Saturday, September 22, 2018

Qwitcherbitchin', Crybabies

Burning Platform has some whiny rant (and coming from me, that's really saying something) about a guy billed $426 for an $8 can of OTC pain spray.

Well, gee, no shit, Sherlock, and if you scroll back a coupla posts, or drove by Homeless Depot any time since 1986, you might have noticed those 200 Julios standing outside their branch in Greater Aztlan Assland, which heritage Mexican homeland apparently stretches all the way to Anchorage AK and Bangor ME. (Who knew?) And unlike whom, you have actual insurance.

Oh, and back awhile, your congressweasel voted in EMTALA, mainly in response to anesthesiologists passing gas for docs doing C-sections on pregnant migras who were crowning, and getting sued by them afterwards, but never actually getting, y'know, paid for their twelve years of higher-education services or their $1M expertise. Those bastards!! Doctors should work for free, amIright??

Short story long, if you show up at the ER, yours, mine, anybody's, you get to play, but you don't have to pay. At least, not up front. Unlike, say, your doctor's office, Urgent Care, or - waitaminute - every other commercial establishment in the flipping country, including the DMV and the Post Office.
Well-played, Fucktard Minions of Stupidity.

So, by the by, exactly how long d'ya suppose Mickey D's or Burger King would be open as a business anywhere, if tomorrow Congress passed the WAAH! My Tummy's Rumbling Active Hunger And Deadbeat Wimpy Act of 2018, dictating that anyone who wanted a hamburger now could get it now, solely on the promise to pay for it next Tuesday?

And if you worked at a business similarly burdened, how long would you have a job when that enterprise subsequently went tits-up, in about a New York minute??

And if the pharmacy at Wal-Mart had to hand that spray out for free, how much d'ya figure they'd start charging for kettle corn bags and underpants to subsidize that largesse? Say, somewhere around $426 dollars, just mebbe?

Anyways, they go on to knee-jerk call the price of the pain spray to government regulation and socialism(!), rather than all y'all getting the system you pissed and moaned for, and now finding out you're getting it good and hard.

Then, a couple of comments down, this nugget:
"Husbands bill was over $2000 to tell him his arm wasn’t broken.
Xrays were separate, about $50.
$256.00 for a tetanus shot.
For comparison, i can get a tetanus shot for a horse at tractor supply for $4.00
Tetanus boosters have been around for decades. Not like they’re rare or anything.
This is after sitting there for 4 hours among a couple dozen non English speaking persons."
Some people cannot put two and two together, and come up with the answer.
Let me help:

And that's why you're paying $256 for the shot.
You're paying for all the Julios and Marias and Wangs and Achmeds and Crazy Homeless Alcoholic Eddie guys with no insurance.

And of course they get a bill too (despite another idiot commenter suggesting we don't bill them).
Which we can't make them pay.
If they gave the right address.
If they gave the right name.

And also, because if your husband got an infection from poor injection technique, or they hit a nerve or blood vessel, or the sun was in your eyes, it was $256 to offset insurance premiums, because you'd then sue the hospital for a gazillion $$$. So you have a doctor ordering it, a pharmacist stocking it, and an RN giving it, rather than you grabbing a dose at Tractor Supply, and doing it yourself.

And of course, if he'd just gone to your doctor and gotten the booster himself, on time, months ago, it could have been had for maybe $20 co-pay, or even less than that, right?

Make your congressweasel pass tort reform, stop suing everybody for everything, build the frickin' Wall at the border, start throwing people back over it, get your annual checkups, and quit using the ER for drive-thru Urgent Care.  Now, how much of that is within the hospital or ER's control, and how much is within yours?

Otherwise, pony up. Walking in the door at any ER worth the name starts at about $1500.
If it was open, depending on day of the week/time of day, you could've gotten the same X-ray and treatment at any competent Urgent Care for a few hundred bucks.

People will price-shop for a ten dollar difference on a cell phone, but they won't use common sense about an ER bill of $2K vs. one at Urgent Care of $500.
Genius, right there.

(And if Urgent Care wasn't available for you, for any reason, then let's be reasonable. You had no choice about the ER, that injury hurt - a lot, and you wanted to know now. Fair enough. You want care now, you pay now.
We take cash, check, almost any insurance, and VISA/MC. Tell me they do things different at Burger King and Target when you want a Whopper or a pair of jeans.)

