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Subsidize It…You Get More of It

In the comments to this post on health care, commenter TJIT left this little gem of a link that has the, supposedly true, conversation between an ER doc and his patient.

Me (after reading triage sheet and rolling my eyes): Hi, I’m Dr.____. I’m the doctor in charge of the EMERGENCY Department tonight. I see that you came by AMBULANCE. What was so bad that you had to call 9-1-1 at 3 AM to be rushed to the EMERGENCY ROOM by AMBULANCE? What is your MEDICAL EMERGENCY? What is your LIFE OR LIMB THREATENING problem??

Patient (clueless to the sarcasm): Oh, I think I’m pregnant again.

Me (thinking that this clueless girl still don’t get it): You must be in a lot of pain or bleeding severely to come in by ambulance, huh?

Patient: No. I just didn’t have a ride.

Me: So you’re not having any pain or vaginal bleeding?

Patient: No, no pain. No bleeding.

Me: Did you take a home pregnancy test?

Patient: I didn’t have one.

Me: You know they sell them at Walmart. They’re open 24 hrs.

Patient: Well I couldn’t go to Walmart in the middle of the night.

Me: So you took an ambulance?

Patient: Yeah, but my insurance will pay for it.

Me: Insurance? It says here that you’ve got Medicaid.

Patient: Yeah, that’s my insurance.

Me: No, dear. Medicaid is not insurance.

Patient (quickly interupting me): Yes it is! That’s my insurance!

Me: No, dear. Medicaid is not insurance. Medicaid is a government hand out! It’s only called insurance if you’re paying for it.

Patient: Well, what ever! Medicaid will pay for it.

Me: Good grief! You didn’t have to take a $400 ambulance to the hospital for a simple pregnancy test.

Patient: But I didn’t have a ride.

Me: You could have taken a cab. Surely you got $20 bucks for a cab. And those pregnancy tests are under $20 bucks at Walmart ya know. $400 bucks ambulance ride versus $20 bucks…You could have save us tax payers a lot of money, ya know.

Patient: My insurance will pay for the ambulance.

Me: Good grief! How many times do I have to tell you that Medicaid is not insurance? And it won’t pay for nonemergent problems.

A quick 5 seconds physical exam. Push on the belly, no pain. Scribbled the discharge instructions and handed to patient to sign:

Go to local pharmacy and buy a home pregnancy test. Follow up with your medicaid assigned gynecologist if positive. If having pain or vaginally bleeding, return to ER.

Patient: So you’re not gonna run a test to see if I’m pregnant?

Me: No, a possible pregnancy is not a medical EMERGENCY.

Patient: But my insurance will pay for it.

Me: Not if I don’t order it. And even if I did order it, Medicaid…Oh never mind, just go to Walmart or any drug store and get yourself a home pregnancy test, alright. They’re the same urine pregnancy test that we use in the hospital anyway, and it’s much cheaper, too.

Patient (indignantly): So how am I gonna get home now? I got 4 kids at home.

Me: Well, you should have thought about that before you took an ambulance. Surely you didn’t think that we would admit you to the hospital for a possible pregnancy, did you? Your kids are not at home by themselves are they?

Patient: You’re a mean doctor!

Me: No I’m not! If I was, I wouldn’t have ask about your kids. They’re not home alone by themselves are they?

Patient: No, they’re with a friend of mine.

Me: Alright. I’ll see if the charge nurse can help you with a cab voucher home. There’s also a cop here from your part of town. Maybe he can let you hitch a ride home in a while.

Nope, if you subsidize medical care, you certainly don’t get people abusing the system like this. James really needs to add a rolling-eyes icon for posts like this.

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About Steve Verdon
Steve has a B.A. in Economics from the University of California, Los Angeles and attended graduate school at The George Washington University, leaving school shortly before staring work on his dissertation when his first child was born. He works in the energy industry and prior to that worked at the Bureau of Labor Statistics in the Division of Price Index and Number Research.

Comments

  1. Gollum says:

    Steve – I appreciate the point, but do you really think that’s a real conversation? It looks awfully manufactured to me.

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  2. Almost certainly manufactured, since very few people can remember a conversation like that word-for-word. The question is whether it captures the gist of the conversation.

    I don’t find such a conversation at all implausible. But I wasn’t there.

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  3. Mark says:

    My mom works at a hospital where a good number of patients are covered by Medicaid. This particular conversation may be fake, but many similar in nature take place on a daily basis.

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  4. Steve Verdon says:

    I’m with Kent, I’m sure it is a conversation from memory perhaps with some embelishment. Overall, I find the conversation to be quite plausible.

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  5. Tlaloc says:

    That was the most ridiculous thing I’ve read in a while. You actually believe that people act this way?

    I’m sorry but it’s impossible to debate the matter with someone who obviously has no connection to how real people act.

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  6. ken says:

    Steve, you actually think a woman with four kids will take an ambulance at three o’clock in the morning to a hospital emergency room for a pregnancy test?

    Name one ambulance company in America, anywhere in America, that would transport her.

    Steve, it is too late for you to take this post down. Leave it up as testimony to your awesome stupidity.

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  7. Steve Verdon says:

    That was the most ridiculous thing I’ve read in a while. You actually believe that people act this way?

    Yes, some. I was at a Kaiser ER with my son when he was quite young. As I was standing around waiting to leave a doctor was talking to a woman. She apparently wasn’t getting the service she wanted and wanted to go to another Kaiser facility. She had apparently just come from yet another facility and was quoting Kaiser’s “Patient Bill of Rights” or something. The doctor was trying to disuade her from riding around in an ambulance, but she was insistent. I didn’t get to see the end of the episode, but she seemed fine to me, and my guess she was looking for somebody to validate her claims.

    Then, like Mark, my mom worked, until recently, in a hospital and she’d have similar stories as well.

    Do I find the story plausible? Absolutely. Could it all be a made up lie? Sure, but it is a good lie then in that it isn’t at all implausible.

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  8. Patty says:

    I can tell most of the people commenting on this conversation have never worked in a hospital environment. I worked in a hospital of a major city for a number of years, mostly in the emergency room, and sadly enough, this type of situation went on frequently. I have heard variations of this conversation many times. This particular scenario may not be verbatim true, but the attitude of the patient is one I recognize quite easily. When you aren’t spending your own money you have no problem spending someone else’s.

    People who don’t think this goes on all the time are simply either naive or clueless.

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  9. Anjin-San says:

    There are certainly quite a few folks in this country who feel they don’t need to pay for insurance because they “have Medicaid”. I have met some of them.

    On the other hand, I could easily make up a conversation between a doctor and a patient who is dying an agonizing, expensive death from cancer due to the lack of a routine screening.

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  10. Tlaloc says:

    Yes, some.

    Okay let’s narrow this down.

    Do you think this represents enough of a cross section of the population as to be worth mentioning in a serious policy discussion?

    Or is this like the random idiots who call 911 because they don;t know how to baste a turkey (i.e. a one in amillion idiot who has no connection to the actions of the greater population)?

    I didn’t get to see the end of the episode, but she seemed fine to me, and my guess she was looking for somebody to validate her claims.

    Okay first of all Kaiser is notorious for failing to do their job. I mean I literally know about half a dozen people who either died or came to “I had to get major surgery or i was going to die” because Kaiser cut every corner.

    Second of all how do you know she didn’t need an ambulance? From your cursory inspection in a waiting room?

    This is your evidence?

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  11. Gollum says:

    Name one ambulance company in America, anywhere in America, that would transport her.

    Actually, Ken, any ambulance company in an area where EMT-initiated refusals aren’t permitted would have to take her in, and there are lots of those. Most parts of New York fall in that category.

