Are emergency rooms really that big a drag on the medical system?

I have learned only this year that they are a problem.

Are they really free to the indigent?
The few times I’ve gone to emergency rooms they were really insistent that I pay. Nobody offered me anything free.

Do they automatically create a huge bill for a small complaint? I’ve heard this in the medical debates. That if only small clinics could treat the poor the costs would go down. But why exactly? Because in the emergency room the hospital gets an overhead cut? Because they just like to inflate costs when the government pays? Because they send surgeons to apply compresses? What?

If the answer is that they like to accept non-emergencies rather than turn the poor away, why not treat them next door at a separate clinic without the hospital overhead? Are they locked into the specific word “hospital” for free treatment?

Emergency rooms are expensive – they are equipped and staffed for the treatment of immediately life-threatening conditions, 24/7. If the poor could take their sniffles and migraines and mysterious “I-don’t-feel-so-good” complaints to a doctor’s office, as the paying customers do (or should), the ER could treat everyone’s medical emergencies as they always have. They always try to collect, but since they don’t turn anyone away, they currently end up treating a lot of non-emergency complaints for free. A visit to the doctor’s office or a clinic is cheaper than an hour in the ER, and would save money for any potential insurer.

I took my wife to an ER for a broken arm. We had insurance and I was amazed they didn’t seem to care much about getting our insurance info at the time. They just said we will get it later. Granted this was in an upper middle class area and I don’t think that part of town gets many poor people in that ER.

A friend who was a business manager at the hospital in the city which my wife and I grew up in, informed me that hospitals were obliged to write off a certain small percentage of debts, as a part of their Medicaid contract. (This was in New York about 25 years ago, so don’t take it as how things are today.)

IMO, lack of clinics where the working poor and those living on limited income can get reasonably decent basic medical care, in most areas, contributes greatly to emergency room overuse.

Emergency rooms have to take everyone regardless of their financial situation. If you are an illegal alien or have no money or real assets, you can get treatment that way as much as you like. A very serious situation like heart failure may rack up tens of thousands or hundreds of thousands of dollars in medical bills but the hospital still has to take you when you get admitted through the emergency room. That happens all of the time. All people in the U.S. have access to medical care through emergency rooms if they can pay for it or not. It isn’t that efficient but some people have to play the system that way.

A discussion of health care costs on NPR quoted a poison control phone center worker. She got a call from an ER about a little girl who had swallowed some bleach. She advised them to give the girl a $2000 glass of milk and send her home. Had the mother called the poison number herself, instead of going to the ER, she would have gotten the same advice, but the milk would have been a whole lot cheaper out of her own refrigerator. :smack:

ER has to treat anyone but only to a point. They have to get you to a stable condition. At that point they are allowed to send you to another hospital if they find out you have no insurance.

One thing that many, many non-business types don’t get is that the difference between wonderful profits and flirting with bankruptcy is, for many firms, a matter of 2-5% of their gross revenue.
As a result, if you take a business running at a nice profit and tack on a part of the operation that costs several million a year and doesn’t get paid by 25% of its users, things can mess up more badly than the layman would imagine.

Hope that made sense.

In terms of cost/benefit ratio they are. The USA is a bit odd among developed nations. If you look at studies, America has the best care in terms of Trauma, Emergency Care and “forefront medicine” (transplants and unique medical conditions). But in terms of every day care, average health and longevity, it is poor.

Obviously it is much better to prevent a heart attack then stop a heart attack. Yet American shines in the treatment of heart attacks, yet fails in the prevention of them.

So you have to look at it like this, is a grocery store, like Kroger or Safeway more efficent that Circle K or 7-11. You get the same products but to do your everday shopping at 7-11 is a simply a waste of money. But not everything at 7-11 is a waste.

Using an ER for every day treatment is a waste, but not everything in an ER is a waste.

That’s the way you have to look at it. Hospitals were dumping patients. Some would stabilize them ,dress them up and dump them in some poor community and drive off.
Hospitals do not feel any need to provide services to the poor.
Many poor can not afford medical care. They have to go to emergency rooms to get any care at all. They will at least get diagnosed at many of them.

Let’s throw a bunch of "many"s in there to make it conform to GQ standards. Gonzo provides some backup to my comment above.

I’m wondering it the question of medical care for the poor might be deserving of GD treatment?

IME, these clinics fail at a very high rate because they can’t collect enough in fees to stay open.

I’ve worked in a few inner city clinics in my day; fortunately my salary was guaranteed. Otherwise I’d have seen 40+ patients a day and gotten reimbursed about $20.

That’s something I encountered several times in the US (and which led to things like “drawing blood, $150; analysis, $25”) but it was never in an ER.

