Biggirl, the fundamental reason that Medicaid expenses are so high here is that benefit recipients routinely go to the ER for every medical problem, regardless of the severity. Medicaid is jointly funded by the state and the feds, and in most (all?) cases, there is no co-pay at all. These folks just have no incentive to go anywhere else.
Sure, they could go to a walk-in (Knead’s “doc-in-a-box”) but if it’s even slightly less convenient they’ll just go to the ER.
When I was seventeen I broke my leg, went to the ER to get it set, and sat in the waiting room for an hour ans a half watching the staff sort out the people who brought in their kids because they had the sniffles.
You care, and I care, but why should the people with no finacial incentive to do differently care?
Laurange, believe me, if CLSC’s were twenty four hour, or I could convince the nurses there that yes, a recurring UTI is in fact urgent, I’d go there instead of the ER, and not be up until 4 am. sighs More money to healthcare, and less to financing the language cops, I say. Mind you, that only really applies in quebec.
gigi, I’m not sure where you live, but in the Northeastern US, ER visits were covered by law, regardless of what the policy said. The states that I worked in were New York, New Jersey and Connecticut, and I don’t remember if it was a national law or state regulations, and I don’t have time to look it up right now. If no one has chimed in with it by the time I get home from work, I’ll look it up then.
And while the ER might be charging the insurance company $5000 for the ER visit, the insurance company is paying much, much less than that. One of the reasons doctors and hospitals charge so much for people without insurance is because of the rates the insurance companies pay out at.
Biggirl, as you’ve probably already figured out, “doc-in-a-box” is what others have referred to as “urgent care” facilities. Sorry for the confusion on the lingo.
Come to think of it, there’s a 24 hour clinic here in town that’s much quicker than an ER as well.
I should have known this, because when I get a migrane headache, that’s where I go. The only thing I can say in my defense is that when I go there I have a migrane and am usually torked out of my head on codeine by the time I get there.
Of course I can’t find the language I remember on the website, but I believe they mean an internal organ here, although how a layperson can tell this I’m not sure. Maybe a compound fracture would be different, who knows.
blur, I would be interested in seeing that law. This HMO is scary in its limitations, but then again I could be being alarmist.
gigi, I haven’t found the actual law yet, but I did manage to dig this up from insure.com
Some states also have a regulation that requires insurance compaines to pay for emergency room care if a “prudent layperson, acting reasonably”, would have considered the situation a medical emergency. Thirty-eight states and Washington, D.C., enforce a prudent layperson standard.
Basically, what this means, (or how we treated it) is that if a normal person would consider it an emergency, then it was an emergency. It didn’t matter if a doctor considered it emergency, it depended on a normal person’s opinion. If you weren’t sure if your situation was an emergency, don’t chance it, the visit will be payed for. The policy itself said it needed pre-certification, but the law said different, and we paid all ER visits, no questions. (And my company was strict about referrals and pre-cert, and half the time denied stuff the first time. So if they paid that, most companies had to be, cause mine was run by cheap bastards)
I already closed the window with the listing of the states, but they are listed on the link to insure.com.
biggirl, maybe you should find another doctor. Every Dr. I’ve ever had has kept a certain number of slots open every day for situations just like yours. When I have something that needs to be seen right away, I call and say I need to be seen that day. Occasionally it’s been late in the day, and I’ve had to wait until the next day, but that’s the longest I’ve had to wait. Now, getting a regular appt. can take months, but when I say I need to get in right away, they fit me in. When the Dr.s were on vacation this year, they had the nurse practitioner on duty just to handle things like this. It seems to me your Dr.'s office should have had someone to cover them for urgent things like yours.
gigi, when I worked for an HMO, we weren’t allowed to offer an opinion about whether or not something would reasonably be considered a justifiable ER visit, but our rule of thumb was “a life- or limb- threatening situation.” A broken bone could, quite conceivably, put you in danger of losing a limb, so it would be covered. A bad attack of heartburn would also be covered, because (as blur pointed out) there is no way for a layperson to distinguish whether it’s indigestion or an incipient heart attack.
I always hated getting calls from people who were confused and worried about whether they could reasonably take a loved one to the ER. One woman called at 5 p.m. to say that her husband was experiencing chest pain that radiated down his arm - would I guarantee that the HMO would pay for the ambulance and emergency room? I told her to call 911 and ask them what they thought.
My personal opinion is that it’s better to err on the side of caution and then nag, wheedle, or bully the HMO into paying later, when no one is in any immediate danger.