    When you aren’t spending your own money you have no problem spending someone else’s.

    But that’s true of private insurance as well. No one with private insurance thinks, “well, I won’t go to the doctor until I’m REALLY sick and that will help keep my premiums down next year.”

    I appreciate that patients facing no immediate out-of-pocket impact from obtaining medical care are more inclined to do so, and I’m also certain conversations very much like this one happen all the time, with both Medicaid and privately insured patients. But if the premise here is that “subsidizing” care by providing Medicaid benefits for the poor somehow increases utilization in ways that are unique to the Medicaid population then I say phooey.

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  12. Tlaloc says:

    I can tell most of the people commenting on this conversation have never worked in a hospital environment.

    Hi, patty. No I haven;t worked in a hospital myslef. But I’ll tell you what, my mother’s an occupational therapist, my father’s a clinical psychologist, my step mother’s a clinical psychologist too, my step sister is an MD. And that’s just my immediate family.

    I spent a great portion of my chioldhood at two major hospitals hanging around either my mother’s or my father’s work. I naturally had countless discussions with all of them about their work.

    And frankly the idea that people routinely go into hospitals for things they don’t need is laughable. A small percentage of hypochondriacs? Sure. But they are going regardless of whether it is subsidized or not.

    Far and away most people actually get under treated. Why? because they don;t like dealing with the hassle and doctor’s exams are usually less than pleasant.

    Most insurances cover yearly physicals these days, how many people do you know who actually get them?

    By steve’s logic people should be getting them two three even four times a year just because they are subsidized.

    And yet they don’t usually even get them once a year which is strongly recommended by doctors. Again why? Because peope don’t like going to the doctor. They ONLY do it when they need to, and sometimes not even then (again leaving aside the tiny proportion of the populous who are hypochondriacs).

    Next you’ll be trying to convince me that people are dying to get into the dentist for their cleanings just because their dental insurance covers it.

    Less economic theory, more reality please.

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  13. Bandit says:

    You actually believe that people act this way?

    Take a visit to planet big city ER. 3 yrs ago I had to take one of my sons to Childrens Hospital in Boston to have his arm set. While we were waiting there was a cracked out women who kept falling down in the waiting room screaming about how her kid was having seizures. The kid kept saying he was fine then the Mom thing would slap him in the mouth and scream at him in Spanglese. Eventually the hospital called the police and they arrested the Mom and they contacted DSS to take care of the kid and the 2 or 3 siblings. What I heard of the conversation was that the women had brought 2 or 3 different kids in in the last 48 hours in order to get either tranqs or something else prescribed which she was either selling or using. But of course nobody acts that way.

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  14. just me says:

    You actually believe that people act this way?

    I am going to go with the “yes” crowd on this one. Of course frequency may be the real question here.

    My husband used to volunteer for a charity that would help get people who needed medical care to their various appointments or to the hospital (in addition to other appointments). He drove a lot of medicaid and medicare patients to various doctors including the ER.

    There were several people he routinely drove to the ER, once he asked one of them why they didn’t go to the doctor’s office, and they responded that the ER was closer and they didn’t have to worry about an appointment, and it didn’t matter, because they weren’t going to have to pay for it anyway. One of the regular ER patients (my husband often suspected she was after drugs based on complaints and frequency of visits) couldn’t even remember her primary care doctor’s name or even the practice (I can tell you the name, practice and the phone numbers to our primary care doctors by heart).

    The whole “I don’t have to pay for it, medicaid will” attitude was pretty pervasive.

    I am not so convinced somebody would call an ambulance to get a pregnancy test, but I am convinced the attitude is certainly there from experience.

    Shoot we have a second grader at school that has medicaid, and he totally destroyed his glasses, and I asked him if he knew how much they cost (I happen to wear glasses and three of the four kids wear them-I know exactly how much they can cost)-his response was “they’re free, medicaid pays for them.”

    I won’t go into details but when my husband was in the military people routinely used the ER for non emergent care, and even worse, when you called for appointments to deal with sick kids, but the situation was non emergent, you would be given appointments days later and then encouraged to “just take her/him to the ER” by the person making the appointments.

    ER’s are and should be for emergent care only, and at the very least I think medicaid and medicare should build in a penalty for people who use ER’s for non emergency situations. It can be somewhat nominal-like many regular insurance companies do, where you have to pay a $50 or $100 copay if you aren’t admitted.

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  15. Anderson says:

    Shorter post: people will try to abuse the system, and sometimes succeed.

    That’s one of the things that annoys me about libertarianism — its fundamentally ungrownup-like take on the world. “Oh, if only everything were PRIVATIZED, then NO ONE would be able to abuse the system ….” Whereas grownups *assume* that the system is indeed going to be exploited, and take reasonable steps to limit same without thinking it can be eliminated.

    In Medicaid, it’s pathetically stupid or addicted poor people; at Blue Cross, it’s greedy executives screwing people as best they can.

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  16. Tlaloc says:

    Take a visit to planet big city ER. 3 yrs ago I had to take one of my sons to Childrens Hospital in Boston to have his arm set. While we were waiting there was a cracked out women who kept falling down in the waiting room screaming about how her kid was having seizures. The kid kept saying he was fine then the Mom thing would slap him in the mouth and scream at him in Spanglese. Eventually the hospital called the police and they arrested the Mom and they contacted DSS to take care of the kid and the 2 or 3 siblings. What I heard of the conversation was that the women had brought 2 or 3 different kids in in the last 48 hours in order to get either tranqs or something else prescribed which she was either selling or using. But of course nobody acts that way.

    So you really think that one clearly insane woman represents a sizable portion of the populous, enough so that you want to base our healthcare policy on that one woman’s actions?

    Yeah…um, alright. I’ll just be over here. No no, really, you don’t have to tell me more. I get the picture.

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  17. Tlaloc says:

    There were several people he routinely drove to the ER, once he asked one of them why they didn’t go to the doctor’s office, and they responded that the ER was closer and they didn’t have to worry about an appointment, and it didn’t matter, because they weren’t going to have to pay for it anyway.

    But that entirely undercuts the argument which was: if we subsidize health care people will use it more. Your example shows they weren’t using it more, they would have gone to a doctor either way the only thing that changed is which facility they used.

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  18. Charity Doc says:

    As the author of the quoted blog, I assure you that the story is real without any embellishment. If you think that such inane ambulance abuse doesn’t exist, I invite you just to spend a day at your local county hospital ER or hang out with an ambulance crew. As the saying goes, “You can’t make up this sh*t!”

    I’ve seen people taking ambulances for simple tooth aches, sore throat, ingrown toe nails, simple sniffles, etc… Most ambulance services across the country do not allow the paramedics on scene to refuse transports for inane non-emergent cases out of fear of possible litigation. These are the realities. I didn’t make them up. It’s sadly all true.

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  19. spencer says:

    Yes, you are right that there are some people who abuse the system this way.

    On the other hand there are other people who get lifesaving care that they would not get otherwise.

    Now, do you have a reliable estimate of the cost of the abuse compared to the benefits?

    If you don’t what is the purpose of this post?

    This is exactly the reason we get some bureaucracy pushing paper and restricting the delivery of Medicaid to otherwise deserving people.

    Do you have a new breakthrough that would resolve this problem?

    Obviously, the free market has not solved the problem.

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  20. Obviously, the free market has not solved the problem.

    Since we haven’t had a free market for medical care since World War II, this conclusion is a non sequitur.

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  21. Tlaloc says:

    As the author of the quoted blog, I assure you that the story is real without any embellishment. If you think that such inane ambulance abuse doesn’t exist

    It’s not that they don’t exist, it’s that they represent such a handful of cases that they are not worth mentioning. You might as well be talking about People surviving be struck by lightning as an argument to get rid of lightning rods.

