What constitutes an emergency to you? A car wreck, seizures, amputation of limbs, or large cuts? I believe they are emergencies and we take care of those on a frequent basis, but unfortunately we spend much of our time and resources seeing people that are not "emergentaly" sick and could benefit from going to a clinic and obtaining a primary care physician.

Understanding the Abusers 

I hate placing a label on anyone or anything. I am not racist and I do not lack empathy for the poor or anyone. I actually have a very good amount of empathy and I can thank my mother and father for that. I understand some of the situations, but what constitutes abuse or fraud.

First I think it is important that we look at those who visit the ER for non-emergent issues. Statistics point to women between the ages of 18-40 as those who visit the ER the most for non-emergent issues, but there are other populations as well. As an ER nurse I see who comes in first hand. The ER is so abused that I constantly have to explain why my job isn't like a TV show. Even I thought that the ER saw much more excitement and critical patients than we actually do. I would say (without actually figuring) that 85-90% of the patients we see are non-emergent and could be seen at a clinic. The problem with a clinic is that they can ask for money up-front. The amount varies depending on the clinic, but usually is less than $100. At the ER our hands are practically tied because in order to ask for money prior to services rendered, we have to prove that without a doubt the patient is not experiencing an emergent condition. While we could do that on the majority, one would essentially fall through the cracks and would end up costing the hospital millions in court costs. So the answer is to simply see everyone.

The majority of patients that we see for non-emergent conditions are part of two different groups. The first group is the uninsured. There are people out there who do not have medical insurance and legitimately need medical care, but being in the ER does not fix things. In the ER our goal is to remedy the acute condition and refer you to a primary physician. For example, if someone comes into the hospital for pneumonia and doesn't need to be admitted but just treated with antibiotics and steroids, they really need to follow up with a physician or provider in a couple days to ensure that they are getting better. Unfortunately many of them do not follow up and some don't even get their medications filled. They will come back, sicker than they were, and when we ask them if they are taking their medication they say no because they don't have the money. If they don't we understand that, but most of the time these are medications that can be bought at Wal-Mart for $4. What makes it even worse is if they are smokers, have a cell phone, or are alcoholics (or all the above). I have told a patient more than once that they could skip a pack of cigarettes to get their antibiotic, or change their cellular service to a cheaper plan. I smoked up until this April so I told them that I understand the addiction, but I also make sure that I can take care of any illness over smoking. I am not going to put off medications that I really need for a pack of cigarettes. They act like they understand and put on the front that they are going to change, but unfortunately the majority of them don't.

There are also a good amount of the patient who are on Government benefits such as Medicaid, disability, or other programs. There are bad apples in every system, but why is it that the majority of our ER patients are not emergent and yet they are going to the ER and racking up a $1000 bill that we will all have to pay for via taxes. Take the information from a study that was performed by the Texas Integrated Care Collaboration that identified nine patients who as a group had 2,678 ER visits. Nine people! Those nine also received state assistance (Medicaid), and as a Medicaid patient, they are not responsible for any amount of the money. These people know that they don't have to pay an overage or anything like that, so they use the ER's as their primary care clinics, which can interfere with the care of truly sick patients. I have seen 2 year-olds that have over 30 ER visits, and they aren't coming for a chronic condition that is emergent but rather for diaper rash's or snotty nose. Many of the conditions that they present for could be managed at home, but why go to the store and buy medication when you can go to the ER for free and get a prescription for something as cheap as ibuprofen? It is not the child's fault, the parent is the one making them do this.

It isn't uncommon for us to have a parent bring a very young child in the ER in the middle of the night for "fever". When you ask the mother what was the fever and what did she give, you may get the answer of, "I don't know, I don't have a thermometer he just feels hot, and I don't have any medicine at home." They know very well that they can go to a gas station and get the medication, but they choose not too. Instead your hard earned money that is taken by the taxes goes to pay a $1000 bill for a child that got one does of ibuprofen in the ER and was sent home with a viral illness.

There are many other examples that I could use but for times sake and my hopes that you will keep reading, lets move on...

Who's to Blame?

I think this is a very important question. Not because it is important to attach blame, but because we need to understand that these problems are not just isolated to one person or system. America is the last industrialized nation to not adopt a social style of medicine. As a nurse (and future nurse practitioner) the medical system is important to me, and I to often hear how "Obama" has ruined our healthcare system and now we are just going to have moochers on the system and lose all of the good doctors.

