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_Howard
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_Howard


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PostSubject: Don't get bitten   Don't get bitten EmptyFri Jul 17, 2015 4:45 pm

...by a rattlesnake.

Don't get bitten Snake%20bite_zpsu2nbsqk5
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NoCoPilot

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PostSubject: Re: Don't get bitten   Don't get bitten EmptyFri Jul 17, 2015 6:06 pm

Fuuuuck me. Who was bitten?
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richard09

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PostSubject: Re: Don't get bitten   Don't get bitten EmptyFri Jul 17, 2015 9:27 pm

What he said.
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_Howard
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PostSubject: Re: Don't get bitten   Don't get bitten EmptySat Jul 18, 2015 9:12 am

I found it on the internet. It seems about right.
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NoCoPilot

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PostSubject: Re: Don't get bitten   Don't get bitten EmptySat Jul 18, 2015 9:14 am

Penknife. Suck. Done.
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_Howard
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PostSubject: Re: Don't get bitten   Don't get bitten EmptySat Jul 18, 2015 9:23 am

Correction: Penknife. Suck. Dead.
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Jenni
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PostSubject: Re: Don't get bitten   Don't get bitten EmptySun Jul 19, 2015 8:26 pm

Doesn't that just make you embarrassed as an American?
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NoCoPilot

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PostSubject: Re: Don't get bitten   Don't get bitten EmptySun Jul 19, 2015 10:10 pm

Depends. Am I an ER doctor?
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_Howard
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PostSubject: Re: Don't get bitten   Don't get bitten EmptyMon Jul 20, 2015 8:28 am

How much of that do you think an ER doctor gets? Maybe a hundred bucks.
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NoCoPilot

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PostSubject: Re: Don't get bitten   Don't get bitten EmptyMon Jul 20, 2015 8:40 am

Maybe more.

This person apparently had no insurance -- which is dumb after the ACA -- and apparently doesn't know how to say 'no' -- radiology? For a snakebite?
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_Howard
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PostSubject: Re: Don't get bitten   Don't get bitten EmptyMon Jul 20, 2015 9:22 am

You're just chock full of assumptions today. Maybe he didn't have insurance, but it doesn't make him stupid if he doesn't qualify for anything or he just doesn't have the money for it. There are many reasons why someone wouldn't have medical insurance - being "dumb" is only one of them.

As to radiology - an x-ray seems perfectly reasonable in this case. If I had a rattlesnake bite, I wouldn't say "No" to any damn thing the doctor suggested.

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PostSubject: Re: Don't get bitten   Don't get bitten EmptyMon Jul 20, 2015 9:36 am

Do you often see broken bones from a snakebite, in your experience?
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_Howard
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PostSubject: Re: Don't get bitten   Don't get bitten EmptyMon Jul 20, 2015 9:42 am

Radiology is for more than broken bones.
CT scans and MRI would be also listed under radiology.
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NoCoPilot

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PostSubject: Re: Don't get bitten   Don't get bitten EmptyMon Jul 20, 2015 9:49 am

_Howard wrote:
I wouldn't say "No" to any damn thing the doctor suggested.
I think that's an irresponsible stance. I certainly do say no to "fishing expeditions" which doctors often perform (especially when patients are under stress) to increase their profits. For-profit hospitals (which most are these days) are famous for inflating their bills with unnecessary procedures.

And if I was uninsured, I *CERTAINLY* wouldn't give carte blanche to any hospital.
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_Howard
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PostSubject: Re: Don't get bitten   Don't get bitten EmptyMon Jul 20, 2015 10:05 am

You left out a significant disclaimer when you quoted me: "If I had a rattlesnake bite", which doesn't include "fishing expeditions." I was addressing a specific situation and my comment shouldn't be generalized to include other situations.

When you enter the hospital with a good chance of dying or losing a limb, it is not the time to worry about your purse.
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PostSubject: Re: Don't get bitten   Don't get bitten EmptyMon Jul 20, 2015 12:02 pm

_Howard wrote:
I found it on the internet. It seems about right.
The doctor who responded to the original post makes some salient points.

Quote :
US physician here. I'm pretty late to the party so this will probably not be seen by many, but I feel obligated to post this, or something very similar, when these topics come up. This seemingly outrageous bill is an artifact of how healthcare is billed in the US. It's incredibly dumb, but here's why it's so ridiculous on its face. The OP will almost certainly pay much less than what's on the bill. Here are some things to keep in mind:

Part of the reason costs are so high in the US is because it's a coy little game (especially in the fee-for-service model). Providers bill far above their actual cost because they know that they'll be reimbursed pennies on the dollar (about $0.20 from Medicare, less from -caid, slightly more from private insurers). The provider, however, can't charge different rates to different payers, so even if they wanted to charge you cost + a bit more to, you know, "have an income," they can't because they'll be audited by the government. So, when you get a bill for 10k, without insurance they have to bill that much, but in reality they may get 2k. Additionally, most hospitals will send you the 10k bill, then take the 2k you pay and be happy with that, even if you're paying cash. But that detracts from the narrative of "greedy doctors and hospitals."