    If you want to claim that this sort of thing happens all the time then, no, frankly I don’t believe you for a second.

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  22. Charity Doc says:

    The reason for my post is to bring light to the situation. I’m not against Medicaid, I’m against Medicaid abuse and medicaid fraud. As a guy in the trench, I see things both ways. On one hand there are plenty of physicians refusing to care for patients because of their inability to pay or refusing to accept Medicaid because the reimbursement rate is piss poor. These patients show up to the clinics and get turned away because of a “negative wallet biopsy”. Then there are also plenty of folks such as this lady who abuse the hell out of the system by taking ambulances to go the the ER for inane non-emergent problems that can be dealt with for much less cost in a walk in clinic. Mind you now, that all medicaid recipients are assigned to a gate keeper. These patients just choose not to go to their gate keepers and show up in the ER out of convenience. We, as health care providers in the ER’s, are forced by federal EMTALA law to care for these patients. EMTALA is an unfunded mandate my friend that needs to be changed/fixed. In my opinion, physicians caring for EMTALA patients ought to have sovereign immunity, not complete immunity, but at least some immunity so that we can apply our clinical experience rather than practice CYA medicine and order unnecessary tests.

    Health care reform is complex and there are no easy answers. But I do have some opinions and suggestions on overhauling the system. Tune in to my blogs for future commentaries. I promise to discuss the need for medical courts, sovereign immunity for EMTALA care, more affordable health insurance, cutting health care costs, and how we as a nation can provide quality care for the ~46 million and growing Americans as well as illegal immigrants. I’m just too busy lately to blog.

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  23. Bandit says:

    You actually believe that people act this way?

    Yeah when I see it – but make your usual ignorant excuses for them, please.

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  24. Tlaloc says:

    Since we haven’t had a free market for medical care since World War II, this conclusion is a non sequitur.

    We’ve had a free market for insurance and that clearly hasn’t worked.

    But more to the point-

    Why is it the people who press so hard for free market solutions are the ones who least understand how free markets operate?

    You can’t have a functioning freemarket unless the customers have a choice and can intelligently exercise that choice. Neither condition is true in the case of health care.

    Serious health care requires large infrastructure which means you don’t just have hospitals on every block. I grew up in a city of 100,000 people. There was *one* hospital and one clinic in town. The adjacent city had one other hospital (both hospitals are now owned by the same group). After that you’re looking at a 100 mile trip to get surgery. Hope you didn’t need it too bad!

    The second condition is violated because the vast majority of the population does not know enough about medical care to make good choices when it comes to selecting a provider. Growing up there were certain doctors my mother would *not* let see me because she knew they were quacks. But she knew that because she worked at the hospital. Most people aren’t fortunate enough to have that kind of inside information.

    Is it too much to ask that the hardcore freemarketers learn something about the solution they propose for every problem? Hrmmm?

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  25. Steve Verdon says:

    Do you think this represents enough of a cross section of the population as to be worth mentioning in a serious policy discussion?

    Yes, in insurance circles it is called moral hazard.

    Okay first of all Kaiser is notorious for failing to do their job. I mean I literally know about half a dozen people who either died or came to “I had to get major surgery or i was going to die” because Kaiser cut every corner.

    Second of all how do you know she didn’t need an ambulance? From your cursory inspection in a waiting room?

    This is your evidence?

    Based on the conversation that I heard and that she was at a full-blown emergency room, yes, I don’t think she needed another ambulance ride. Based on the conversation I heard from the doctor, again yes, I don’t think see needed another ambulance ride. Am I certain? No, but I’m fairly certain and it fits with this story, and the ones my mother told me.

    Anderson,

    Shorter post: people will try to abuse the system, and sometimes succeed.

    That’s one of the things that annoys me about libertarianism — its fundamentally ungrownup-like take on the world. “Oh, if only everything were PRIVATIZED, then NO ONE would be able to abuse the system ….” Whereas grownups *assume* that the system is indeed going to be exploited, and take reasonable steps to limit same without thinking it can be eliminated.

    In Medicaid, it’s pathetically stupid or addicted poor people; at Blue Cross, it’s greedy executives screwing people as best they can.

    I think this is a bit of a strawman here. I acknowledge that people will do all they can to abuse any system, private or public. I just happen to think that there is more incentive to construct better incentives and to catch cheaters in the private sector. The lesser of two evils if you will. And as I’ve been pointing out in several posts now, I’m not opposed to some sorts of government intervention, just not the kind everbody on “your side” of the discussion seems to favor.

    Tlaloc,

    So you really think that one clearly insane woman represents a sizable portion of the populous, enough so that you want to base our healthcare policy on that one woman’s actions?

    Yeah…um, alright. I’ll just be over here. No no, really, you don’t have to tell me more. I get the picture.

    She isn’t insane, it is the extreme outcome when you have a bad incentive structure. Will everybody behave this way? No, some people will be guided by their internal moral compass…others will not.

    Spencer,

    If you don’t what is the purpose of this post?

    The point is obvious, read the title a few times.

    Tlaloc again,

    It’s not that they don’t exist, it’s that they represent such a handful of cases that they are not worth mentioning. You might as well be talking about People surviving be struck by lightning as an argument to get rid of lightning rods.

    Okay, so you at least admit that some people engage in this kind of behavior. I guess I should be happy to get this concession.

    As for you claim to the total costs, I have read a little about Medicare/Medicaid abuse and that the costs go into the billions. What have you got Tlaloc?

    Now, building off of what Charity Doc has written,

    We, as health care providers in the ER’s, are forced by federal EMTALA law to care for these patients. EMTALA is an unfunded mandate my friend that needs to be changed/fixed.

    This is basically an open-ended subsidy. This means that if you can’t pay, have no major resources (i.e. are collection proof) then abusing the system is not necessarily a bad option for you. Would solving this problem bring about nirvana in the American health care system f*cking hell no. But it IS one of the problems. Moral hazard is indeed an issue with all types of insurance and health care included. So is adverse selection, so is Gammon’s Law, and the barriers to entry to entering a medical profession. All of them push up prices/costs and contribute to the rapid growht rates in health care.

    Health care reform is complex and there are no easy answers.

    This is absolutely right. I’ve outlined some of the things I think would help, but that is at a very high level and as they say, the Devil is in the details.

    To simply say, “Oh no big deal here, move along, nothing to see,” strikes me as the very heart of the reason why we are in this mess.

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  26. Tlaloc says:

    She isn’t insane, it is the extreme outcome when you have a bad incentive structure.

    Steve, no. When you have a woman in an emergency room shrieking that her child is critically ill despite the kid being totally fine, AND SHE’S DONE THIS REPEATEDLY WITH DIFFERENT KIDS it has nothing to do with the “incentive structure.” The woman is insane or possibly seriously drugged up.

    Again nothing whatsoever to do with how subsidized her care is, the problem is that she thinks her little billy is crawling with cockroaches.

    As for you claim to the total costs, I have read a little about Medicare/Medicaid abuse and that the costs go into the billions. What have you got Tlaloc?

    When did I talk about total costs? You lost me here. But to address your point by all means let’s look at this data, I’m curious what they qualify as medicare/medicaid abuse. My guess is that the vast majority is not about individual patients but about fraudulent billing practices.

    Time to put up.

    While you’re looking for that data answer this series of questions: How often are you going to get your teeth cleaned at the dentist if it costs you $1000 a visit? What if it costs you $100 a visit? What if it costs you $10? $5? $1? Free?

