Saturday, July 14, 2007

Patient Billed $12k for Broken Rib - This is news? Give me a break.

From page C-1 of the San Francisco Chronicle a little while back:

Uninsured patient billed more than $12,000 for broken rib

Synopsis: Some gentleman was in a motorcycle accident. The paramedics who arrived on scene were concerned that he might have some internal injuries, so they sent him to a hospital. A few X-rays, a few CTs, and eight hours later, they give him the good news: You had a broken rib, and nothing else. Sounds like he got off lucky, eh? I mean, a motorcycle accident! Could've broken every bone in his body and he gets to walk away. Lucky guy.

But no, all of a sudden some reporter looks for something to complain about... and apparently makes a headline twisted enough to make the front page of section three.

$12,000? for a broken rib? How could this be? This is horrible. Surely, this is news.

This is something that Vitum will find on when he is killing time, with plenty of points because lots of readers think it's an atrocity.

Well, first of all, surprise. This guy is uninsured. He lives in a country where insurance companies negotiate with hospitals to reduce the costs of hospital bills. He is not an insurance company, nor does he have one on his side, so he is going to have to pay the premium. Any kid who's seen Sicko could tell you that.

Beyond that, there is no way that a hospital charges $12,000 to tell a patient "We let you sit in one of our beds for 8 hours, and in that time we simply took an X-ray of your ribcage. You have a broken rib." In fact, if you skim the article, you quickly see that the article disputes its own headline: the patient is paying for much more than a broken rib. You don't even have to hunt for it. Everything done to the patient is itemized in the article.

So then why is it still news?

Apparently some people don't understand what actually goes on in a hospital. The patient, for one, claims he only got "fifteen minutes of care."

Let me tell you something. From my limited experience, I can vouch for the fact that hospital emergency rooms are always trying to EMPTY beds, not keep people there as long as they can. If he was there for 8 hours, I would bet a lot that he got 8 hours of care. During every minute of those eight hours, something was probably being done during that whole time, or he was in line for something to be done - a lab test being run, a CT being read, etc.

Anyone who thinks this is "news" clearly fails to comprehend the ancillaries that come with, say, an X-ray being ordered. You need to pay the doctor to order the X-ray (not free, and a doctor may not be able to see a patient to do this); you need to pay someone to bring the patient to the X-ray machine; you need to pay for the X-ray tech's salary, undoubtedly unionized; you need to pay for the cost of the X-ray film; the cost of using the X-ray machine; and the cost of the radiologist who reads the X-ray. Same goes for CT, and for lab tests.

Agreed, each item in this patient's bill is overpriced, but there were undoubtedly costs that the hospital incurred, and good reason for him to have been in the hospital for 8 hours.

Someone who read this article told me that with an explanation like that, okay, sure, everything in that article makes sense. Everything except the $4,650 "trauma page." According to the article, "a page was sent to doctors and anesthesiologists on call at the time. That page alone cost Palmer $4,659, and he hadn't even set foot yet inside the hospital."

Yeah, okay. The hospital can really get away with billing almost five grand for thirty seconds of work by their switchboard operator. You have to be dense to not think there must be more to it than that.

When a trauma page goes out, it means that the entire trauma team is assembled and is standing in the trauma room for when the trauma patient arrives. I've seen it.

This assembly of hospital staff can be up to a dozen different highly trained health care professionals. This can include a hospital clerk to document the patient's arrival and details, a nurse to write down what the doctors are shouting out during the initial assessment, the attending doctor who oversees, a resident doctor who does the assessment, any other residents who respond to the page to watch learn and gain experience, an anaesthesiologist in case the patient needs to be intubated or sedated, a respiratory therapist to run the ventilator if needs be, another nurse to start doing the things the doctor orders such as place a foley catheter, a trauma X-ray tech to start setting up a bedside X-ray machine, and the lab tech to be able to draw blood and rush it to the lab ASAP, to name a few.

What are you paying all those highly-trained, highly-paid people for? You are paying for them to drop everything they were doing, and be at the trauma bay for when the patient arrives, and for their salaries for the next hour or so, which is assumed to be how long they will be standing there working on the trauma patient to get the patient stabilized.

Of course, once this patient comes in and they see he is awake, breathing, and ambulatory, perhaps some of these people will leave (ie. the respiratory therapist) but the bill is still issued to the patient for them even showing up. Most of them do their job, anyway; the lab tech still draws blood, the doctors still assess the patient, an X-ray is still taken.

You are also paying for the use of the trauma room, one of the most high-tech and largest patient rooms in the hospital. Rent doesn't come cheap, especially with all the fancy dillybobs on the wall. That is an extra amount of money.

As well, the lab tests that are ordered come standard; you need to be able to find out if the patient, say, has a bleeding disorder, or was drunk or high, or is running low on blood, or has an infection, or any other condition that would change the way the patient is handled. For example, if he had a huge crushing injury to a muscle, this could release a large amount of potassium (there's more potassium inside the cells than outside), which if this gets into the blood, could stop the heart. Doctors look out for these things.

