One way universal coverage can save costs


Category : Medical Rants

Who Needs to Be in the Hospital?

An ER physician justifies an admission for expediency. This patient needed an outpatient evaluation, but our dysfunctional health care “system” make him consider inpatient evaluation the best option.

So this patient spent 3 days in the hospital, at an outrageous cost, to obtain the evaluation. Of course the ER physician justifies the admission.

But this story really tells us why universal coverage can make a difference. We need more primary care to allow proper outpatient care and evaluation. In a coordinated system, we could decrease hospitalizations and therefore costs.

Comments (9)

What doctor did here is good and bad at the same time…he broke the rule and which should not be allowed but then the rules are not useful and hence he was justified in breaking.

We need to provide preventive or wellnesscare fro free.


Universal coverage will not solve the problem identified in this article. What this piece identifies is the lack of adequate integrated health care systems designed to efficiently manage patients with complex medical problems who are not sick enough to require acute hospital care. Even with universal coverage, coordinating the appointments for outpatient consultations and tests at multiple different locations would prove to be a time-consuming nightmare which would probably be completely uncompensated. The hospital has always been traditional medical hub where this can be accomplished. However, we cannot afford to continue to use the hospital for this. We need more than universal coverage. We need a complete re-organization of the health care delivery system.

The simplest way to integrate everyone into the health care system is to give everyone the same card and access to the same care.

We believe in systemic disintegration and then compensatory integration with such entities as the Mayo Clinic. The Mayo Clinic is a great institution but it is not a system for everyone. It cannot move into North Dakota or into the remote areas of Minnesota.

Integration can take many forms.

I think that to somehow try to replicate the Mayo model across the country strikes me as totally naive or disingenuous. We are holding our uninsured hostage.

Giving everyone the same card is an excellent first step in integrating everyone.

Bohdan A. Oryshkevich

[…] by GruntDoc on August 1st, 2009 One way universal coverage can save costs | DB’s Medical Rants An ER physician justifies an admission for expediency. This patient needed an outpatient […]

I had a patient go to the Mayo clinic, after exhausting specialists locally. In 10 days she was charged $45,000 for tests that showed nothing new from what I and the local specialists had found. Her copay, as it was a new year, was a $5,000 deductible, which caused her to file bankruptcy. I received about 20 pages of single space notes from more of the same specialists without any new findings.

I would not want to be an ER doctor. Most patients in their 40s-60s with CP are automatically admitted, as a missed MI is an automatic lawsuit. If I want to admit a 40 something year old female or male patient from the office, I have to jump through hoops with the insurance companies and beg for office admissions for chest pain, as most chest pain workups are felt to be outpatient by the insurance companies. Once the patient is admitted through the ER for CP and has the EKG/Enzyme/stress test rule out, the patient goes home with a multi thousand dollar bill.
Patients with most abnormal labs are admitted for the fast workup in the ER. Strangely patients with UTIs or pneumonia are admitted without first trying outpatient oral antibiotics, which is what I do for my office patients.
Most ER patients with chest pain under 40 get a CT of the chest, making sure there is no PE. Most ER patients with abdominal pain get a CT of the abdomen and pelvis. Thousands of dollars per patient are spent doing defensive medicine. The young ER patients in their 20s-30s with back pain are told normal back xrays but to follow up with the assigned primary care doctor for an MRI, whereas most office outpatients would receive NSAIDS, maybe a muscle relaxant, and be told to do home exercises/stretching/ice/heat for back pain.
The ER is a loss leader for most hospitals, as the money is made by the hospital through insured and Medicare patients who need surgical procedures or admissions. The self paying patients drain the ER but cannot get into private offices, as the self pays end up not paying their bills and costing the system more lost resources.
As a side note, my state has a $2 copay for Medicaid patients, but the patients have no copay if they use the ER for sore throats, colds, sinus infections, UTIs, etc. This is more wasted resources. I have even heard ER doctors mention that the Medicaid patients try to get school physicals done at ER visits.
Unless the new public plan has stopgap mechanism to prevent patients from overutilizing the ERs and specialists, the new plan will not save the system any money.