    See according to your logic you’ll go more often at each step. Frankly that’s absurd. Nobody is going to get into a dentist’s chair every other week just beause it’s cheap. THEY DON’T WANT TO. Which is the part you keep leaving out of your analysis. People don’t go to the doctor because they want to, they go because they have to (again leaving aside your colorful examples of the insane and the seriously drug addled). I don’t enjoy turning my head and coughing when I get my physical and I don’t intend to have to do that more than is medically necessary.

    Not even if you make the visit free.

    Not even if you pay me $5 each time I go.

    Is there a law or something that requires economists not to pay attention to reality? I swear…

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  27. Quoting Tlaloc: And frankly the idea that people routinely go into hospitals for things they don’t need is laughable.

    Start laughing. Don’t stop yet. What’s this: one in five ER visits are unnecessary?

    Who’s laughing now?

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  28. just me says:

    But that entirely undercuts the argument which was: if we subsidize health care people will use it more. Your example shows they weren’t using it more, they would have gone to a doctor either way the only thing that changed is which facility they used.

    Um no it doesn’t.

    They were using the ER more, but weren’t using the primary care doctor-why is this bad-a visit to a primary care doctor at most is about $70-100 depending on the area and type of primary care doctor. A visit to the ER (not by ambulance) is about $500-$1000 depending on the situation and what tests/drugs are ordered.

    You may see it as simply choosing to use a different facility, but the cost to the taxpayer is leaps and bounds different. And most of these rides weren’t one shot deals, over a six month period my husband carried the same man to the ER about 5-8 times. His wife went to the ER 4 times over that same period of time.

    In the last six month I have had one of my kids at the ER-she crushed her finger in a van door, and that is the only ER visit for anyone in our family of six in well over a year-maybe even two.

    If said person abuses the ambulance-around here it is about $800 for an ambulance to carry you to the doctor.

    I am not so sure that this problem is only with a “handful” of individuals-and even that handful can be a huge burden on the medicaid system-which is funded by the taxpayer.

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  29. Steve Verdon says:

    See according to your logic you’ll go more often at each step. Frankly that’s absurd.

    No it isn’t. Clearly if it costs $1,000 I will go much less than if it cost $25 or $15. And simply becasue there is no monetary cost to me doesn’t mean there is zero cost. I suggest you google the term “opprotunity cost”.

    Nobody is going to get into a dentist’s chair every other week just beause it’s cheap.

    And I never said they would…you did.

    THEY DON’T WANT TO. Which is the part you keep leaving out of your analysis.

    No, you are assuming that I am leaving it out. As an economist I live, eat, and breath opportunity cost. Believe it or not I used that exact phrase while on the phone with my mother the other day.

    Is there a law or something that requires economists not to pay attention to reality? I swear…

    Sorry, I didn’t say people would go constantly or as often as possible, what I did say is that when you subsidize something you get more of it. Subsidizing something means it costs less. Now that doesn’t mean people start going every other week, but they might start using various services more intensively.

    Failure to consider this is what has led to so many perverse outcomes with government.

    Kent,

    See why I’m so cynical in the post on intellectual property?

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  30. just me says:

    See according to your logic you’ll go more often at each step. Frankly that’s absurd. Nobody is going to get into a dentist’s chair every other week just beause it’s cheap. THEY DON’T WANT TO.

    Dentist probably isn’t a good example, because you don’t generally do much with a dentist beyond maintenence.

    But if you perceive your medical care to be free, and you get a slight sniffle-or your child does, you may decide to take them to the doctor “just in case” rather than wait it out to see if the visit is needed. If the visit is going to cost you $15 or $20-on our budget at least, that copay while not steep, is cost prohibitive if the visit isn’t really needed.

    But I am not bothered as much about the use of a doctor in his office seeing not too sick people, I get very irritated with ER abuse. My insurance comes with a $100 copay for non emergent care-we don’t head off to the ER unless we think somebody really needs to go. Also, our insurance only covers ambulance rides, if the ride was for an actual emergency.

    Building in a cost balance to the patient makes them decide whether a visit to the ER or a call to the ambulance is worth it, if it isn’t really an emergency.

    I think giving things the appearance of being “free” does end up leading to more use and abuse of the system, and frankly-there is no such thing as “free” healthcare-and we need to get away from even associating the word free with it.

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  31. Tlaloc says:

    Start laughing. Don’t stop yet. What’s this: one in five ER visits are unnecessary?

    Okay let’s look at your sources, kate.

    first one: “The report also noted that between 10 and 50% of all emergency room visits are for non-urgent and avoidable conditions.”

    10-50%? First off that’s a pretty big range, and at the lower end is probably pretty good really. More importantly what precisely do they mean by non-urgent and *avoidable* conditions? It’s also worth noting that this is a report from a group with an inherent bias- they are trying to discourage emergency room use.

    Second source: ““Emergency department overcrowding is a national issue,” said Dr. Ted Chan, medical director of UCSD’s emergency department. “A lot of that is because of patients who come to the emergency room (for non-emergencies) because they don’t have a primary doctor.” ”

    And that has what to do with it being subsidized? Same mistake as before: a person using an ER rather than a PCP is not a case of them using too much health care due to it being subsidized. It’s merely a case of them using the wrong source for the health care they are getting.

    third source: “An estimated one in five visits to the emergency room is for a non-urgent condition. People who go to the ER for non-emergencies often hope to get immediate relief and don’t want to wait to make an appointment with their doctors. This is especially true for parents who may feel a heightened sense of urgency about seeking care for their infants.”

    See above. Same thing- no increase in health care usage due to subsidizing, which was, you know, the entire argument.

    Who’s laughing now?

    Yeah I’m chuckling a bit, frankly.

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  32. Charity Doc says:

    It’s not that they don’t exist, it’s that they represent such a handful of cases that they are not worth mentioning.

    You obviously have never worked in our health care system to be so blissfully ignorant of the fact that the majority of ER visits, ~70-80%, in this country are for non-emergent cases. How many of these cases are brought by ambulance? Truck loads of them. I deal with them every day at work. Not all of them are Medicaid patients either. They come from all walks of our society. But the majority of them are from folks who are uninsured. I give them all the usual lecture about ambulance abuse and taking an ambulance from an area where there may be a dying person who truly need it and the delay in response, etc… They don’t care. I get the usual reply:

    “I didn’t have a ride.”

    I’ve had folks who call an ambulance for their non-emergent problems such as sore throat, toothaches, ingrown toenails, etc…and when asked and pushed for an answer, they’ll say that they called an ambulance so that they wouldn’t have to wait outside in the waiting room with the rest of the crowd and be seen earlier. These people actually think that we would abandon our triage system to care for sicker patients first if they came by ambulance.

    Sadly, my friends, it’s way more than just a handful of cases.

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  33. Tlaloc says:

    Um no it doesn’t.

    Um yeah it kind of does.

    Steven’s argument is that by subsidizing health care costs people will over use it. The example provided do not establish this in the slightest. All they establish is that some people use one provider vs another. unless you can show that
    A) they use the ER more than they would use a PCP, AND
    B) that they do so because some subsidy makes it to tempting for them
    then the evidence in no way supports the argument.

    You may see it as simply choosing to use a different facility, but the cost to the taxpayer is leaps and bounds different.

    That may be but that isn’t the issue which was whether the subsidies increase usage. That the ultimate total bill ends up being higher isn’t the question.

    Analogy time:
    Steven says that by subsidizing twinkies people will buy more of them. Then as evidence we get offered examples of people who, rather than walking to the nearby cheaper grocery store chose to bus all the way across town to buy a twinky at an expensive 7-11.

    Unless you can show that they bought more twinkies and they did so because it was subsidized more at the 7-11 the evidence does not support the argument. You can point out all you want that they spend more at 7-11 than they would at the grocery store but it’s just not the issue at hand.

