I would argue that ER in the US has long ceased to be useful, unless the patient is wheeled in by police/paramedics. Last week my daughter fell and cut her forehead in a way that required stitches. We went to the nearest children's hospital (a huge one) ER, got triaged (just some gauze) and waited for a doctor. Gave up at the 4 hour mark and walked out. Went to the nearest urgent care clinic, was seen by a doctor in 10 minutes and we're out in 30 minutes after my daughter got the stitches. I am sure we will get billed an astronomical amount for this, but there were no other options. We have good insurance.
Urgent care doesn't have everything a hospital/ER has. One example is checking for blood clots/markers of a heart attack. I was worried once and went to Urgent Care (trying to save money, my last two ER visits for this exact same check, which was basically me sitting in ER for two blood draws and an X-Ray over 3 hours, which turned out to be nothing, was $1300+ each), and Urgent Care said they could do an EKG but for the rest I'd have to go to ER.
> I would argue that ER in the US has long ceased to be useful, unless the patient is wheeled in by police/paramedics.
Well, in some cases (it varies by time and particular ER) they are less-than-useful for things that don’t urgently require stabilization because they are loaded with cases that do require such stabilization, that's what triage is about. And, yes, lots of them are overloaded.
> I am sure we will get billed an astronomical amount for this, but there were no other options. We have good insurance.
If it is possible you will be billed an astronomical amount, you have “good” insurance, if at all, only in the sense of preserving a somewhat greater degree largely meaningless choice of providers for which you will be partially reimbursed.
Good insurance that has bounded, low out of pocket expense for both urgent care and emergency room visits exists.
Amazing. I agree that the ER was not necessary for your daughter, but am impressed you can extrapolate that one experience to the entire set of patients with heart failure, pneumonia, sepsis, pyelonephritis, appendicitis, intestinal obstruction, gastrointestinal bleeds, electrolyte disorders, fractures, NSTEMIs, and many others who are not wheeled in by police / paramedics but need urgent complex diagnostics and imaging. What deep understanding and wisdom you hold, and with such high confidence too.
What do you mean? We're hackers. We're masters of the universe. We run the economy and solve problems. Of course something as trivial as health care can't be too hard. After all, they don't even Kaggle.
</snark>
Amazing what people can read from a comment. Notice that I said ER has long ceased to be useful and not that ERs are useless. May be the subtlety in the difference is only in my state of mind as I wrote the comment. But, what I meant to say was that for a vast number of genuine ER cases that come in, even with triage prioritization, the care is delivered later than it should because of the number of non emergency cases clogging up the system. Most people I saw in the ER the other day had non acute symptoms, (while I cannot really say anything without knowing their medical history, the fact that most people were munching on takeouts or vending machine food and seemed to have been there for hours tells me the symptoms are probably not acute. Their circumstances may be such that ER is the only place they can go to, but that is a different problem.
He described that he was able to go to urgent care for his daughter for a quick fix and the ER was not necessary for them (and the urgent care doctor who saw them must have agreed or they would have been sent back to the ER). What conclusion should I have come to?
People go to the ER because they don't want to fuck around with situations that they know they are insufficiently trained to diagnose. When your child is bleeding out of their face why in the world would you roll the dice at the local strip mall urgent care when there is a giant children's hospital nearby? Why didn't the ER send a nurse out to triage this after 2 hours of waiting to say they could get sufficient help elsewhere?
My experience with ERs over the past 20 years largely mirrors that of GPs. Then when we started going urgent care out of frustration we ultimately got inferior care for my wife that delayed a cancer diagnosis by 3-4 months.
A few hospitals now have urgent care and ERs right next to each other, with a triage nurse in front saying which area to go to. That seems like a good system. I obviously agree with you that people can’t be expected to perfectly discriminate which they should go to.
The root of my comment was to defend the availability of ER services against someone who literally suggested that ERs were not needed for anyone who didn’t arrive by ambulance or by police, not to argue the specifics of his child’s case for which neither one of us have any real knowledge.
I am sorry about your wife’s experience. It contributes to making healthcare discussions so challenging, because there are incredibly emotional, stressful, and unfair situations in each direction (people who got billed tens of thousands on one side; people who were not diagnosed on the other) — including in countries with socialized medicine.
I would suggest that your wife would have been best served not by an ER doctor, but by a highly trained and thoughtful primary care physician who could have followed her and understood what she’s going through longitudinally. Sadly, we burden medical students with $200K in debt and then ask them to choose between a high-paying good-lifestyle specialty or a low-paying poor-lifestyle specialty.