In the comments on these sorts of posts, populist appeals just find their way to the top of the discussions. Ever read the posts about how a bag of saline costs $0.44 to create so that's exactly what inpatients should be charged (who cares about sterilization, standardization, regulation, storage, provider oversight, IV access, etc). Somehow, the fact that administering tylenol costs $6 in the hospital is a reflection of the prescribing physician's greed and the insane margins that hospital administration can yield. Because, as we all know, everybody pays their bills and those costs are in no way related to high human resource costs, liability, regulation, and displaced reimbursement for services rendered below cost.

An enormous part of the "high cost" here is also the fact that anyone with coverage is subsidizing all people without coverage. Guess what happens when some gangbanger gets his tib/fib blown up? Ortho admits him and does the floor work/surgery/post-op for free. The radiologists read the studies, the nurses care for the patient, the lab uses reagents to run tests, etc. Plus the opportunity cost of a bed being used by someone who doesn't pay jack shit. Physicians and hospitals do a ton of what is essentially free work for a significant portion of the hospital population and you, insured responsible adult, are paying for the care of such individuals.

This is exactly the type of situation that things like the bronze level plan were designed for in "obamacare" - catastrophic medical emergencies. And let's be very clear here: this person likely would have died without ICU level care and (extremely expensive) antivenom. Even with a bronze plan (the coverage of which is total garbage, admittedly), the total out of pocket maximum for this care should be around $6500. While that's not cheap, I kinda think that's a bargain price for something that saves my life. If this person didn't have insurance... well, that seems like a really bad life decision. It's now legally required and subsidized for those who can't afford it.

edit: The replies to this comment are (seemingly) unending and range from "yeah this guy is correct" to implying that I'm a terrible person and bad physician who clearly only cares about making money.

The truth is nothing so cynical, I'm afraid. At least not for those of us "on the ground:" the nurses, technologists, physicians, ancillary staff, and everyone who's trying to do what's right for the patient. I've never once thought about the cost of something in the hospital - if a patient needs a procedure or test or whatever, they get what they need. I am also fully aware that the current US healthcare system sucks and is in dire need of overhaul. To answer many people's implicit questions, some of the largest drivers of cost in the United States are (1) insurance companies and (2) patient expectations. Let me address the former, then the latter.

Overhead on insurance runs something like 20%. Medicare's overhead used to be about 1-2% until they let private insurers sell "medicare advantage" plans, and the overhead on those is somewhere in the ballpark of 20%. Our highly complicated private insurance market is a driver of this, because it will always be in the insurance company's best interest to deny as many claims as possible. This is, of course, preposterous and bullshit like that should be illegal, but the health insurance companies have powerful lobbyists and we're stuck with this system (for the record, I'm of the personal opinion that health insurance companies should be operated exclusively for the benefit of the members, not for shareholder dividends). Anyway, this system results in even more overhead costs since hospitals and physician practice groups have to employ people just to submit bills for the care they provide.

Our system is absolute insanity and the insurance market should be heavily regulated the way it is in other countries. There are multiple different types of healthcare systems that are all still far better than how the US does it. Many of the best systems are run entirely through a (highly regulated) private insurance marketplace. It doesn't have to be a binary choice between our current system and single payer.

As to my second point - patients have unrealistic expectations at almost every level of the healthcare system. For instance: It should be both extremely good and extremely cheap. All of our diagnostic tests should be 100% sensitive and specific. All of our treatments should be 100% efficacious and have no side-effects. All procedures should carry no risk. Et cetera.

Those insanely high expectations are an enormous driver of cost - we do tons of unnecessary testing and find things we never needed to find all because patients expect it, and providers are terrified of being sued off their ass if they miss anything. There are substantial downsides in doing unnecessary tests. In addition to their direct cost, there's the issue of finding what we call "incidentalomas" - findings which would have never become clinically apparent or every affected the patient, but since now we have the data point of, say, 2mm lung nodule, that has to be worked up (for even more money). But when you have a patient come in and demand a scan, many doctors do it anyway because they're worried that the "patient satisfaction" score will be too low and they'll get dinged by the hospital and the insurance company. Healthcare is increasingly being treated like a consumer industry and it's costing us all more money because of it.

Lastly, we defer far too much to what medically ignorant (and I mean that in a non-pejorative way) families want for their very obviously terminally ill family member. We spend something in the neighborhood of 30% of a given Medicare beneficiary's total cost in the last year of life. The goal of care in people who are clearly dying and have less than 1 year of life expectancy should be palliation, comfort, and dignity - not in an ICU with 5 tubes and lines on a ventilator. We defer far too much to what the family wants rather than only offering what is appropriate. But if you say stuff like that, people accuse you of wanting "death panels" - which is especially ridiculous when you look at the way physicians die. It's overwhelmingly in their homes with appropriate hospice care and pain control, but without heroic interventions attempted.
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_Howard
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PostSubject: Re: Don't get bitten   Don't get bitten EmptyMon Jul 20, 2015 12:16 pm

Some true (and well known), some the typical attempt at rationalization. To paraphrase: It's the patients' fault that bills are so high. My God - they expect the doctors to find out what's wrong with them and treat it properly. How can patients be so demanding?

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