    All that this evidence supports is that some people find doctors inconvenient and improperly rely on ERs to fill the gap. But AGAIN unless you can show that they would use a PCP *less* and that the difference is related to subsidies instead of say wait times you have NOT supported the contention.

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  34. Tlaloc says:

    No it isn’t. Clearly if it costs $1,000 I will go much less than if it cost $25 or $15. And simply becasue there is no monetary cost to me doesn’t mean there is zero cost. I suggest you google the term “opprotunity cost”.

    Yes the difference between $1000 and $25 will be significant because at $1000 people will not be getting proper care. But you conveniently ignore the region from $25 down to free. In that region there will be virtually no change because as soon as you saturate the need for the service a change in price makes no change in demand. It’s saturated.

    No, you are assuming that I am leaving it out. As an economist I live, eat, and breath opportunity cost. Believe it or not I used that exact phrase while on the phone with my mother the other day.

    So then answer the question: how many times a year will you get your teeth cleaned if it costs $25, $15, $10, $5, and $0 for each visit?

    Sorry, I didn’t say people would go constantly or as often as possible, what I did say is that when you subsidize something you get more of it. Subsidizing something means it costs less. Now that doesn’t mean people start going every other week, but they might start using various services more intensively.

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  35. Tlaloc says:

    No it isn’t. Clearly if it costs $1,000 I will go much less than if it cost $25 or $15. And simply becasue there is no monetary cost to me doesn’t mean there is zero cost. I suggest you google the term “opprotunity cost”.

    Yes the difference between $1000 and $25 will be significant because at $1000 people will not be getting proper care. But you conveniently ignore the region from $25 down to free. In that region there will be virtually no change because as soon as you saturate the need for the service a change in price makes no change in demand. It’s saturated.

    No, you are assuming that I am leaving it out. As an economist I live, eat, and breath opportunity cost. Believe it or not I used that exact phrase while on the phone with my mother the other day.

    So then answer the question: how many times a year will you get your teeth cleaned if it costs $25, $15, $10, $5, and $0 for each visit?

    Sorry, I didn’t say people would go constantly or as often as possible, what I did say is that when you subsidize something you get more of it. Subsidizing something means it costs less. Now that doesn’t mean people start going every other week, but they might start using various services more intensively.

    Another way of stating that is that as price decreases usage increases. See how open ended that stataement is? It is certainly true TO A POINT. But what you ignore (and mysteriously claim you aren’t) is that *after* that point there will be a 0% change for a drop in costs.

    Want to guess what that saturation point is? It’s when people are getting adequate medical care. It’s what we should be shooting for.

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  36. Tlaloc says:

    You obviously have never worked in our health care system to be so blissfully ignorant of the fact that the majority of ER visits, ~70-80%, in this country are for non-emergent cases.

    Sorry, but no, I don’t believe you for a second. Not only does that not match my experience it doesn’t even match the most likely inflated numbers that “Venemous Kate” linked to.

    If you want to seem convince me I’ll need a lot more than the claim of a random internet entity.

    (which is still besides the point of the argument in general).

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  37. just me says:

    A) they use the ER more than they would use a PCP, AND
    B) that they do so because some subsidy makes it to tempting for them
    then the evidence in no way supports the argument.

    My evidence was admittedly anecdotal, but as for your A-yes these people he hauled did use the ER more than they used their primary care doctor-shoot one of the trips to the ER was at 2 in the afternoon during office hours, but they went to the ER, because the person couldn’t get a same day appointment.

    And considering this person made the comment that where she went didn’t matter because it was all free, for her at least I would say your B applies.

    Since you are demanding that this is very uncommon-where are your links to back up your points?

    My main point is give something the appearance of being “free” and people are going to take advantage of it.

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  38. [...] Blissful Ignorance Hey all! Blogging to ya from a remote tropical place where the sands are sugary white, the wind blows hard, and those little drinks with the colorful umbrellas never stop flowing. Being unemployed have never felt so relaxing. Truly this windsurfer’s paradise. It’s so awesome rippin’ a duck jibe on a 65 liter board with a 4.0 sail on a daily basis! Just visited the local ER, and they’re hiring! Sweet! Tempting, but I haven’t made a decision after the interview.The internet connection here is slow and spotty.I just checked Technorati and discovered that there’s a healthy discussion here about one of my post. Unfortunately, many of these folks are non-medical and think that ambulance abuse is a rarity! [...]

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  39. That guy says:

    I love watching these debates continue back and forth with eloquent points and counter-points by folks who have never stepped in the shoes of an EMS worker or ER/ED staff member.

    Sure you guys may KNOW people, but that doesn’t give you a sampling regarding the realities of a 12 hour shift in “the trench” as Charity Doc puts it. (It’s so very fitting)

    As an EMS worker I have to say the system is chock full of abuse. I can count EMS abuse calls on my fingers and toes a dozen times over.

    Why?

    Like Charity Doc said, liability. I work in CA and lawsuits are as common as suntans here. Also, where I work, we are REQUIRED to take any patient to the hospital that requests to go. I took a guy in the other night complaining of an impending anxiety attack…only to have him ask for a sandwich from the doc as we put him in the ER bed.

    I’ve had patients tell me they want to go, no matter what the chief complaint, because it’s free due to Medicare. We do our part to explain it to them, but when you see them for the fourth time that month…well, it’s pretty obvious they didn’t get it or they don’t care.

    I’m not going to comment on the economics of this discussion because, honestly, I want to poke my eyes out when it comes to that topic.

    I know I may have sidetracked and I apologize, but I just need to say that his whole arm-chair look into EMS and the ED is really funny to me.

    Yes the system sees lots of abuse. LOTS AND LOTS of it. I don’t expect EVERYONE to work in EMS because, honestly, you have to be kind of nuts to work this job.

    Just wanted to get that point out there since I didn’t see anyone else in EMS post.

    Be safe.

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  40. ken says:

    Charity doc is a fraud. Spend a few minutes at his web site and you will see that it is just a fictionalized version of what a libertarian thinks about medical care in emergency rooms. His site is agenda based.

    My brother in law worked as an ER doctor for years. Car accidents, workplace injury, heart attacks, broken bones, strokes, cuts, dog bites, vaginal bleeding, asthma attacks, pregnancy problems, etc these are the reasons people go to emergency rooms.

    Occasionally someone will come in who has a high fever and it is just the flu, but that is not so often to make it anything other than an interesting workplace anecdote. Serious people do not base policy on the stories told by libertarians.

    And Steve Verdon does not know the difference between apples and appendectomies. He things that if the price of apples goes up and the price of appendectomies go down people will choose appendectomies over apples every time.

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  41. Kent says:

    Kent,

    See why I’m so cynical in the post on intellectual property?

    Steve,

    I’d never try to tell you your cynicism didn’t have some basis in fact.

    Everyone,

    Please note that I am Kent-with-a-T. I don’t want to be confused with the other guy.

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  42. JohnJay says:

    Huhm, quite a different article than I expected for the Subject line. I thought it was going to be about incorrect Reagan-Bush1-Bush2 economic belief that if we subsidize the cost of government through deficit spending, people will somehow want less of it.

    But the health care debate needs more facts and less anecdotes. I would think being stranded at 3:00AM with no cab ride home is a disincentive to come to the ER for no good reason.

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  43. I’ll second Charity Doc’s comments. I have worked in both EMS and the ER, and the vast majority of ED cases and emergency ambulance transports are totally unnecessary – I’d say on the order of 75% neither need EMS nor an ER visit.

    Yet they call day after day, expecting treatment for nothing.

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  44. Tlaloc wrote:

    “That was the most ridiculous thing I’ve read in a while. You actually believe that people act this way?”