Of course, I could also mention the incidentals - the receiving triage nurse's time on the radio with the paramedic, the hosptial switchboard operator's time to send the page, and the cost of sending 14 pages to all those people. Total cost for this is probably about $3, but it's included in the $4,600 trauma page.

Okay, fine. I'll admit. Even though they still did most of the workup, this patient probably didn't get his $4,600 worth for this trauma activation page because he was much healthier than anticipated. The respiratory therapist, for example, wasn't needed, and he probably still paid for the RT to show up.

So why would they page the trauma team for a guy with a broken rib? Isn't that overkill?

Let's see. Your typical trauma page might say TRAUMA MVA ETA 5 MIN NEED U ASAP. Beyond that basic indication of what's going on (in that page, motor vehicle accident) the doctors and hospital staff have no idea of what the actual case is. Nine times out of ten, the information that comes in before the patient does isn't entirely accurate.

So in this case, the trauma team likely heard that a trauma patient was coming in from a motorcycle accident, and that's it. Because the paramedics were concerned of internal injuries, they called it a trauma. At this point, there is no way for the paramedics - let alone the trauma team - to know for sure that this patient has only a broken rib.

In fact, based on that info alone, the hospital has to be ready for a patient with anything from a broken fingernail, to multiple broken bones / internal bleeding / pavement abrasions all over his body / possible c-spine injury / burn wounds from a gas tank explosion / the list goes on. For all they know, the ambulance is also bringing two other bystanders who got shrapnel embedded in their torsos. So, they assemble the entire trauma team. And when he gets there, they fully work up this guy.

You might still think this is overkill. But think again. If things weren't like that, this would be the headline instead, and the article would be much more newsworthy: "Hospital Takes 1 X-ray, Uninsured Patient Pays $11.95 and is Discharged in 24 Seconds; Patient was Hemophiliac and Later Dies Bleeding from Lacerated Spleen"

"$12,000 for broken rib." Yeah, right. Try "Hospital thoroughly checks out patient after his motorcycle accident; patient gets lab tests, nice room, pain meds, doctor supervision, X-rays, CTs, full trauma workup, and 8 hours of top-noch hospital care for only $12,000" - oh wait, that wouldn't make the news.

I see how it is. Twist the headline, and then people will be interested in reading the story.

You want a headline that screams injustice and ignores the fact that there might be another side to the story?

How about this one: "After hearing of doctors involved in London terrorist plot, Royal Bank clerk tells Canadian medical student from Middle East: 'I don't feel comfortable giving you a large line of credit anymore.'"

Actually, I didn't really twist the headline at all. You'd think that would be straight from The Onion. Too bad that poor kid says it actually happened to him.


Anonymous said...

I can understand your point of view. This is the same for Dentistry. Because health care is covered by the government, canadians don't understand that dental care, a subdivision of health, is expensive just like any other part of health. The difference is they see the direct relation with cost whereas health care is buried in their taxes.

Harry said...

Hey vitum

One of the best posts I've read this week, well explained - esp to someone from the UK where medicine is socialised and insurance companies don't come into it.

GeorgeH said...

"After hearing of doctors involved in London terrorist plot, Royal Bank clerk tells Canadian medical student from Middle East: 'I don't feel comfortable giving you a large line of credit anymore.'"

Sorry, but restricting business ties to all Muslims and/or Middle Easterners is perfectly reasonable.
It may not be nice or politically correct, but they are a greater risk.

Anonymous said...

"Let me tell you something. From my limited experience, I can vouch for the fact that hospital emergency rooms are always trying to EMPTY beds, not keep people there as long as they can."

I found this amusing. In the United States, most hospitals are for-profit businesses. The longer they keep a patient, the more money they make.

I spent some time in an ER recently for minor chest pains. Within ten minutes of seeing the doctor, he and I agreed that the chest pains were from shingles. He refused to discharge me until they get lab results ruling out a heart attack.

It took 3 hours to get the test results back - negative (I have no problem with that) and then another 6 hours to process the discharge. Had I gone out AMA, I later found, my insurance company would have refused to pay for the visit.

I was in the hospital for 11 hours. I leave the cost to my insurance company to your imagination.

Anonymous said...

I broke a few ribs and one hospital wanted to fly me to another, I said no. Once at the other I laid there for 5 days, drawing blood, physical therapy, meals and the like. I did recieve a chest tube to drain the fluids accumulating in my chest but later recieved an infection that continues to plague me 1 week later. Also the fluids they drained out were only surpased by the fluids that accumulated beneath my skin that doctors say is being absorbed by my body. I was funny though, while in the hospital I realized i was becomming a "profit center". When I told them I was a cash customer and will continue to refute treatments or tests they all got a massive attitude. How dare I they thought. I have had for many years and have since recently contributed to my belief that I don't need these idiots in my life as the true caring professionals of this industry come too few and far between