I agree that this is not a recommendatin for a public plan!

The time inbetween knowing you have a problem and getting diagnosed with cancer/treatment plan set up is what people usually consider the worst part of the whole process! The waiting involved is enough to test even the most serene.

Even people with regular insurance don’t have doctors and offices falling all over themselves to take care of them. People get shuffled around, beg for appointments in crowded schedules and find that their plan doesn’t offer the same choices that other people have.

That woman wasn’t going to die tomorrow if she wasn’t admitted.

[…] one corner, the respected internist, Robert Centor (yes, of the Centor strep criteria fame) complaining about Dr. Pines admitting an uninsured woman for a cancer workup. GruntDoc, another EP blogger, fires back across the bow that Dr. Centor hates EPs, and Dr. Centor […]

You’ve made a fundamental error here, assuming that once a universal plan works its “magic” on the doctors who don’t retire early that there will be both budget left to do the workup on the public dime and the overworked, underpaid physicians left will have enough caring left to actually do the work right. Neither is likely to be true in a mature universal system.

There are a lot of places to rob peter to pay paul and goose the results in one measured area or another but the downward spiral of care is continual in all universal government systems to date. This is observable fact. Wrecking the foundations of a salvageable US system is no solution.

Did you consider that the reason this woman had no medical home (and thus needed admission to draft the hospital team into the role) was because the government did not have the money to pay enough so there was a Medicaid accepting doctor that would take her as a patient? What makes you think that a universal system would magically create more wealth so that such a patient would have a medical home?

You all may be talented doctors and one of you may indeed save my life someday with your diagnostic and treatment skills. Your economic analysis skills are much less impressive, dangerously so.

A Skeptic and TM Lutas have a point. I’ve not been impressed with DB’s critique of our medical system beyond the obvious statements that cognitive specialties are undervalued compared with interventional/procedural specialties. Much of his critique falls short because he sees things like he wants to see them. His critique of the ER admission is precisely that—this patient gets admitted unnecessarily (according to him), and universal coverage would have helped. That does not follow– this patient was not uncovered (she had Medicaid), but the ER doc’s concern was that she’d fall through the cracks. Universal coverage, meaning that everyone gets medical coverage, would not have solved that problem unless all physicians were forced to accept this “universal coverage” and of course if there were enough physicians to do what needed to get done (think of Massachusetts and its mandate). Do you envision universal coverage to mean universal access with all physicians forced to accept universal government insurance? In other words, we all have the same insurance? If so, this is radical. Perhaps you believe in that, which is fine, but I doubt it from reading your blog.
One other point—you are a strong proponent of individualized medicine—take care of the patient, not the disease. The ER doc justified the admission based on the assessment that the patient would not be able to navigate the system. He was taking care of the patient. Is this not, in essence, individualized medicine? Don’t the “bean counters” win if she is not admitted? Isn’t your critique of internists who keep patients in too long, a critique of their practice style, which is individualized medicine? It is very easy in medicine to think you’re the smartest guy in the room, and your thoughts reflect seem to reflect that. That’s fine, I’m just not sure that leads anyone towards anything better. (As an aside, if you want to be a good blogger, study Andrew Sullivan, a political blogger and writer. He actually uses his blog and the comments from his readers to refine his thoughts and writings. He doesn’t like preaching to the choir, but values conflicting well formulated responses, and is quite respectful. You would not find calling others “bean counters”)
Although I continue to read your blog, it is not necessarily for your thoughts on issues. Your guests and stories you point to tend to bring up points about medical economics that help me think about things. If your blog serves to help you flush out things, that’s fine, but you’re critiques tend to miss the mark. What concerns me (and should concern others) and why I am writing this is that you’re an ACP regent, which makes policy for the ACP, and which has put itself in the debate. I think many would expect a higher level of critique from you.

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