How stupid! Why didn’t I just phone my internist or the person taking calls for him? When I didn’t do that and went to the ER instead, why didn’t I just answer the first physician, ‘No, that’s not necessary,’ when she suggested referring me to a couple of specialists?
In most settings, the doctor has far greater incentive than disincentive to order excessive services — that is, those that aren’t indicated by practice guidelines or evidence-based medicine. – Jack Coulehan in Health Affairs, reprinted in the WaPo
This reminds me of my own ER story.
I travel a lot for work. A few years ago, during a convention in Denver, I began feeling a little ill. I called off the evening plans and went to bed early. The next morning, I had incredible nausea which ended with projectile vomiting — think “Ren & Stimpy.” It was actually kind of funny, in the few clear-headed moments I had. All throughout the day, I attempted the usual things (principally ginger ale) but couldn’t keep anything down at all. By the end of the day, I was beyond lightheaded — I’d now gone 20 hours without fluids, my abdomen was sore from all the retching, and in the most recent episode (at a bagel shop) I’d noticed flecks of blood amidst the soup. I needed fluids, and fast. I somehow managed to pack up what I was doing and told a cab driver to take me to the nearest hospital.
That hospital turned out to be Denver Health, the recently privatized county general hospital — but still the city’s primary safety-net provider. (Where I was on 17th was actually a bit closer to St. Joseph’s or St. Luke’s, it turns out, but the drive down Speer is faster.) I walked into the ER and waited as the triage nurse saw patients. He was doing an admirable job: although his Spanish was no better than mine, he maintained his composure far better than I would’ve in the face of a parade of misery that included gunshots and gangrene among other ailments. Quite a lot of them looked to be in much worse shape than I, but when I was called up I pretty quickly gained admittance to the ER. I suspect that I might have been turned away had I been just another one of the uninsured out there.
Once in, I did get an I.V. drip for fluids and a couple pills of a strong antiemetic; after a brief nap, I felt okay. Yet the attending physician, not seeing any obvious cause for this, said that perhaps the abdominal pain was from appendicitis (when no, it was just sore after spending a day violently vomiting) and that a CT scan might be in order. Even at that moment, I highly doubted it, but ended up playing along. Soon after the CT scan, I was discharged and told to follow up back at home in a week. Several weeks later, I get some confusing statements from my insurance which clearly say “do not pay” — and soon thereafter, a notice from a collection agency, even before I was instructed to pay anything. Since I was out of state, the reimbursement rate was lower than it would have been at home, and that pointless little trip through the CT cost me $1,000.
Contrast this with my most in-depth experience with a single-payer system of sorts: Kaiser Permanente. A month before I left for college, my brother and I went mountain biking on some trails near home and I endo’d on a downhill — braked too suddenly up front, flipping myself over the handlebars, and breaking my right collarbone upon landing. (This is a common injury among cyclists, since the clavicle is a pretty wimpy bone.) I didn’t know it at the time; all I knew was that I couldn’t really move my right arm, and therefore couldn’t bike out of the park. We walked our bikes along a few miles of equestrian trails — the most direct, if muddy, way back out. It just happened that the Kaiser medical center was not far from the park entrance, so we stumbled in — bloody and smelling of horse shit — scanned the little ID cards that brought up our records, and waited a little while. I got called from the waiting room, got a bit of cleaning up and an X-ray, and got a bit of joking from the staff as they pointed to the fracture. There’s not much one can do about a clavicle, anyhow, but what was equally notable was how there weren’t huge bills afterwards. Our premiums (and co-pays) covered basic services like, well, X-rays for broken bones.