    First chance I got to read all the comments. I can assure you that yes, people actually DO act this way, far more often than you can imagine.

    Some public, third-service EMS systems will refuse such transports, but many across this country will not.

    And they learn to play the system – just cook up a plausible excuse or, then change the story once they’re dropped off at the ER. Most systems abusers know the “magic words” to get an ambulance ride, and they make up a significant portion of the run volume of the typical EMS system.

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  45. Heather says:

    I believe all of what Charity doc had to say in his post. I may have been an event that only happens once in a while (meaning lady asking for a pregnancy test coming in by ambulance) but all kinds of people come in by ambulance for silly stupid reasons.

    This one was better than average because she didn’t even have a ride home. I’ve had a lady come in by ambulance because she couldn’t sleep and she lived 2 blocks away from the hospital. She ended up leaving and walking home herself!

    Subsidizing will do nothing for these people because these people aren’t thinking in a clear state of mind when they are either A)calling the ambulance because their issue is SOOO important at that moment or B)haven’t thought clearly for the last 30 years of their life.

    This was a poor choice to illustrate the need for reform in medicine because yes, these people are abusing the system but people like this will ALWAYS abuse the system and will continue to call an ambulance no matter who is paying for it or if health care is paid for them elsewhere. However, it’s very true that something does need to be done, something I am hoping will happen soon. P.S. people coming in with a fever that turns out to be just the flu— that happens every single freaking day, not just enough to tell a little story about once in a while.

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  46. “It’s not that they don’t exist, it’s that they represent such a handful of cases that they are not worth mentioning. You might as well be talking about People surviving be struck by lightning as an argument to get rid of lightning rods.

    If you want to claim that this sort of thing happens all the time then, no, frankly I don’t believe you for a second.”

    Visit an ER some time Tlaloc, as Charity Doc suggested. You need an update on what actually is going on.

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  47. TJIT says:

    It is entertaining watching Tlaloc, Ken, et al discuss this issue.

    The way they utterly disregard the experience and expertise of people who have actually worked in the field is great example of how to be ideologically strong and intellectually weak.

    They know people, they know things, and they have their powerful slogans to throw around. They use these slogans as magical talismans that ward off the bother of actually doing some critical thinking.

    If you show clear evidence and statistics that prove that they are completely, utterly wrong their response is to stick their finger in their ear and say I can’t hear what your saying. Then they pile on a few more slogans.

    One example of this is the way Ken declares charity doc’s blog a fraud. Ken does not know the guy, and he does not know where he practices.

    Ken does know that what the physician writes does not agree with ken so it just takes a few quick minutes for Ken to look at the blog and declare it a fraud.

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  48. TJIT says:

    Tlaloc continues to demonstrate his ignorance of the issue. On an earlier thread he said

    As above there are a lot of success stories for government paid helath care. There are zero success stories for private insurer paid health care.

    Which shows he is blisfully unaware of situations like this

    It’s like paying the lowest bidder to keep you alive!

    Imagine you need a life saving cardiac operation for your severely diseased and failing heart. Then imagine your surprise when you find out that your Medicare government health insurance pays less than 40% of what private insurance reimburse anesthesiologists for the same procedure! Now imagine your concern when you learn that because of such poor reimbursement rates only a scant few anesthesiologists in your area will provide services for cardiac surgical cases when the insurer is Medicare!

    Looks like another great success for the government health care Tlaloc swoons for.

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  49. TJIT says:

    This is a complicated issue. A good change in government policy could improve the situation. A bad change in government policy could make it much worse.

    I am tired of people making the default assumption that throwing more government at the problem will fix it.

    Especially when there is abundant evidence that government run healthcare often produces results no better and possibly worse then private systems.

    Doctors admit: NHS treatments must be rationed

    Some PCTs have been bitterly criticised for refusing to pay for expensive new cancer drugs; treatment to prevent older people going blind through age-related eye degeneration and operations to help obese patients lose weight through stomach-stapling.

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  50. Cathy says:

    Oh for goodness sake. I live in a high rise condo and some of these people take the ambulance to the ER sometimes weekly. It amazes me how many of them abuse this service. Most are elderly but still they call the ambulance for everything imaginable. Last week it was a lady across the hall who called them because her foot was sore. She has arthritis in her foot and knew it was her arthritis. I have seen them call the ambulance for things like the flu, a headache, you name it, they call them.

    Whoever the person is that things people don’t do this, do you live in a hole some where? Because, you are totally out of touch with reality.

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  51. med student says:

    I’m a medical student, and I have seen this abuse while working in the ER and on ambulance ride along before I started med school. Before these experiences, I may have thought these stories were made up as well, who would think people would actually behave this way? But they do, each and every day in county hospitals in major cities. In fact many medical students at our school who originally thought they were interested in emergency medicine changed their mind when they realized that it is half primary care. As one student who matched in orthopedics told a group of first year students “if I wanted to do primary care I would do a family medicine residency and have a normal schedule when I start my practice.”

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  52. Steve Verdon says:

    Tlaloc,

    Yes the difference between $1000 and $25 will be significant because at $1000 people will not be getting proper care. But you conveniently ignore the region from $25 down to free.

    No I did not. See that link on opportunity cost? Right there, people aren’t going to go every other week or even every month simply because it is free. People have better things to do with their time than go to the dentist. Still, this doesn’t disprove the general conclusion: subsidize it, you get more of it.

    You seem to operating under the assumption that if you get to a zero price then consumption is infinite or very, very large. No, that isn’t the case. However, if you subsidize something that is normally quite expensive and cut the price to a 10th of what it normally costs you’ll get a huge jump in demand.

    Basically you are agreeing with me, finally, and arguing only over magnitude. I think that medical care, which is typically expensive, is a case where subsidization should be approached cautiously.

    Sorry, but no, I don’t believe you for a second. Not only does that not match my experience it doesn’t even match the most likely inflated numbers that “Venemous Kate” linked to.

    Well, I called my mother last night who worked for years as an ER nurse. Here is one memorable story from her.

    Lady comes in (via ambulance even though her perfectly able bodied husband could have driven her). She has been vomitting for about an hour. The woman is insisting she has a serious problem. They hook her up to an IV drip, order all these tests. Send for somebody to take and x-ray. By now she has stopped puking. But she feels to bad to hobble from her gurney to the x-ray table (a few feet) and refuses the x-ray. Then she says she really has to defecate. My mom grabs the portable/bedside toilet thingy. Lady starts crapping like crazy. Test come back. Basically the intestinal flu. They tell her, “You’re fine, go home and in 12 to 18 hours you should be feeling much better.” Nope, nope, nope. She insists they are wrong and demands…wait for it…surgery (hi ken)! They refuse, take out the IV and my mom says, “You can stay here as long as you like until you feel ready to go home.” She and her husband are hanging around for an hour to an hour-and-a-half then leave.

    She also said it was not uncommon for a woman, usually with several kids, to come in and complain of abominable cramps. They’d start all the testing, etc. and before they do any x-rays come the questions:

    1. Are you on birth control? (Answer: No)
    2. Are you having unprotected sex? (Answer: Yes)

    At that point, time to get out the pregnancy test. Bingo, she’s pregnant and funny enough the abominable pains subside. She leaves. Basically, all she wanted was a pregnancy test she didn’t want to pay for. Like Charity Doc she also saw people arriving via ambulance for minor not emergency health problems.

    If you want to seem convince me I’ll need a lot more than the claim of a random internet entity.

    That is funny coming from a random commenter. How about this Tlaloc you post your full name and work location and then we’ll see if perhaps we can’t persuade Charity Doc to do the same. What’s that? Not such a hot idea?