If we have an emergency, we just ring the local police office, they connect us with the doctor on duty (at night, or when the doctor’s offices are closed). We ring said doctor on his cell phone. He pops over, usually in about 30 minutes, gives us whatever treatment we need (he’s got a big big black bag), prescriptions or whatever.
We pay him 35E (about $30) and he’s off on his merry way. If we need to, there are 24hr pharmacies where we can get a prescription filled.
The cost of the doctor’s visit is covered 100% for our child and 80% for us. The prescriptions are free.
One of the things everyone must understand is that New York City has what is probably the most grossly distorted medical care market in the United States. One of the results is that the few services that aren’t price-controlled are absolutely sky-high, in an attempt to make up for the amount lost for Medicaid, charity cases, physician training (New York City’s hosipitals train a wildly disproporationate share of the nation’s doctors, and lose money in the process despite high tuition and obscene work hours), featherbedded union contracts (health care is now one of the major employers of the minority working class), etc., etc. The incentives are simply bizarre.
In my prior life one of my projects was reviewing the bonds - federally backed, of course - one of NYC’s major teaching hospitals issued in the late 80s and early 90s. This hospital was hemorraging cash, but perverse subsidy structures meant that it could mask its condition by spending hundreds of millions of dollars on new facilities, of dubious need and at exhorbitant overruns. I recall a New York Times articles a couple of years ago which estimated that NYC’s hospitals were carrying well over $2.5 billion in debt from just this program.
InternetLegend I had those calls too. “Ma’am, I’m not qualified to give medical advice, I’m not a doctor, please hang up and call 911”.
OxyMoronI know nothing about the bond issues, so I’ll take your word on that one, but another problem is when the hospitals enter contracts with the insurance companies, they agree to get paid at huge discounts from the insurance companies and the government in the case of medicare or medicaid. Using the ER visit as an example, the hospital may charge $5000 for the ER visit, but the private insurance pays $1000 max, medicare pays $700 max and medicaid pays $300 max. So the poor guy with no insurance is stuck making up the difference.
that’s why you get medical insurance…!
believe it or not a $80-$100.00 monthly bill is easier then getting seriously injured and in 1 day have a bill of $5k-10k! and have to wait 8 hrs. to get it !
If only! As a Type I diabetic, no private insurance company will cover me for less than $250/month. Since I’m on disability, that’s over a quarter of my monthly income. Rent, phone, food, and my insulin and syringes leave me no money to buy insurance. Oh, but it gets better–AHCCCS (the Arizona version of Medicaid) says I make too much money for them to cover me.
The only reasons I’ve gone to the emergency room are truly emergencies, but that doesn’t comfort me much when I’m looking at around $15,000 in hospital and doctors’ bills.
Biggirl, I sincerely mean no offense, but when you got the wound, you should have immediately cleaned it (I prefer hydrogen peroxide), put an antibiotic ointment on it, and bandaged it. That may (or may not) have staved off the more serious infection.
Doctors get screwed. Hospitals bleed money. Patients get considerably less than their money’s worth. Insurance companies failing (EBCBS has had problems with reserve money for years. The state keeps threatening to decertify them because of it. Not that the state would ever do that-- millions of uninsured New Yorkers would not go over too well). Where in the hell is all this money going?
I think lower cost urgent care facilities in all the hospitals that have ERs would be a step in the right direction. But then, as the study I linked to mentioned, how would the private hospitals fund other, less lucrative departments.
If you read this thread very carefully Jules, you will see that I do indeed have insurance. Squish what gave you the idea that I didn’t clean the damned thing? I am also a diabetic and I take all my cuts quite seriously.
Jules4love, I wish I could get medical insurance for the low rates that you stated. I would pay twice, nay, thrice that for coverage. But as a 45 year old self-employed woman with MS and a pre-existing heart condition; I’m shite outta luck. I have a CD (accruing dismal interest rates) set aside for medical emergencies.
Biggirl, your $5000.00 figure doesn’t seem that far off to me. When I had my heart attack five years ago, the ambulance ride was $1200.00, the ER charges over $3500.00, and then the bills for the doctors kicked in. Not to mention the daily room rates for the two days I was actually in the hospital.
When the time comes, I’m going to put a bumper sticker on my wheelchair that reads:
I recently rang up $29,000. + in just under 5 days in the hospital.
Ten years ago our second son spent three months in the hospital, it was almost $300,000. by the time the dust settled. About $3,300. per day. So I’m not surprised, nor do I doubt Biggirl’s estimate.
