I’ve long heard (and believed) that it is much more expensive to provide care in an Emergency Room, as opposed to other settings, and that this was one of the major reasons it was important to devise alternatives so uninsured people obtained health care other than in ERs.
Why is it so much more expensive to provide care in an ER? Does it represent actual costs, or merely facility billing practices? I can imagine there being some costs associated with keeping the ER open 24/7 and being ready for all contingencies. But in other respects, do ER doctors and staff get paid that much more than other doctors and staff? Why should an x-ray, or stitches, or meds… cost more in an ER than in the hospital or professional offices that are often in the same building?
Or are there inefficiencies and costs other than financial?
My guess would be that in a routine medical situation, you can plan ahead for what you’ll need and have that amount of staff and resources on hand. But in an ER, you have to consider the possibility that you might be handling any number of different medical situations and you might be handled any amount of each of them. So you have to have the staff and resources available for any of these possibilities even though most of them won’t be needed.
Because while in the best of worlds people would only rush to the ER for *actual *medical emergencies, in actual fact very many people conflate the ER with “no appointment needed medical visit for my routine case of the sniffles”.
The high price tag is not so much a function of supply and demand (although I suppose it also is that), but more a deliberate disincentive for people treating the ER as their ad hoc GP.
As for the notion of the ER being ready for all contingencies 24/7… don’t get a rare or difficult condition past 5 PM would be my advice
From a purely economic standpoint, I expect that an always full ER, would (fairly) efficiently utilize resources.
For example, while that chest cracking tool is only used in a small percent of cases, it seemed that they whipped it out every other episode when “ER” was running.
From a purely business standpoint, if inpatient admissions are lucrative, ER’s can lose money but still make the hospital money (but I hate that kind of economics).
I suspect the ER room is the source of most of the bills that are never collected because those who can’t afford care will wait until it is an emergency or use emergency services when ordinary care might do if they only had a doctor they could go to. So the billed price has to be higher to make sure the ER room comes out not losing money on average.
That’s certainly true. I expect this is especially true for busy urban ER’s, which would negatively offset any efficiency gains they get for being busy.
I’m guessing probably the best place to site your ER would be in Aspen, CO or someplace similar.
-or-
The very, very best place would be this place described in a Monty Python sketch:
*(Sign: ‘St Gandalf’s Hospital For Very Rich People Who Like Giving Doctors Lots Of Money’. Pull back to show another doctor.)
Fourth Doctor: We’ve every facility here for dealing with people who are rich. We can deal with a blocked purse, we can drain private accounts and in the worst cases we can perform a total cashectomy, which is total removal of all moneys from the patient.*
-and-
*
(Sign on wall: 'St Nathan’s Hospital For Young, 'Attractive Girls Who Aren’t Particularly Ill. Pan down to a doctor.)
Third Doctor: Er, very little shortage of doctors here. We have over forty doctors per bed - er, patient. Oh, be honest. Bed.*
Docs in Emergency Departments (ED) are much more likely to order labs and imaging for the same “problem” than someone in an office setting would. Some of that is a simple of consequence of ease of access but more is based on how they are trained. A 2 year old with a fever, a cough, a stuffy nose, and loose stools would be assessed clinically in their pediatrician’s office and if looking like typical viral crud reassured, given home care instructions, and sent home knowing to call us if it did not follow the expected course as discussed. Generally we already know their past history and have their chart and the family knows us and already has a relationship of trust with us. All that saves time. But in the ED that child would get a CBC, a basic metabolic screen, a pulse ox, probably a CXR and maybe a nasal swab for influenza and/or RSV in the ED. Probably some fluids run in by IV and a script for an antibiotic, well just because. Then told to follow up with their primary in the office tomorrow. By training ED docs are to do that which is necessary to be able to prove later that anything that later happened bad was not present at the time they were in the ED. To them that usually means labs and imaging more than noting how well the child appears. It will always look better to have been more aggressive than less from a defensive medicine POV.
Yes a large fraction of ED care is traditionally to the uninsured who end up never paying the bills, so those who do pay the bills get charged more to cover.