    And the thing is it isn’t that some of these cases don’t deserve treatment, just that they don’t deserve EMERGENCY ROOM care. Going to a clinic the next day and getting a pregnancy test for a fraction of the cost is the best alternative. Same for the lady with the stomach flu. So you are vomitting, it isn’t usually life threatening–AFIAK nobody has puked themselves to death unless they are drunk or high and then aspirate on their vomit–so again, waiting till the next day and going to see their family doctor is the best course of action. Using and ambulance and insisting on surgery is just ludicrious. Emergency room visits are expensive. That lady in my mom’s story…several thousand bucks right there. Expensive ambulance ride, all those tests, a nurse, doctor and radiology tech spending time on her (and not somebody who really needs it) are all costs…very high costs. Not ken’s dipshit apples and appendectomies. If she had gotten surgery then it would tens of thousands of dollar…wasted because the lady had a stomach virus which would have passed in 24 hours or so.

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  53. Steve Verdon says:

    One example of this is the way Ken declares charity doc’s blog a fraud. Ken does not know the guy, and he does not know where he practices.

    Ken does know that what the physician writes does not agree with ken so it just takes a few quick minutes for Ken to look at the blog and declare it a fraud.

    No kidding. Here is how ken’s logic works.

    Steve and Charity Doc share the same view on emergency room abuses. Steve’s a libertarian, therefore Charisty Doc is a libertarian. If that last part didn’t make you do a double take, then your logic processor’s are highly flawed. Now maybe Charity Doc is a libertarian, but his statements about thinking Medicare and Medicaid are things he doesn’t disagree with, at least in theory, suggest strongly to the contrary.

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  54. The funny thing is, because my employers have provided health care plans with relatively small emergency room co-pay, I’ve probably made questionable use of the emergency room myself.

    For example, my wife accidentally stepped in a sewer sump one evening and took a golf-ball-sized chunk out of her shin. I took her to the emergency room, even though her condition was not really an emergency (she wasn’t bleeding much, she just had a gaping hole in her leg), because there wasn’t another obvious venue and the co-pay was within our budget.

    (We never did find the chunk. But there were a lot of cats in that neighborhood …)

    Since then, the HMO in question has opened urgent care clinics that are just right for this kind of thing.

    I’ve also taken in family members with severe flu. I plead in my defense that even the doctor thought it was appendicitis until the CAT scan and blood work came back.

    That, of course, is the rub: You really can puke yourself to death, albeit under very unusual circumstances. The hospital doesn’t dare to ignore you if you insist you might have something seriously wrong. Hence, the hospital can’t make any kind of cost-benefit analysis on whether a diagnostic procedure is worthwhile. You can make that cost-benefit analysis, but only if you are presented with something like the actual cost.

    I have a suggestion (it will send Tlaloc’s blood pressure into the stratosphere): Contingency-fee health care! If you really do have something serious, you’re heavily covered. If the diagnostics fail to detect anything really serious, you get to foot the bill for treament.

    On second thought, it’s not clear that this is very different in practice from catastrophic-only coverage, which I already thought was a good idea.

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  55. girlvet says:

    Lets hope that none of you come to the ER for a “real emergency” and then die as we move these idiots who misuse the ER out of their room to accommodate you. Having been an ER nurse for 17 years, I spend a lot of my time dealing with these people. They use the ER as a clinic. It’s a fact. Come down from your ivory towers and face the real world. We do every day.

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  56. M1EK says:

    Basically you are agreeing with me, finally, and arguing only over magnitude. I think that medical care, which is typically expensive, is a case where subsidization should be approached cautiously.

    But oddly enough, your statements basically say it’s wrong to subsidize the cheap stuff that can help save big costs down the road (your oft-abused oil change analogy). IE, you don’t want to subsidize checkups; pregnancy tests; doc-in-a-box antibiotic dispensation; etc. But that’s precisely the stuff you’d WANT to subsidize if you had any interest in efficiency.

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  57. just me says:

    Kent I would love to see more urgent care type centers going up. This type of facility is a good way to handle some of the minor, but serious and may not be able to wait a whole day type stuff, while leaving the ER open for the real emergencies.

    Although I think abdominal pain in general is a good reason to go to an ER-only because there are a large variety of problems associated with abdominal pain-some of them minor some of them very serious.

    But a lot of what comes into ERs seems to fall into something somewhere between ER visit and waiting until the doctor’s office opens the next day.

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  58. Matt says:

    Well, I called my mother last night who worked for years as an ER nurse. Here is one memorable story from her.

    This suggests to me that this type of story is fairly uncommon; otherwise, why would this particular one be memorable?

    Also, I don’t know if I would call this a case of abuse of the system, but rather it’s a case of a person mistakenly thinking they truly were in an emergency. Who would demand surgery unless she seriously thought she was in very bad shape? Of course, if the ER weren’t subsidized, and she knew she would be paying $1000 for her trip, there is a good chance she wouldn’t have gone in. But what if, on the other hand, she had been in an ER-appropriate situation?

    As almost everybody agrees, this is a very complicated problem. There are two major things we want to avoid:
    (1) People going into the ER when they shouldn’t
    (2) People not going into the ER when they should

    Subsidizing, of course, tips the balance in the favor of reducing (2) at the expense of increasing (1). Almost any system of charging or punishing (1) will also, inevitably, increase (2). Subsidizing less costly (non-ER) visits, like M1EK just suggested, is the only exception I can think of.

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  59. Steve Verdon says:

    But oddly enough, your statements basically say it’s wrong to subsidize the cheap stuff that can help save big costs down the road (your oft-abused oil change analogy).

    Health insurance should cover those things that are rare and costly. Thus, these things should be paid out of pocket.

    IE, you don’t want to subsidize checkups; pregnancy tests; doc-in-a-box antibiotic dispensation; etc. But that’s precisely the stuff you’d WANT to subsidize if you had any interest in efficiency.

    You’d only want to subsidize it if there is some sort of public good/external benefit. If it is the case that people who get regular check-ups are healthier later in life when they tend to suck up the most health care resources and thereby actually suck up less; then yeah you might have a point. Frankly, I don’t think this is the case. The old bormide of “an ounce of prevention is worth a pound of cure,” isn’t going to stop the ravages of aging on the human body. Or to use the “oil change analogy”, even if I get regular oil changes, alignments, and other routine maintenance, my car’s transmission will eventually give out. In other words, you’ve assumed your efficiency conclusion, you haven’t demonstrated it.

    And even if you are correct, then we want to subsidize these things intelligently. We subsidize the things like routine check-ups, mamograms, etc. We don’t subsidize morons using ambulances as taxi cabs and people going to the ER to get an enema. These people should be hit with additional costs to disuade them from doing it. On top of that we want to be careful in how we subsidize even costly and rare events.

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  60. Steve Verdon says:

    Matt,

    Nope, that was just one of literally hundreds. Another involved a college age woman literally crawling into the ER complaining about vomitting while pushing along her vomit bucket. Pretty much the same thing, stomach flu. And then there are the regular abdomominable-pain-to-get-a-pregnancy-test visits I noted earlier.

    Of course, if the ER weren’t subsidized, and she knew she would be paying $1000 for her trip, there is a good chance she wouldn’t have gone in. But what if, on the other hand, she had been in an ER-appropriate situation?

    Yes, that was Kent’s point above. In the case of the woman from my mom’s story she should have been forced to pay the full costs of the visit. If it turned out she did need surgery and it was an emergency she shouldn’t have been required to pay beyond a deductible/co-pay. Today we have health insulation, not insurance.