But don't bitch when you got the gold-plated care you demand, at prices your insurance company mostly pays, while you rarely see 10-20% of that cost.

This is the system you wanted, and now it's not so bitchin. I get that.
Now go fix it, as outlined.

I'd chat further, but I'm on duty at the ER tonight.
Where, if someone comes in with a heart attack, and we save their lives via the Cath Lab and first-world medicine that should be the envy of every Swinging Richard in human history since Adam, the only thing they'll remember afterwards, and go online to bitch about afterwards, is that the baby aspirins we gave them were billed at $20@.

So don't take this the wrong way, but as someone who couldn't have made two car payments in their life if they received $100 for every "thank you" heard from patients or families in 20 years of saving actual lives, if you complain about anything but gross negligence or egregious harmful malpractice, like having the wrong leg amputated, please, I beseech you most humbly and sincerely, go and fuck yourselves up the ass with a lit flamethrower, m'kay?

Because If I gave you that enema, I'd bill you for it at the price you deserve, and laugh while I did it.

Maybe when the shift is over, if I feel like it, I'll tell what you ought to be doing, and bitching about.
Knowing full well the odds of you taking such concentrated experiential wisdom is about as good as the odds of you listening to the discharge instructions you get.


Divemedic said...

Emergency rooms only collect from about 40% of their patients.

Same with an ambulance. In order for their to be ambulances available for calls, they have to be idle about 1/2 of the time. Since less than half pay, the patients of that ambulance have to pay for the time they were patients, the 1/2 of the time that the truck is idle, the insurance, fuel, wear and tear, salaries, and medicine.

A single dose of glucagon costs $114. Some patients require 3 or more doses. All of those drugs are expensive expire, even if never used, and must be paid for.

Unknownsailor said...

You are leaving out the fact that, unlike every other business, you cannot get a binding quote for care from any hospital before you get treatment.

Nor can you find out the prices for services beforehand, because the hospital won't tell you.

Any other business who operated like that would be hemmed up in criminal court today, with executives on the dock for time in prison.

I know you work in emergency medicine, and I even agree with you that migrant invaders and EMTALA have driven prices through the roof, but that is not the end of it.

The entire medical industry needs a thorough application of anti-trust laws, from the pharmaceuticals to the family doctor, and it needs it done yesterday. No other industry is allowed to collude with insurance agencies to set prices, practice anti-consumer pricing practices, or charge consumers for screw ups created by their own employees (see post-operative infections).

Badger said...

Denninger had an interesting piece awhile back over at his place on this subject. No one with the power to do anything about it would touch the idea, of course, because it's full of non-fuzzycuddly krap like "full disclosure" and notions like "you won't even try to take care of yourself & want ME to pay for your Type-II diabetes?"

Everyone who interacts with the system of the provision of care, who has insurance on their own, forked over out of their own pocket, understands who they're really paying for with that premium. The denial stems from their fear that they might have an impure thought about one of their [diversity whose cause they embrace at cocktail parties].

Anonymous said...

Unknown has a sorta point. In emergency medicine people usually won't shop around, they don't have a ton of time. "Hmm, I seem to be having a coronary, let me price check these places..." That doesn't happen.

But what is right on is the fact that unless you're going in for a cosmetic procedure, nobody's willing to tell you anything, even IF you have a code upfront and ready for them. I've called billing before with codes provided to me by my physicians (awesome doctors and nurses when they give you those), and once you hit a certain sized network of doctors, the billing department suddenly gets REALLY vague.

In fact I've even offered to pay out of pocket to see one specialist and they REALLY freak out at that - "We don't see patients on a cash basis." Oh, pardon me, I guess my money is no good, what with upfront payment in cash and all. But let me get a price quote from the SAME PLACE on a cosmetic procedure for my hands, and that price chart is right in front of my eyes and my money is ALL GOOD to them. It's the insurance companies and MediCare (who develop the codes that all insurance companies and medical practices run on), that's the CAUSE of all of this nonsense, not the solution.