And then one layer down, the primary issue is it’s hard to pay PCPs more when 99.5% of their visits are for common colds, medication renewals, knee pain, etc. and 0.5% of their visits make huge impacts (e.g. diagnosis of cancer early). Just like trying to discriminate urgent care vs. ER, how does one know which patients to send to an NP who can take care of routine issues, and which to send to a PCP with a better understanding of complex issues including management of multiple specialists’ recommendations.
Urgent care won't take anything outside of a minor scrape
or cut. Daughter woke up with a 107 fever and was denied at a urgent care and forced to an ER. ER just gave her both Tylenol and Ibuprofin and sent us home after her fever came down.
Urgent care did a great job when I had kidney stones. They took blood work and an x-ray, made a diagnosis, gave me a shot that took care of the problem, and all of it in an hour.
A friend had a case of a bad virus and the urgent care did a great job with her too.
I'm sure it varies from place to place and need to need, and few of us have the training to tell which. But at least some urgent care centers can do really good work for a lot more than cuts.
In your case the urgent care center did the right thing. A fever of 107 could be a lot of incredibly dangerous things, some of which require surgery, and ASAP. I'm glad your daughter required nothing more, but it was absolutely a situation where the urgent care center was not sufficient.
You and I can't be expected to know that, and it would be great if we lived with a system that didn't draw such sharp lines in order to reduce cost. The urgent and emergency places should be part of the same system and co-located as much as possible. But that requires a complete rebuild of our system from the ground up.
"There isn’t good evidence that people overuse the ER"
Have any of the people quoted been in an ER? Even accepting the premise that hospital prices are outrageous for ER visits, walk into any hospital and it should be clear that a lot of the patient population is not there for an "emergency". In the US, the ER acts as a catch all for what often should be handled by social services (some of which don't exist). Drug seeking patients, homeless patients, and patients with mental health issues very often end up in the ER.
> Drug seeking patients, homeless patients, and patients with mental health issues very often end up in the ER.
A lot of these people end up in the ER because they don’t have any health insurance at all. But that’s well outside the scope of the “issue” the health insurance company describes in the article. I have had friends and family who had to be dragged to the ER because they didn’t think their situation was enough of an “emergency” but it absolutely was: chest pains were a heart attack in progress and a fever with a stiff neck was a pretty serious infection, for example.
How many legitimate emergencies vs “non-emergencies” will be discouraged from receiving ER treatment? I suspect legitimate emergency treatment foregone will be larger (and represent a significantly larger cost savings to the health plan) at the expense of our collective long-term health and well-being.
Indeed, I think the whole "ER overuse" thing is a smoke screen. Yes an ER has certain facilities that are needed for truly critical situations. Been there. But if someone walks in with a stubbed toe, that person is questioned at the front desk, and is directed to a waiting room and an experience that is pretty much just like regular urgent care.
Simple non-technical solution: Build a regular urgent care facility next to the ER and shunt the non-emergency people to it.
Was doing dinner with the owner of the company I work for, some of his family stopped by to join us. They said we don’t need universal health care for everybody, because the homeless people can just use the ER
aside from the homeless, what about all the people making minimum wage who neither qualify for medicaid, nor work enough to get employer supplied insurance?
sometimes the head in the sand attitude here is fucking sickening
Not by much, and frankly they will get lifesaving treatment regardless whether or not they pay the bill. What is the negative for not paying? Destroying the credit of someone who has effectively no credit anyway? Empty threat.
People making a minimum wage or who are minimally employed can qualify for lower cost affordable healthcare insurance through the ACA. It’s available, whether people take advantage is up to them. I know someone who pays less for their ACA plan than they do for their mobile and Internet services.
Where the ACA fails is more at the middle class family level. That is where the income vs. family plan costs tend to be out of balance.
yes! I'd probably argue that a majority (or at least significant plurality) of acute care (hospital care) in the US is the direct result of the failure of social services. I include in this mental health issues directly resulting in poor health, inability to access primary care (so minor/treatable issues become severe), housing issues, drug issues, lack of elder care options, etc.
Or get fucking GERD/other minor issues that masquerade as heart attacks (tight chest, numb left arm, heart racing, lightheaded), wonder if you should go, really don't want to pay yet another $1000+ to find out it's nothing again, hear the "better be safe than sorry" voice in your head that doctors keep telling you, and then maybe go versus waiting it out.