That couldn't be further from the truth. We already have a system for those who don't have money, Medicaid. So Obama implementing these changes could change the people who are on Medicaid and make them have a bit more financial responsibility. Second, if you have insurance and have for quite some time, you should blame them for essentially screwing you and taking advantage of you.

Lets play this out... I will use myself as an example. I would consider myself to have good health, I have a heart condition, but it is easily managed at this point. It probably cost's my employer around $150/month to insure me, and if I want optimal coverage, I am going to elect to pay $60 more a month for the best plan. So in the end the insurance company is making $210 a month on me. Now if we total that cost to a yearly amount, the insurance company has made $2520.00 on me. Now lets look at what I cost THEM. I'll make up an average and say that twice a year I have to have antibiotics and then my maintenance medications. I probably see a doctor no more than 5 times a year, and don't have any major operations. For the medications I figure that they pay somewhere around $1000.00 a year. Next is the doctor visits, those run around $175 a pop. So if I go 5 times it cost's them $875 (procedures, lab work, and other items included). So in the end I have costed them $1,875.00. One could easily argue that even though it is short, in the long term I will win if I get sick, but we haven't figured the cost that I have paid. It would be perfect and just fine if they were paying the entire amount and profiting one year and maybe not the next, but even with prime coverage, I am responsible for deductibles and other things. If you have ever dealt with an insurance company you know that they can be hell. I remember I went to the ER for my heart having abnormal beats. I was diagnosed with PVC's and they billed me $2000 for an EKG, some Lab Work, and a pill that is $4 bucks for a month's prescription at Wal-Mart. I figure ok, I have an 80/20 plan so I will owe the ER $160.00 plus my deductible which I paid at the door. Unfortunately that wasn't the case. The insurance company denied the claim the first time and said it was a pre-existing condition. I had my physician send records over that showed I had NEVER had that diagnosis. Even with that evidence they would not move, and this was one of the largest insurance providers in Texas and supposed to be the best. The continued to come up with excuse after excuse and at the same time I have the hospital hitting me up for a crazy bill with no savings from my insurance. I finally told the hospital that they need to discuss this with my insurance company and that I would only pay what I should which was 20% of that visit. I don't know how it worked out, but I am sure it hurt my credit.

The moral of that story is that you may think you have saved because your medication is cheaper and you don't have near as much out of pocket as you think, but when you break it down, you have also paid money out of your pocket while they still see a profit. I understand that like everything else insurance is a business of profit and it wouldn't work if they didn't make money, but that's why I believe that a social system is so effective. You have essentially one insurance provider, your government, and there is no competition. When you eliminate the competition and possible profit, you end up with lower costs for you as well as less of a chance that your care may be effected by you insurance status because even though no hospital can legally do it, it happens all the time.

So when deciding who to blame I think there are a few systems to blame. First CMS (Centers for Medicare and Medicaid Services) because they have not required these people who carry their insurance for free to be responsible. Whats wrong with telling them that if their condition is non-emergent than they will be responsible. It doesn't have to be extremely strict, they can just say that if you go for a condition such as a cold or something that can be remedied at home then you will pay for it. They could also require the hospital to tell you that your condition is non-emergent and you will be liable for the bill. It won't fix things but it is a good start. There is also the whole thing concerning people who are addicts, smokers, or people who have very nice cars and high tech devices. I am sorry but if you have a better car and phone than I do, you don't need government aid. I have taken care of someone who was on disability, had hepatitis C and Cirrhosis of the Liver, and a very nice smart phone along with a pack of Marlboro cigarettes. This person was in the ER first because his/her significant other was in a fight and got beat up. After being told that the staff were in there with him and it would be a minute before she could come back, she went to the waiting room. After she asked for the 3rd time, she decided that she needed to check in because her knee hurt and she was in the fight. She had a SCRAPE on her knee and it appeared as if she was checking in out of some kind of boredom. This costed around $1000. Not only did we eat the bill, but she did not work and received disability checks, so we were paying for her to smoke, use her phone, get drunk, and abuse privileges. Shouldn't what she purchases and if she abuses substances be part of the package when determining her eligibility? Why is she able to abuse the system so easy? Yet we want to blame the Democrats for Obama care when we obviously already have a huge problem. To shut any Republican up, know this, there is NO perfect welfare system and no matter who is the president, it will be abused and used in the same way until someone does something, which is what our president has done.