In a physician’s office the facilities cost is built into the office visit charge mostly and is fairly low; the charges for the use of the facilities is much higher in the ED as you are paying for a share of lots of stuff that minor complaints do not use.
Nursing support staff in the ED is highly and specially trained for, well, a wide variety of critical emergency issues. They get paid fairly well on that basis. General office nursing staff does not need that degree of special training and are not as costly, and many office support services do not need nurses to do it but can be done by nurse aides.
Also a factor but probably the smallest is that ED docs tend to get paid better than do primary care docs. Not as much as many specialists but still more than office based primary care.
Bolding mine.
The staff in the ED can do all that cool stuff you see on TV, and more importantly do it right away and not dick around with “i’m not sure…maybe we should do that…”.
The ED tends to do more tests and interventions for many reasons including those noted by DSeid. In addition we* assume* that you** are** ill. You came to the EMERGENCY department after all.
The Federal government has decreed that the ERs have to give care to anyone who staggers in and is at risk of dying. Also, if they dump a free-loading patient and then that patient later dies or suffers permanent injury, the hospital may face a suit for malpractice.
Second, the way the hospitals “negotiate” with health insurance companies is by raising their prices to monopoly money levels. I don’t know why they have to do this, but this screws over all the people who can’t afford/don’t have great insurance who get caught in the crossfire of the fight between hospitals and insurers. Somehow, it has been decided that those who can’t afford to pay for insurance *can *afford to pay more in cash than the insurance company would have paid. Often, a shit-ton more.
And the Federal government who is supposed to regulate this just sits by, hamstrung by certain political people who believe that this is the “free market” at work and also that letting the “freeloaders” who cannot come up with $1000 for a bandaid die is a good thing. Never mind that plenty of people could afford medical care, without insurance even, if they could just pay the costs the insurance companies pay or even the actual costs of the care.
They don’t just sit by, they actively enforce it in their own programs. A doctor or hospital wanting to give a break to someone without insurance, by charging them less than the “negotiated” rate (including Medicare rates,) is considered to have committed insurance fraud.
If you go to ER and not committed to the hospital as a patient you could end having to buy for the bill . Insurance companies are cutting back on what they cover , they’re in business to made money not save lives .
ER nurses are paid a bit better than floor nurses, but more importantly, there are many more of them. A floor nurse might have 5-6 patients in med surg, as many as 8 patients in psych, and overnight sometimes that goes up to 10 or 11 patients for each nurse. ER is usually staffed at a 2:1 ratio - two patients to every nurse.
ICU, Critical Care, and NICU/PICU are likewise usually 2:1, and the other most expensive areas of hospital care outside of the OR.
It’s not just that it’s more expensive for an ER to do the same procedures. People who rely on emergency rooms for their medicine don’t get preventive care or follow-up care, because emergency departments don’t do that. A diabetic who doesn’t have a regular doctor can end up in emergency with different types of crises over and over, while one with a regular doctor can avoid that. Someone with high blood pressure who doesn’t have a primary care physician is a lot more likely to end up in the emergency room with a stroke or kidney failure. Preventive care is a lot cheaper than emergency care.
We can play dueling anecdotes I guess but I typically see ED reports with those work-ups done and a PE noting child well-appearing. And often begun on Zithro or Augmentin when no antibiotic at all was indicated and if one was Amox would be just fine and much preferred from an antibiotic stewardship perspective. From multiple EDs, academic and community alike.
I don’t see many kids with a head injury with mild dizziness and mild headache with no focal neurologic signs and no LOC would getting out of an ED visit without a CT. In the office setting? Rarely part of the evaluation.
Way back in 1997, I had a heart attack. I drove myself to the hospital in the middle of the night because I thought the pain was something else. The last thing my wife said to me before I left was, “You know, if it’s not an emergency, the insurance won’t cover it.”
Hospitals are something like $500+ billion a year in business. So unpaid bills are barely 5% of all medical expenses hospitals face. In that case a mild price surcharge should do it, but hospitals charge many thousands of times the cost for various medical procedures. Evenso I think emergency rooms still lose money.