I swear I won't really know when I've actually had a heart attack because I've been faked out too many times by GERD reactions.
I've gone about 6 times to ER for it over the past five years, and probably stayed home another ~20 times. Each time I decided to go it's been nothing.
I've driven myself to the ER each time, though, even if maybe I shouldn't, so that saved a little money. Helps that a hospital is only 5 minutes away.
I am finally getting an endoscopy soon, maybe it'll discover something treatable.
I can't help think that also ties up to some mental health issues. Anecdotal, but I know a hypochondriac, a bad one, and I think a lot of her issues stem from anxiety of leaving her daughter behind if she dies or of losing her daughter (she's raised her kid to be one too). It became really clear this past year when taking to her how she thought every little thing she had waa Covid, even when it never matched the symptoms, and was always worried about how it'd affect her daughter.
She's also very much an overprotective parent in a lot of other ways, and I can't help but think the hypochondriac part stems from that.
Could someone with more knowledge explain to me "urgent care" and if there could be a case made to expand it?
I got injured (not too bad) and went to urgent care - my wait time was about 10 minutes. It costs me nothing, seems like a good system that would catch a lot of these borderline ER cases we hear about.
In my case, my insurer runs the hospital so it seems like they have an incentive to keep costs reasonable. But maybe, if you're a hospital and you are running numbers on adding ER or Urgent Care you default more to ER since you know you can just bill the insurance 10% over cost (or whatever) no matter what.
And this, my ladies and gentlemen, is why healthcare shouldn’t be “insured” but a fundamental human right catered for by an essential public utility (universal healthcare).
Routine healthcare shouldn't be insured, but dealing with unforeseen health problems should. There's no level of coverage that could possibly considered complete so it should be up to the individual to decide how much resources to dedicate to it.
The problem with this approach in the US is:
1) Until very recently there was no law requiting even estimated costs for medicine. Since the insurance company always pays for this there was just about no market pressure to lower costs (in other words: we took a "free market" approach without actually having a market.)
2) Insurance is used to cover routine medical procedures. This is the polar opposite of what insurance should be used for.
3) The US has a fairly week social safety net. Most other countries have fairly extensive social programs but in the US people are supposed go ... somewhere. This is probably the case that you're most upset about.
1) Until very recently there was no law requiting even estimated costs for medicine
This is the wrong way to frame it. At the most basic level, forming a contract requires agreeing on consideration. For some reason, medical providers are allowed to create arbitrary post-facto charges and then enforce their baseless fantasies through the legal system, likely due to corrupt state laws. For any meaningful market-based healthcare reform, this and other regulatory capture needs to be addressed.
Yeah I had a similar experience with a secondary infection 11 days after a lion fish sting. I went to my primary care DR as a “sick visit”. After evaluation he said to go to the ER. Since I needed treatment sooner than a schedule procedure could be scheduled, the only option was ER even though I could have waited a day or two. It seems like something between the two would be valuable.
At least I had an uncommon condition so nearly every dr and resident on duty came by to check it out. I didn’t get forgotten in the crowd and had some nice chats while waiting for a slot in the imaging schedule.
The US has urgent care for situations that need attention, but are not hospital worthy.
Edit: Infections can be really serious, but “I found a tick in a spot where I couldn’t safely remove it by myself.” and sprained ankles etc don’t need to go to the ER.
Some patients are too complex, in terms of pre-existing health conditions, to go to urgent care.
I am American (living abroad) and I have 2 rare immune-mediated neurological diseases affecting my peripheral nervous system, plus type 1 diabetes (autoimmune and insulin-dependent). My doctors in America told me to never go to urgent care for my health issues in the US.
Even ear infections can be complex. One time I had blisters on my eardrums (bullous myringitis) which is considered to be excruciatingly painful. After 3 out of 5 nights being sleepless due to pain, I wish I had went to the ER instead of waiting to finally see an ENT--after going to an urgent care (where I received improper treatment).
ProTip: With respect to cleaning your ears, don't use Q-Tips, ever. Get a digital otoscope (technically an ear endoscope) instead. It is the best piece of technology that I purchased on Amazon, that I thought would be junk. It allows me to thoroughly clean and inspect my ears daily.
> With respect to cleaning your ears, don't use Q-Tips, ever. Get a digital otoscope
There is absolutely no need to clean your ears ever. Ears are self cleaning. That's why they produce wax and they only do it in the outer section of the ear canal where that can't impact hearing.