The next one to blame is the people who receive these services. If they abuse the Medicaid services, they have most likely been told by an ER provider that they are doing it, and they have continued to do it. There are also some women who have said they got pregnant because they needed health and dental insurance along with government aid, how does this work? See the above as well for those who abuse the services. The fact is that common sense tells you that a diaper rash isn't an emergency, but they keep on coming.

I also think that hospitals have to accept some blame here. The hospitals are the ones who continue to see these non-emergent patients and do extensive workups that aren't necessary. Many of these hospitals could require payment for non-emergent services but they choose not to. Their reasons differ, but the fact that they do this is enough to place some blame with them.

Finally I blame the uninsured who take no initiative to obtain resources for healthcare. My mother and brother are uninsured because of the cost, so I can definitely talk about this without being in a glass house. The difference between those who go to the ER because they don't have to pay and my mother is that instead of abusing the ER she paid to see a physician and when she required ER services and surgery, she spoke with the hospitals and qualified for assistance. The resources are there, but it requires work on the part of the patient, the resources aren't going to find you, you find them. Purse laziness sticks the hospital with bills that will never get paid.

Will there ever be a solution? 

Maybe, but it depends on the state you live in.

Some states such as Washington have implemented laws that instruct the hospitals to not do extensive work-ups on non-emergent visits or those that would be better served in the clinic. The bills aren't on the patient, but on the hospital, which drives the hospital to deliver cost-effective and non-excessive healthcare. One could say this isn't a solution, but the hospital can require payment for non-emergent visits (some kind of co-pay) in the ER and the patient then makes the decisions whether or not it is worth it to get care in the ER versus a clinic.

My personal preference is to get rid of the capitalistic portion of medicine. I believe capitalism is very important for an effective society, but it has its limitations and place, and healthcare is not the place. Why are CEO's of non-profit hospitals making upwards of $500,000 versus for-profit CEO's who average much lower in the $200,000 - $300,000 range. Those are both great salaries, but I would assume that a for-profit would make more profit yet they are paying more taxes as the non-profit's pay no taxes and zoom by with extreme salaries. CEO salaries don't have much to do with it other than it shows that we are backwards on the system. Second we need to remove the insurance aspect and rely on one payer, the government. The price of medicine (the practice) has doubled over the past ten years in many areas and there seems to be no end in sight. What drives this increase? I think private insurance does. If they know that a private company will pay 80%, why not increase the amount you charge so that you make up for losses on government insured and those without insurance? Why not? Because it is wrong, why should we punish those who have insurance by increasing the prices. Ultimately the one who suffers from our private healthcare system is those who have insurance and pay their bills. The hospitals rely on you and tax dollars for support and they make sure they get their money. If we reduced it to one payer (the government), there would be no reason to continue to raise the price of a procedure unless you are staying with the cost of living and cost of procedure. Essentially all citizens would pay taxes for a program that could be ran without the "money" aspect and could focus on better care instead of how to make a quick dollar. Critics say that this won't work and we lose quality in care, but if that were true then why do Americans go overseas at times to get medical care for rare conditions and why are we not the healthiest and longest living people on earth?

It's time for people to get out of their denial and realize it's time for a change. The system is flawed and although there is no perfect system, a good start would be to figure out a way to fix some of the problems. Obama made it his personal mission to overhaul healthcare and although you'll hear from those that don't work in healthcare and some that do, I promise you this, the current plan is flawed much more than you think, and it is not going to get better until we overhaul and implement Obama's plan. It is not a fix all, but it is a start at fixing a very flawed system.

To decide what side of the issue you are on (capitalism / all private medicine or social medicine) answer this one question...

Are you comfortable paying $100 dollars for than triple antibiotic ointment packet that costed the hospital less than a dollar for you laceration repair, and are you ok with paying $40 dollars for 2 Tylenol?



If you answered no, which I hope you did, then the current system is not for you, because this is what hospitals are doing to their patients, especially if you have insurance (not the other way around).



*The views/opinions expressed above are just that, opinions, no privacy violation or defamation is intended thus why no names are listed. If you have any problems with the above information please notify the author.*