Meanwhile Aesop does all this in place where his patients don't say thank you - I asked my ER nurse her favorite wine and sent her a case afterwards for being so awesome. Aesop, go practice rurally. Seriously. It's a better thing for your blood pressure. They still have manners up in these hills.

Anonymous said...

If you would like the Mojados to clear out just shout "MIGRA!!" at the top of your lungs.

Reltney McFee said...

Aesop: You couldn't make TWO CAR PAYMENTS? Hell, i couldn't but a freaking tire, at $100/ER thank you, and I've been medic, RN, and PA for cumulatively around 40 + years.

So, this fool is complaining about the 400 some dollars (his insurance company) paid for the (allegedly) $8 dollar can of freeze spray?

You're correct. Additional costs Wal Mart doesn't have to pay include security, and work comp for nurses, and other staff, injured wrestling with jackwagons. In addition, Wal Mart closes from midnight to 0800 or so, hereabouts. Wanna bet your subject would shrug, and placidly go home should his ED try the same "no night shit differential for you!" cost savings?

Then, as you, Aesop, well, well know, there is the capital cost as well as ongoing costs (DiveMedic alluded to in the outdated-meds reference) of maintaining the ability to respond IMMEDIATELY to life threatening emergencies, in he setting of URIs, sore throats, UTIs, and sprains-that-might-be-fractures (but are very unlikely to worsen overnight). That, as well, ups the costs of operation.

Which Mr. Price Sensitive Arm Pain neither is aware of, nor, I wager, cares about.

As you suggested, he could have saved himself a lot of money (paid on his behalf by his insurance), should he in fact be that price sensitive and righteously indignant, by waiting his cheap butt until morning and going to the urgent care. Which, in fact, you suggested in your analysis.

I can tell I'm getting more and more irritated with this dope, because I'm repeating myself, repeating what you said.


The Gray Man said...

Ten months ago I decided to expand my RN expertise into the field of Emergency Medicine, and now I can see why no one pays their bills for the ER. All you have to do is make up a name and claim not to have your ID, give us a fake address and phone number, and disappear into the wind when we discharge you.

Mike_C said...

I'm on the road (just got back from an investigators meeting at a cardiology conference) and didn't have time to read the original Burning Platform post (key thing being whether the person has insurance), but in general, another major factor is discounting. Apart from subsidizing the uninsured and the deadbeats issue. Here's an example.

Say we do a procedure, a transthoracic echocardiogram ("echo"). We bill $1250 for the echo, knowing that Medicare/Medicaid has "negotiated" (i.e. You'll take this and like it) an 80% discount, so when we bill 1250 we expect to get $250. And the major insurers have similar deals. Hospitals nominally bill 3x, 4x, 5x what they'll really get, because of these "discounts". It's all an elaborate game. But the poor bastard working three part time jobs, staying off of welfare, and has no health insurance? THAT GUY gets hit with the same $1250 bill, only NO DISCOUNT, and the corporation that owns the hospital will pursue that poor bastard for every damned penny of that $1250, even though it accepts $250 as settling the entire bill (the patient is not on the hook for the "remaining" $1000).

Take a real careful look at your medical bills, those of you with insurance. Look at what your PCP bills for your annual checkup (A), what insurance pays the doctor (B) and your co-pay (C). You'll find that A >>B+C. It's a ridiculous numbers game.

Anonymous said...

@Mike C

Hospitals do give discounts for ER services, at least they did ten years ago. At that time, I went to one of the local ER's as I woke up feeling something not right going on in my chest at 2:00AM. Bill came to $3200.00 with a diagnosis of "nothing found" (not the correct medical terminology, I know). Went to the billing dept and explained that I had no insurance and asked for a discount. They gave me 10% without even batting an eye.

Went to my Primary Care phys. next day on advice from the ER doc. Phys examined me, gave me an ECG and again pronounced nothing found. Billed me around $600.00. I went to the DR's office billing and explained no insurance, asking for discount. They said NO. So I waited for them to send it to a collection agency and they ended up getting less than they would have if they had given me the same discount as the hospital. BTW, there's no record of collection agency action on my credit report.


Anonymous said...

You are also paying for all the Free Shit Army care when you get those hospital bills or pay your medical insurance bill.
-Winston smith

DAN III said...