Just don't mess with your ears and everything will be fine.
This is wrong (not that ears are self-cleaning, but that you never have to clean your ears yourself), or else ENTs wouldn't pick earwax out of ears and doctors wouldn't do ear flushes.
Like me, I have Tinnitus in my ears, and when the earwax builds up it gets 2-3x worse. I was starting to get real distressed about it, then went to an ENT, and he picked out a bunch of ear wax, and now the Tinnitus is manageable again. Still there, but quieter and easier to ignore.
I agree (and have been told by doctors) you should never use Q-Tips, though. That often does more harm than good (pushes ear wax further into your ear).
But there are other things, like Debrox, that can help you remove earwax without sticking Q-tips in your ears.
Yes, but urgent care would not have been able to address the issue described here. In general urgent care is only qualified to address simple, common illnesses and conditions.
The way US healthcare is structured these days, I think increased costs mean more profits for the insurers - it's their customers as a whole that get screwed.
Around 2010, I separated my shoulder and couldn't move my arm. I went to the er and got checked out.
A few days later the insurance company called and said they didn't want to pay for the visit because "it wasn't an emergency". I very calmly explained that their position was nonsense, and I went to the ER because I COULDN'T MOVE MY ARM. Eventually the insurance agreed the ER was justified.
According to this article, it sounds like this would be a new behavior for insurance companies. But it seems to me like they are just making this behavior official now.
Not mentioned is that they’ve been doing this forever. Private insurers exist to deny reimbursement, the so-called “administration” could be handled by a SAAS billing package.
It's hard to say the ER is overused because most of us are not medically qualified to decide what constitutes an emergency. A heart attack, an infected gallbladder, and heavy duty heartburn present similarly enough that the suffering patient can't be expected to walk himself down a diagnostic flowchart. But if we could get proper diagnostics and triage in before admissuions and a lot of other resource allocation, it might improve results.
I could see adding the a bank of triage experts "in front" of the ER. The ambulance, of course, skips this phase, but if you come in conscious and able to walk in, they can perform some basic checks before admission, and turn away some patients as better served by urgent care. Maybe this costs some modest flat rate, billed sort of like a repairman who doesn't charge for the trip and diagnosis if you get actual repairs performed.
I suppose then you get into a related matter-- once you're at the hospital, being told to go somewhere else means "get back in the car and travel to the strip mall urgent care elsewhere" which would lead to frustration and delay.
Of course that's not true. I mean, the Netherlands and Switzerland have private insurance for healthcare. Are you saying they have no incentive to maintain their health?!?
The Netherlands subsidizes about 75% of healthcare costs using taxpayer money, and implements a system of price controls on private insurers while making coverage mandatory. This would certainly be called nationalized, universal healthcare by the standards of US politics.
Because the government stepped in and said “we are going to use the enormous power of the state to make sure every citizen in this country is covered”, whether that involves using private insurance but dictating how and when it can charge, or paying for service directly, or subsidizing costs and then allowing private insurance to administrate.
It doesn’t matter to me if you call it “nationalized insurance” or “universal healthcare” or “healthcare that is overwhelmingly funded and controlled by the state but leverages some private components in controlled ways” -— that’s just semantics. All that matters to me is that we don’t try to fool people into thinking that the Netherlands or Sweden have anything like the broken medieval mess we have here in the US, when obviously what they’ve done is radically different.
YOU are the only entity with the incentive to maintain your health. The government could care less. It's a giant unfeeling AI that follows rules and incentives laid down by politicians. The overriding concern when government gets involved is cost, not outcomes or quality of care.
This is mostly an U.S.A. point of view.
As an European, and now Canadian, of all the countries I lived in, the U.S.A. was the only one who did not think that the health, education, and opportunities of their citizens was good for the nation and more importantly the state.
Governments do have incentives to keep the population healthy, as seen by free covid vaccinations by a GOP administration. The dead don’t pay taxes.
The important bit is a lot of healthcare makes minimal difference. People have a huge bias around doing something even if it doesn’t help. Governments on the other hand care a lot more about the cost/benefit from healthcare thus vaccination is considered an obvious win but Medicare puts limits on physical therapy etc.