    As almost everybody agrees, this is a very complicated problem. There are two major things we want to avoid:
    (1) People going into the ER when they shouldn’t
    (2) People not going into the ER when they should

    We can’t avoid (2) and even if we could we probably shouldn’t, that efficiency thing that M1EK brought up rearing its rather ugly head. There will always be people who don’t think they need to go to the ER when they should and suffer fatal consequences. And our current situation is un-sustainable. With the current growth rate in health care spending being higher than the growth in GDP we can’t maintain the current situation.

    Just like with setting speed limits at 55 or 65 MPH we are going to have to accept the fact that people are going to die. That is part of the efficiency point that M1EK raised, although he might not like it all that much now.

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  61. just me says:

    We don’t subsidize morons using ambulances as taxi cabs and people going to the ER to get an enema. These people should be hit with additional costs to disuade them from doing it. On top of that we want to be careful in how we subsidize even costly and rare events.

    Absolutely.

    I figure if these people get hit with an $800 ambulance bill and a $400 ER bill, they will think twice about going to the ER for less than emergent care.

    I think a move towards having urgent care type centers, and trying to steer people towards those is the route to go.

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  62. SylviaRN says:

    Before I was an RN, I was an EMT. I had a patient call 911 for a hang nail on the big toe. And yes, by law we had to transport. Had a patient call for “gas” pains and yes we again transported, she passed flatulance in the rig and felt better, we still had to transport to the ER. People call 911 for stupid crap all the time. They show up at the ER for non emergent reasons often. It is NOT unusual. As an RN, I don’t work the ER, I work on the floors and we get our share of frequent fliers too, some need to be there and some don’t.

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  63. scalpel says:

    Of course Charity Doc knows of what he speaks. Those of you who don’t pull shifts in an ER are understandably skeptical, but what he says is true.

    If a parent brings three or more kids into the ER with “fever” and sniffles, it’s guaranteed that they are covered under Medicaid, because they have zero copay and zero out-of-pocket costs. Heck, even their prescriptions are free. Usually, one of the kids has no complaints, but since Mom was bringing the other three in, she thought little Juan should get checked out too. Why not?

    When a family of four comes in two days after a car accident with headaches and neck pains, you know they were rear-ended. None of them ever are from the car that caused the accident. Hmmmm. Of all the hundreds of x-rays and CT scans I have ordered on such people, how many of them ever showed a serious abnormality? None. But they are eager to have the tests, because someone else is paying. And I’m not eager to refuse them and punch their lottery ticket.

    Charity’s pregnant patient must not have learned the ropes yet. Most of the Medicaid pregnancy specials will complain of some sort of belly pain so they can get their free ultrasound.

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  64. [...] Subsidize It You Get More of ItOutside Beltway – Did you take a home pregnancy test? Patient: I didn t have one. Me: You know they freemarket unless the customers have a choice and can intelligently exercise that care doctor-shoot one of the trips to the ER was at 2 in the afternoon during [...]

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  65. Andy says:

    It’s funny how a majority of the people who say this doesn’t happen have a friend or relative in the ER or, more likely, in non-emergency departments (like therapy). All the ER docs know it happens.

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  66. Hal says:

    My god. It’s just the Welfare Queen Who Drives a Cadillac all over again.

    ROFLMAO. Keep it up Verndon. It’s posts like these that really solidify that reputation as an economist.

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  67. An EMT says:

    And frankly the idea that people routinely go into hospitals for things they don’t need is laughable.

    That statement right there proves you have nothing to offer this discussion, because you have NO FRACKING IDEA what you’re talking about.

    Name one ambulance company in America, anywhere in America, that would transport her.

    The one I work for, and every single one of our competitors. And any private ambulance company anywhere, actually.

    And any municipal 911 service. All because the one time you refuse to transport a patient whom you think is full of it, THAT will be the one who actually has something legitimately wrong, and they’ll die, and their family will take advantage of the completely out of control tort system to ruin you and your family and your service.

    It’s not that they don’t exist, it’s that they represent such a handful of cases that they are not worth mentioning. You might as well be talking about People surviving be struck by lightning as an argument to get rid of lightning rods.

    Again, no clue what you’re talking about.

    Ever respond to a subsidized housing building at 3am for a “fall with back pain,” only to find the same guy you picked up yesterday, who for the 8435956th time has “fallen” with his cellphone, medication list, and Medicaid card conveniently in hand? And oh by the way, he’s allergic to every painkiller except Morphine and Dilauded?

    No?

    Then shut up.

    first one: “The report also noted that between 10 and 50% of all emergency room visits are for non-urgent and avoidable conditions.”

    10-50%? First off that’s a pretty big range, and at the lower end is probably pretty good really.

    Good LORD this site is full of morons.

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  68. Platy says:

    Don’t believe it? The ER where I work does pregnancy tests all day and night long. Many arrive by ambulance with no thought to how they’re getting home (and good luck getting a cab voucher from us).

    The only part of it I find hard to believe is Charity Doc’s refusal to order the test. We just roll our eyes and do it, but C Doc knows what he did more than the rest of you.

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  69. [...] Read more, click Live Search News: insurances Related Entries: [...]

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  70. [...] By now everyone has heard the story of the woman who died of a perforated bowel in an emergency room waiting area in Los Angeles a couple of days ago. This article on the internet talks about it. This is going to affect ERs across the country. Patients will see it and bring it up to us in the ER, maybe even trying to get back sooner24 hour nurse talks about it on her blog today. She points out the coverage has been one sided. Its typical of to days journalism, sensationalizing an event and using it to get people stirred up. Its depressing. No one should die in an ER waiting room. But no one ever asks why are ERs so crowded? People are always shocked when they come into an ER and see what really happens there. They don’t realize what is going on in medicine and they don’t care if it doesn’t affect them. Witness this discussion relating to one of charity doc’s posts at outside the beltway.Why are ERs overcrowded? A lot of it is a nursing shortage all over the country. There are not enough nurses to staff hospitals and therefore there are less beds to send ER patients to and they sit in the ER waiting, taking up those precious beds. Then there is our immediate gratification society that prompts people to go into an ER for things that are not an emergency and waste everyones time, (we can’t possibly have any discomfort these days or wait to see a doctor in an office) again taking up more precious ER beds. Doctors in ERs, so worried about liability and lawsuits, order complex tests so that the they won’t be sued for something they missed and that causes longer ER stays that use up those precious beds. These are only a few reasons why you have to wait when you come to the ER. It isn’t because we are mean, don’t care. We do the best we can. We use our knowledge to prioritize patients. Sometimes mistakes are made. We aren’t perfect. We try hard. No matter what, it seems like it is never enough. [...]

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  71. Xerxes1729 says:

    I’ve worked in an ER for a while, and I can say that CharityDoc and the others are all exactly right. While there are always some people who really, legitimately need to be in the ER, about 50% should not be there. Patients have admitted to me that they know their problem isn’t serious, but they don’t want to wait at the urgent care center or a physician’s office. At least one or two times a day, I hear an ambulance paged out for someone with back pain. We’re lucky here that EMS can refuse to transport a patient after consulting with the physician on duty.

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  72. Yvonne the RN says:

    I work in an emergency department and will attest that people arrive by ambulance for some of the most absurd things. Some women will not come out and directly say they want a pregnancy test but will complain of vague, abdominal discomfort…and oh yeah I haven’t had my period in 2 months now, do you think you could check on that. Once these women have their results refuse further testing.
    I had a man arrive by EMS for a wrist laceration. I had my trauma cart ready picturing a major serious wound. The lac was not bleeding and was about 4 millimeters in dimension.
    Some people use the ED as a form of entertainment. Bored? Fake a seizure and ride in the ambulance and get some attention. Get home and then have your spouse fake one too. Hey the hospital is great..action, food and no responsibilities for the malingerer.
    Maybe that conversation did not happen verbatim but I have listened in on several similar ones myself.

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