Anonymous said @ 2024 22SEP,

My long-time dentist has always provided excellent service. After a visit one day I went out and bought a $100 bottle of Scotch to show my appreciation for his expertise. Delivered it to his office. Never got a "thank you" from him.

I justify the lack of manners with the possibility the receptionist drank it.

Bottom line is good manners, appreciation for otners and general good will towards friends, relatives or strangers is dead in the fUSA society.

DAN III said...


Rather than debate the pros/cons of medical care in fUSA, I would prefer you folks question WTF we are warring in the Middle East, Iraq, Afghanistan, Somalia, the African continent and elsewhere for 25+ years.

In the meantime fUSA's borders are wide open. Our treasonous politicians care more for invading, foreign attackers than they care for taxpaying CITIZENS. And federal politicians, particularly Democrats, commit treason daily.

And folks want to whine about healthcare ?


billrla said...

@DAN III: If you cannot afford to gift me a bottle of Macallan 18-year-old (about $175/bottle), just buy me a bottle of Jack Daniels. I promise to thank you, regardless.

As for all those small wars we are fighting overseas, think of them as job-training for ER docs and nurses. Don't you feel better, now?

Aesop said...


You are leaving out the fact that, unlike every other business, you cannot get a binding quote for care from any hospital before you get treatment.

Hey, Asstard:
A Binding quote for what treatment???
That chest pain that's you eating seventeen tacos too with much jalapeno?
The chest pain that was you lifting a sofa and carrying it downstairs as if you were still 20 years old?
The chest pain that's two 98% occluded coronary arteries, requiring cardiac catheterization and double stenting, a week in ICU, and cardiac rehab, after your full arrest and resuscitation?
The chest pain that's a blood clot from you sitting on a plane cross-country, then that thrombus breaking loose and lodging in your pulmonary vasculature, requiring vascular surgery to go in and pluck it out before it pushes through and turns into heart attack or stroke?
So tell me, Amazing Karnak, WTF chest pain is your problem? Not after a full work up, but before we even talk to you?
And how can you tell, without a full workup, including chest X-ray, blood tests, chest CT, etc.?
Would you like us to just charge you $50-200K for every time you strain a muscle and come running into the ER?
Or would you rather we just close, because we have no fucking clue what we're quoting a price for until we do the goddam work to find out?
Or did any of that obviousness that, perhaps, slip your mind?

Nor can you find out the prices for services beforehand, because the hospital won't tell you.
1) Once again, for what services? You have no idea what you're going to need, so they have no idea how to quote you a price for mystery meat.
It's like asking a restaurant how much it costs for dinner: it depends on what you order.
2) bullshit.
3) Try calling your insurance company, and asking what price they've already negotiated for 10,000 procedures and treatments you've never heard of. Let me know how that works out.
Bonus: Find out what they pay at hospitals where you're covered, and then find out what the same thing would cost at the hospital where they don't cover you (i.e, you're eating 100% of that bill yourself). And since you're not paying 80% or more of the bill anyways, WTH do you care? Just asking.

Aesop said...

Any other business who operated like that would be hemmed up in criminal court today, with executives on the dock for time in prison.
Any other business required to give away free everything to every swinging Richard who walks in the door would tell you to go fuck yourself. With your congressweasel.
And BTW, let me know what other business has to diagnose what's wrong with, say, your car, and fix it, while it's still running?

I know you work in emergency medicine, and I even agree with you that migrant invaders and EMTALA have driven prices through the roof, but that is not the end of it.
No. The end of it was ObozoCare. The beginning was when wages were frozen during WWII, and so businesses began to offer benefits like health insurance (which wasn't counted as wages), until it became near universal.
And then, 20-30 years later, when those former 20-30 year olds were now hitting late 50s/early 60s, businesses started getting socked for bigger slices of your health care, that you hadn't paid for (or your parents hadn't) for 30 years. So they started throwing you under the bus. Or declaring bankruptcy. And instead of you taking the financial responsibility for Grandma or Uncle, you let the government do it. IOW, you foisted elder care onto everyone not the family to pay for it. See how cheap government "free" shit is? And Uncle Sam started paying doctors and hospitals 2-3 cents for every actual dollar of care delivered. So in order to stay in business, the hospitals, and the government, shifted the price of health care onto the younger and healthier (stop me if you've heard this one), and onto the insurance companies who were actually paying the bills that you weren't, and which you hadn't paid since time out of mind. And those companies cut benefits and raised premiums, without telling you it was for everyone's decrepit grandpa who'd smoked for fifty years, and now was dying, for 25 more years, of emphysema and lung cancer. And even if your grandpa was dead, and had never smoked, you still got to pay for everyone else's, because employed, insured, young, and healthy. And eventually, now that there's 17 old folks in the cart, and three of you pulling the wagon for them, you're starting to notice there's a wee bit of unfairness and disparity going on.