If you count everybody who’s on “24h access duty for hospital emergencies”, then the ER at my local hospital has a constant complement of:
1 doctor from every specialty in the hospital - that’s over 30 doctors;
3 on-site doctors on “general” duty;
anesthesiologist (also a doctor, and the ones with the highest pay);
radiologist (also a doctor) plus a radiology nurse
plus other nurses, custodians, nurses’ aides, two admin…

Add the people in the ambulances, the two GPs and two nurses from the area centered around the hospital who are also on 24h, house visits from doctors leaving regular duty (not interrupting it, but house calls are done after in-office) and you can get a huge sum. Now do the accounting considering that “people who aren’t required to be IN the ER” aren’t part of the ER’s expenses (they’re still emergency, but not ER) and suddenly you get completely different costs.

So I guess what I’m saying is, I’d like to see how have those costs been calculated. Find out how they’ve been calculated, apply similar accounting to other areas, and you’ll be able to draw a realistic comparison.

Also, I’m not sure whether the comparison between “costs of emergency treatment” vs “cost of non-emergency treatment” per patient or per million inhabitants is worse or better in the USA than in, say, France - both in terms of costs to the medical system and to the patient, given the different costs of the treatments and drugs themselves in both places.

Only in the sense you can’t get blood out of a turnip. They have to provide treatment to all comers. If you have no money, well, there’s no money to collect. That doesn’t mean they won’t try - they will send bills, make phone calls, and, if they find out you lied and DO have money, there might even be wage garnishment. You can’t just show up and say “I have no money but you still have to give me care, suckas!” and not expect a bill of some sort. It’s just that for those who can’t pay they stop trying to collect at some point.

Right, nobody will OFFER you free stuff. None of it is free, it’s just that if someone really doesn’t have money they can’t collect for the bills.

There’s not some evil cabal of shifty-eye accountants in the back room issuing big scary bills, no. The bill you get is based on the care received - usually the doctors’ time, the nurses and other staff time, any supplies used, etc. Some complaints require more expenditures than others. Broken bones, for example, require x-rays and casting materials. A heart attack requires EKG’s and a tech for the machine, plus various medications. Anyone who goes to an ER can request a detailed bill listing all of this stuff and how much it costs.

And yes, the various items DO have a relatively high price. That’s because in the ER the emphasis is on fast, single dose, and sterile. Just as paying for 1 or 2 Tylenol in a convenience packet at the 7/11 costs more per unit than getting a bottle of 100 pills at WalMart, the separate packing for the items in the ER cost more than if everything was in bulk - but it has to be done that way given the nature of where they are. There are additional labor costs in keeping every bay in the ER properly stocked, but it has to be done because if someone is dying the doctors and nurses can’t take the time to search for stuff, it has to be THERE. ER’s also tend more towards chaos - flying blood and stuff in injury cases, projectile vomiting in others, and so on, which makes keeping things clean more of a challenge and more costly. Security is required, particularly in big cities with crowded ER’s because emotions can run high and people - both patients and those with them - can get out of hand. For all of these reasons, and probably some I haven’t thought of, costs in the ER will be higher than in other areas of a hospital simply because that’s how reality works.

Because a small clinic is a much more controlled environment with less chaos, where some supplies can be purchased in bulk rather than individually wrapped for sanitation, where not every room has to be kept 100% stocked 24/7, they don’t required security guards (usually), they don’t have to pay for a night shift, and the really catastrophic stuff they send to the ER (which is what should go to the ER) rather than trying to treat it on site. People are far less likely to bleed out and leave pools of blood, or vomit copious amounts, and otherwise generate cleaning up nightmares (again, that stuff gets sent to the ER). Most of the docs at a clinic are generalists - ER’s have specialists of all types on call which are more expensive as a general rule. Clinics might have an x-ray or two, but they usually don’t have MRI’s or PET machines, which are wonderful but really, really expensive.

In short, clinics are cheaper to run because the environment is more controlled, and they send the sickest/most expensive patients to the hospital or ER.

You say that like it’s a bad thing - someone has to pay for the lights, water, oxygen, band aids, janitors, etc. required to run an ER. Actually, hospitals invariably lose money on ER’s because, despite the large bills sent to patients, they cost more to run than they bring in.

Actually, it’s private insurance that pays the most towards ER’s. There are also charitable donations and government grants to hospitals, but the government reimbursement rate for ER treatment is, in fact, below cost for virtually all procedures. In other words, no ER is getting rich by treating the poor and billing the government - if an ER’s patients all fell under Medicaid and Medicare the ER would bleed money.

I’ve been to ER’s (as both patient and concerned relative/friend) where only a generalist was needed and other times when no one knew what the hell was going on and you get a parade of specialists tromping through, all of whom will want to be paid for their time and trouble.

That’s part of the issue with ER’s - you can’t state what a “typical” case is, really, because you get everything from the common cold to limbs ripped off and burn cases arriving with steam still coming off them and exotic diseases picked up on adventure vacations and bog-standard heart attacks and sprained ankles - they have to treat anything and everything. My doctor friends have told me about industrial accidents where someone comes in impaled or wrapped around machine parts and you’ve got docs tying to do medical stuff while guys from hospital facilities are wielding saws to cut the non-organic bits away from people at the same time. You get all kinds of crazy stuff happening, it all has to be dealt with on the fly, and it all has to be paid for after the fact.