Paying taxes can only act as an incentive for governments to keep the population healthy if it costs them less than they'll get from that person in taxes - so if you're old, retired, or not able-bodied enough to work, well... (This kinda resembles how the NHS in the UK decides what treatments to fund if you squint, though that's not the official justification.) There's also a lot of pressure to fund treatments of dubious effectiveness for high-profile diseases like cancer which politicians tend to give into because they care about being re-elected, whilst unglamorous but quality-of-life affecting stuff like physical therapy gets deprioritized.
A coworker is a volunteer EMT. The majority of his calls involve going to various homeless encampments. Once there, they have to walk around and figure out who needs help. More often than not, it is a malingerer who is good at pretending. They cannot refuse transport to the emergency room. Once there, the malingerer gets free food and a respite from the heat/cold, which is what they wanted. After the trip, the crew has to delouse themselves and the ambulance, which takes a long time.
I'm not a fan of United Healthcare, and would never subject myself to their tender mercies, but why should they and other insurers end up holding the bag for colossal policy failures like the above?
Seems like a pretty good argument for building an alternative and less-expensive infrastructure for feeding the homeless, rather than yanking up the ladder for ER visits.
Yeah, I guarantee United Healthcare getting to deny paying for these is not going to stop the homeless person from making these calls. It's just going to stick the hospital with the bill, most likely.
And in fact, one of the major criticisms of this arrangement is that it provides an opportunity for private firms to rake in big profits based on fixed fees paid by taxpayers and reduced service offered by the administrating company. United Healthcare is extremely profitable in this area. https://www.macpac.gov/subtopic/managed-cares-effect-on-outc...
It’s incredibly disappointing the government has shown little interest in lowering the cost of healthcare. Instead, elected officials seem obsessed with talking about breaking up big tech and the associated political grandstanding.
That’s a weird framing. One party would introduce single-payer in a heartbeat, the other demonises it. Let’s not pretend we’re talking about “government” as a whole here, rather than the GOP
It’s a weird framing when the only way you propose to lower costs is through a revolutionary change which sees major political barriers to actually happening.
How about lowering costs anyway? I assure you, there are real and meaningful ways. Start by removing anticompetitive Certificate of Need laws, at the state level.
And for prescription drugs, tie the prices to what some other countries pay.
Some of the solutions are really easy but it’s hard to get done when some politicians are paid off, some want the system to fail so they can do single payer, and some are vehemently anti regulation.
Something more drastic would be making all health insurance plans be high deductible (as in, make it insurance again), and ensure that prices are up front and transparent. You’d see prices plummet relatively quickly.
Agreed. The development plans, break big tech, taxing, and other political stunts are useless if foundational issues around education and healthcare are not addressed.
Comments like this one are depressing. Many in government are passionate about lowering the price of healthcare. A number of politicians support some pretty dramatic proposals for solving the problem. The issue right now (to put things politely) is that the voting population does not agree on the solution, and our political system makes it very difficult to get anything done unless the voters are willing to express their preferences by voting for politicians that support one approach, giving them a super-majority and control of multiple branches. Last time that happened was 2008.
TL;DR: If you actually care about this issue, you shouldn’t be offering vague platitudes blaming it on “government”. You should advocate for your preferred solution and name the politicians/party you think we should vote for to get it passed. I know this is political and not loved on HN, but this is how the system works.
My girlfriend is a physician in the ER at the largest hospital in Philadelphia and her informed opinion is that very few of the cases she sees are truly “emergent”.
I would happily go to Urgent Care for more things (and have gone enough times, used to basically be my PCP back in the day), but there are certain things that if I go there they just say "We don't have the ability to do these tests, go to ER".
So now I paid an extra $100-150 just to be told to go to ER anyway. I don't go to Urgent Care for those things anymore (heart attack scares that end up being heartburn with heart attack symptoms, for example).
There's also the issue that most Urgent Cares around here aren't 24/7, so if it happens late at night (like after 9pm), ER is all you got.
I agree, but the problem is the decision as to the level of care necessary is ultimately up to the person needing care. Normal people have no idea what their ailment is, much less what level of care they need.
I try to steer clear of the ER at all times. If I'm not functioning enough to be able to make that decision, it's probably time for the ER. Just a personal philosophy.
I had a girlfriend years ago who made me take her to the ER because her stomach really hurt. We waited for 8 hours and by the time she got seen, her stomach didn't hurt. I could have strangled her.
I'm just building CRUD software and I don't scoff at the kinda stuff people report as bugs, particularly non-technical users. But working in an ER and judging people for being unable to judge the severity of their ailments? That borders on sociopath lack of empathy.