And that coffee is suddenly rather bitter.

Aesop said...

The entire medical industry needs a thorough application of anti-trust laws, from the pharmaceuticals to the family doctor, and it needs it done yesterday.
No other industry is allowed to collude with insurance agencies to set prices, practice anti-consumer pricing practices, or charge consumers for screw ups created by their own employees (see post-operative infections).

Post-op infections have been a fact of life forever. Welcome to reality. You knew the risks when you opted for the surgery. They even made you sign consent, knowing exactly that. Go to Vegas, and ask for your money back at roulette when your number doesn't come up, or you crap out. Tell us how that goes for you.
You want perfection, skip the surgery and get a 100% chance of no improvement at all, and possible death.

Make you a deal: if you signed consent for surgery, you agree not to sue if the hopital's post-op infection rate is at or below the national average (ballpark <1.5%). So even if your dick falls off, if their infection rate is lower than average, you get $0, and may not sue, ever, for anything.

And BTW, WTF do you think eats the entire cost to pay for post-op infections and complications? The patient? Nope. The insurance co.? Nope. So, who does that leave to eat that whole cost? I'll wait while you work that problem out.

"Yeah, because you'll totally sue your way to a better system when government does the suing." - said no one ever.

Just woke up from 1875, or what?

Why do you think auto shops charge Price X? Because that's what it costs? Or because that's what seven insurance companies, on average, will pay for it??
Why do you think college tuition has gone up at seven times the rate of inflation, with government now subsidizing 100% of student loans, and no bankruptcy defaults allowed? Why do you think Podunk JC now charges the same tuition that Stanford and Harvard used to charge? (Because, just maybe, that's what the government lets them charge, and because you're not the one paying for it?)

This is you, the American taxpayer, with both hands and your mouth latched onto Uncle's nipple from cradle to grave.
Like he wants.

You bought the ticket for this ride in 1932.
If you don't like it, force TPTB to cancel it outright.
And even if they don't, refuse to take it even if you can.
No Social Security for you, ever.
No Medicare.
Drop that teat, and stand on your own two feet.

Yeah, that'll be the day.

Everybody wants everyone else off the tit, but they won't unlatch themselves, because they're entitled to it. Just ask them.

Nobody asks the price of the food at a catered dinner, because you're not paying for it, therefore unless you're the host (and with health care, you aren't) it's none of your damned business.

You want to find out the cost of something at the hospital?
Open a business, and hire employees, and then be forced to cover them
Then get an insurance policy.
They'll tell you in a New York minute what they cover, and what they'll pay, and where they'll pay for it, out the yazoo, in a plan book that looks like the Manhattan white pages. And god help anyone, even the owner, if they try to get care at an out-of-plan facility, even if the appendicitis happened on vacation in Timbuktu.

In short, you're not tall enough for this ride if any of that is news to you.

But hey, if you think anyone is Scrooge McDuck in this field, diving into vaults full of gold coins, open your own branch, and let us know how that goes for you. I know doctors retiring early because they're tired of the mickey mouse shit in the system, spending half their income for malpractice insurance annually forever, and spending most of the rest to hire twice as many people to keep up with the insurance policy paperwork b.s than the number of nurses and techs they hire to actually help treat patients.

Reltney McFee said...

Mr. Aesop: (golf clap).

I suspect that one of the reasons "Unknown" is "Unknown", is that s/he has given no thought whatsoever to the question of how it is that the Magic Ice Cream Machine, that is 21 st century American Health Care, functions. You, being in the trenches, have. And, with blistering eloquence, provided Mr./Ms. Unknown, the benefit of your ruminations.