Because an ER is required by law to evaluate all comers. ALL of them. There usually isn’t a free clinic next door because the “free” clinics, as already noted, can’t make enough money to stay open even with lower costs. ER’s MUST treat anything life-threatening, and they usually treat anything serious, and in many cases, because the people working in them actually DO give a damn, they’ll do whatever they can to help the indigent even if that, strictly speaking, isn’t cost effective on the balance sheet.

Not so much that as they know that, no matter what, the ER cannot turn them away. A clinic may well have criteria and if you don’t meet it they won’t help you - but an ER takes everyone.

The costs of emergency rooms are so high because there are a lot of different medical emergencies out there. And an ER must theoretically be ready for any of them at a moment’s notice. For every item they used on you and billed you for, there were dozens of other items that had to be bought and kept ready just in case but were never used.

Imagine trying to run a restaurant with no menus. You just let the customers order anything they feel like having. To be ready for this, you have to keep thousands of different ingredients in your kitchen. Sure, nobody may order lobster or goose liver or rabbit stew or plum pudding or boiled cabbage today - but you have to have all of these available in case somebody does.

As for billing, people who show up in an ER at three in the morning with a gunshot wound often do not have a solid financial background.

I think the guy’s name was Robinson, and that he was the former head of the American Hospital Association. His rule of thumb was that any trauma center more than three miles from a major highway would always lose money.

The rationale was that people who present at an emergency center with blunt force trauma from traffic accidents often have insurance. Those who present with penetrating trauma, from gunshot wounds or knives, never do.

If you are mandated to treat everyone whether they can pay or not, you have to charge those who pay more to cover for those who don’t.


Nitpick: Note that there are different types of emergency rooms. Most people are thinking of level-one trauma centers, which are the ones equipped and staffed for the highest level of care. But some emergency rooms are not so equipped and staffed.

Another issue is that the standard for insurance reimbursement of acute injury and illness changed. In the past, you had to get pre-certified to go to the ER, which meant that the nice customer service rep would deny that certification if they felt that the problem wasn’t major enough to justify emergency care. Now the standard is whether a reasonable person would seek emergency care. This saves lives when a child with asthma has an attack or someone has a heart attack or stroke, but it’s also pretty wasteful when someone with a minor problem seeks care because it’s more convenient for them to do so after hours.

Some insurance plans also require ER visits after hours, no matter how trivial the problem is. Tricare Prime, the insurance program for active duty military, is one such plan. If the local Army clinic is closed for any reason, and one of us needs care, it’s an automatic trip to the ER even if the problem could be treated in the office setting. Believe me, it’s a treat to deal with the ER for strep throat because the clinic closes at noon on Thursdays.

And in defense of some ERs, they are trying to control costs by hiring physician assistants and nurse practitioners to treat minor problems like sprains, thus freeing doctors for major problems like heart attacks and gunshot wounds. There are also contracts in place to outsource ancillary specialties like radiology and pathology to countries like India and Australia; the patient and treating physician get the report almost immediately, and it’s more cost-effective than having a radiologist or pathologist on-premises around the clock. It also saves the patient money because a sprain on Saturday doesn’t have to be re-treated as a fracture on Monday when the x-ray has actually been read and the fracture found.

On Friday night about midnight, I was walking downtown, and a man asked me for help. He said that he thought he had had a seizure. I offered to call 911, and he said yes. He also complained vaguely of chest pain, and asked me if it was cold. He kept saying that he didn’t know what it was, but something was wrong with him.

He was clearly homeless. He was shaking/shivering some, but it may just have been from the cold. He was wearing thin clothes and had bare feet. When the paramedics came, they told me that they pick him up all the time.

Now, I don’t have medical training, so I can’t say whether or not this man had a legitimate medical emergency. But he certainly could have used a blanket, a pair of shoes, and a warm bed. I’m sure that there are many people who end up in the emergency room not because they need medical care at all, but because it’s warm and a few of their basic needs are met. Met by highly trained and expensive paramedics, nurses, and doctors.

They are not supposed to be free, but they must help everyone, and some never pay the bill. My wife is a Physician, and worries about this all the time. If a patient doesn’t pay her bill, then who ends up paying it? She does. As shodan said, “If you are mandated to treat everyone whether they can pay or not (and that IS the case to some extent), you have to charge those who pay more to cover for those who don’t.” We currently have a national health care system without a detailed policy for those that cannot pay. The patients, the insurance companies, and the Physicians have little means of controlling the costs.

Being “against” national healthcare is meaningless. We have always had it (whether we are talking about traditional Medicaid, traditional Medicare, federal government employees, and yes, those that simply don’t pay). The question is whether we want any control over what is happening, or not, in the case of those that cannot pay, and “not” is a just plain stupid way to do business.

I agree with MsRobyn, iamthewalrus(:3=, Little Nemo, Bijou Drains, Shagnasty, etc.

Polycarp said, “hospitals were obliged to write off a certain small percentage of debts, as a part of their Medicaid contract.” Even non Medicaid patients get service; write offs are not relevant in that case.

Thank you,