Well done.

Anonymous said...

fuck yeah spot on....I went looking for primary care provider after Obama(BTW fuck you Obama)Care and one place said bring in a paystub!? I asked why, they said so they can figure out what to charge me?? I asked again why? they said the poor/unemployed can not pay as much as someone who is employed/middle/upper class. see how that works. I told them not in fancy term to go fuck off communist assholes.....

Anonymous said...

Of course, then there's the PA that lied to me about my medical care in order to get me to stay past midnight - so they could charge me (and my insurance company) an extra - unnecessary - day's charges.

Convinced me (threatened actually) I needed to stay over-night. No medical care during that time, no nurses, and checked me out first thing in the morning.

The game works on both sides.

Ex-ambulance driver and fire/rescue member.

Anonymous said...

I know I’d didn’t agree to the current scam. So where does that leave people like myself who know that the charges that hospitals put forth are criminal? One price for,the insured, another for uninsured? Why the F is it on people without insurance to make up the cost of theft, ineptitude, lack of infection controls and who,know what other excuses for ass raping the uninsured? no cost transparency is a huge driver of this rip off, along with insurers and people who aren’t paying the bill not caring about the cost. Sure, I don’t expect the er to know how much that injury from a car crash will cost, but they sure as hell know what a hip replacement, or live birth costs? Abortion docs seem to have figured out how much that immoral procedure costs.

Aesop said...

1) There's no rip-off. Every business gives discounts to certain patrons. Just because you're unaware of that reality doesn't make it evil.

2) No, they don't know what a hip replacement costs, because no two hips are identical, nor the patients they go into. You're asking for piece-work rates, for custom artisanal craftsmanship. You will not purchase the Sistine Chapel ceiling at paint-by-the-numbers prices. If you can pay, you can get something-for-something; you cannot have something for nothing.

3) Cost transparency is a myth, based on the ridiculous fiction that any two people are identical. They aren't. That people don't know that intuitively without being beaten over the head underlines how ignorant people are of basic realities.
The average nurse is getting essentially that same rate as phone sex operators on a per-minute basis.
The doctor is getting approximately triple that, for about three times the education the nurse has.
Then you owe pro-rated costs of the building, including utilities, maintenance, upkeep, sanitation, supplies, etc.

If hospitals billed like hotels did, your per-visit bill would triple.

Yet no one claims hotels are a racket.

4) The only part of payment that works is plastic surgery, which in nearly all instances is paid for with cash, on a cost per operation basis, and almost never by insurance. That's the model you're groping for: capitalism, versus, cost-shifting.

5) Repeal EMTALA, and tell the uninsured they're fucked and on their own, then get back to me. Either you likes you some socialism, or you don't. What you cannot do, is have it both ways, depending on your mood.

6) And give up the right to sue if you don't like the outcome. Your right to sue should be the same as it is in Vegas: nil, other than for actual malicious behavior, or gross negligence. And even then, limited solely to actual demonstrable damages, not recompense as if a favorable verdict were a powerball lotto win. Then doctor's could use their best medical judgment, instead of gold-plating every visit for CYA reasons, lest they be accused of short-changing your care and getting reamed for it by some shyster. (Which reason, btw, should require hospitals to charge a 4000% mark-up to all attorneys, on principle. Sauce for the gander.)

Bottom line, health care is a commodity.
If you don't want it, don't go.

But you can't come in, then bitch about the prices.
And the analogy ends there, because the reason you don't get a menu with prices up front, is because unlike a restaurant diner, you are the last person who knows what you want to order, and in most cases, neither are you paying the bill.

So in the analogy, a patient is most like a child getting fed off daddy's wallet, and then bitching about the cost of the meal.

It's quite frankly none of your concern, unless you're that rare person who pays out-of-pocket.

When you have to pay it all, every time, you get a say. Because then and only then are you an adult.

And dine-and-dash is a crime, not a bill collection.
When the police come to the hospital to arrest people for not paying their hospital bill, as they should, and as they do with deadbeat restaurant patrons, then you can whinge.

If that upsets you, I apologize. The truth stings.