SHIFTING THE COST OF EMERGENCY ROOM CARE TO YOU

Medical 2014
by – Sheri de Grom

The telephone startled her. She didn’t recognize the number but today had to be the day she’d break her rule and answer. The official sounding voice was one she’d never heard before. Without preamble, he told her his name and confirmed hers. He also confirmed her relationship to a patient he had in the emergency room of the local medical center.

Before she could ask questions, the voice on the phone was gone. She had questions: what, how, when, why an ambulance. Thank God she’d already had her shower and hurried to find jeans, sweater, run a comb through her hair, grab her purse and she was gone. Gone to the emergency room. Sheer panic had set in and she moved into auto-pilot.

How could it be? He’d been his usual cheerful, energetic self as he’d left the house that morning.

When she arrived at the Emergency Room (ER) the staff explained that her husband had passed out at work and so far, there was no known reason why.

A clerk interrupted, “Do you have your insurance cards with you?” Payment is at the front of every hospital’s mission in today’s economy.

She was advised that the specialists were running tests and she could have a seat in the waiting room.

What would happen to her if she screamed, “No, the only thing I want is my healthy husband, the man I love.” That wouldn’t happen now and she settled into a hard plastic chair in defeat.

It seemed she’d waited hours but it’d actually been less than two. Two hours with her guts turning over and over and a hammer in her head that refused to stop. It banged her front temporal lobe a million times a minute. She was sure of it.

Finally, someone from the ER staff asked her to join them and said, “The doctor will speak with you now.”

Unfortunately, she learned nothing other than her husband passed out at work, numerous tests had been completed, and nothing conclusive explained the incident. He was now resting but the doctor thought he’d be more comfortable if her husband stayed a while longer to ensure his stability.

She nodded her head yes and signed more papers. She didn’t want to take chances and agreed to a new strategy in emergency care (although she wasn’t aware that’s what was happening).

This new movement in emergency care is shifting the cost of expensive emergency care rates away from hospitals, Medicare, Medicaid and all commercial insurance companies. Patients are classified as ‘short-stay emergency department inpatients.’

National data collected by researchers at the School of Medicine at Perelman in December 2013, suggested that keeping selected patients under observation in a dedicated hospital unit with defined protocols could yield hundreds of millions of dollars in cost savings for everyone but the patient. More often than not, the patient doesn’t understand the hidden cost of being transferred to observation status until a large charge appears on their statement.

The ‘kept for observation’ status has been a topic of controversy for Medicare patients for years, and in 2012 an investigation by the Department of Health and Human Services Inspector General found inconsistency between hospitals in how they determined whether a patient was admitted or kept under observation. For Medicare patients, such ‘observation stays’ are associated with higher out-of-pocket care costs and a lower likelihood that nursing home care will be covered.

Please be aware, any time you or a loved one is moved from a dedicated Emergency Room Department to an Observational Unit, there will likely be a reduced amount in what any insurance company is willing to pay.

This shift in cost for emergency care affects all patients. It is not exclusive to Medicare and Medicaid. I encourage you to read your health insurance policy carefully.

Any stay in a hospital beyond 24 hours is considered an admission to your insurance company but you may remain on observational status per the hospital. It is a catch-22 for the individual responsible for the account.

Many same-day surgeries result in observational status (i.e. the recovery room). However, if surgical complications or recovery from anesthesia occur, the surgery patient is placed in out-patient observation status.

Please be aware, any time you or a loved one are moved from the dedicated Emergency Room Department to an Observational Unit, your cost may be higher than expected.

          The entire financial burden could be yours.

 

 

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About Sheri de Grom

Retired Fed/JAG, 5 yrs. on Capitol Hill. Former book buyer for B and N. Concerned citizen of military drawdown. Currently involved in mental healthcare reform, health care strategist and actively pursuing legislative change wherein dual retirees are exempt from enrolling in Medicare at their own discretion without losing tertiary healthcare benefits. Monitor and comment on Federal Register proposed legislation involving Mental Health, Veterans Affairs, Health and Human Services, Medicare and rural libraries. Licensed OSHA Inspector to include Super Fund sites. Full time caregive to Vietnam era veteran. Conceptualized, investigated possible alternatives, authored, lobbied for, and successfully implemented Title X, Section 1095 (known as the Third Party Collection Program of Federal Insurance).
Aside | This entry was posted in Medical Care 2014, Medicare and tagged , , , , , , , , , , , . Bookmark the permalink.

70 Responses to SHIFTING THE COST OF EMERGENCY ROOM CARE TO YOU

  1. benzeknees says:

    This is an interesting look into the American Health Care system.

  2. jbw0123 says:

    Thanks for the heads up.

  3. Jane Sadek says:

    The real question is, “what options do you have?” Check the patient out of the hospital? I’ve been in enough hospitals to know that the usual options are do-what-we-say and go-home. When Mom or Dad would go in, I knew there was no way I could take them back to their house to be on their own and I didn’t feel competent enough to handle things. Hire nurses? That’s another money drain. I think the real answer is that there is no answer. You just have to bite the bullet.

    • Jane – Mega Medicine and the insurance companies including federal coverage (i.e. Medicare, Medicaid, etc.) are doing everything they can to put more of the health care cost onto the patient. Medicare specifically is looking for ways to cut cost and they are doing it by eliminating health care from the sickest patients. [Who said the death squad didn’t exist]. When you ask, what can you do? When the hospital holds the patient in observation, that’s the medical equivalent of ‘we can’t send the patient home or we would be medically responsible.’ It’s at this point that the advocate for the patient has to insist the patient be admitted. We have more medical beds available in hospitals than ever before due to Medicare paying hospitals less than ever before. Medicare doesn’t want to admit patients and all of the other insurance companies are following what Medicare does. Our medical care is eroding faster than we can keep up with it. It’s not going to change until concerned citizens ban together and demand that change.

  4. mihrank says:

    Reblogged this on mihran Kalaydjian and commented:

    SHIFTING THE COST OF EMERGENCY ROOM CARE TO YOU

  5. I hope you have been doing well, Sheri!

  6. 1EarthUnited says:

    Reblogged this on 1EarthUnited and commented:
    Very good information to be aware of, thank you Sheri! Yes hospitals started playing the financial shell game in this new reality. Patient care has become secondary, and doctors have dropped their hippocratic oath unless you have insurance. 😦

  7. huntmode says:

    Sheri, this may be duplicative. I wrote an earlier comment that isn’t showing. I wanted to thank you for this very important piece. John Flanagan beat me to it and said it better. I have reblogged. Well done, Sheri. Best ~ HuntMode

  8. huntmode says:

    Went to leave praise for your clarity, Sheri, but John Flanagan beat me to it. Reblogged this one!

  9. huntmode says:

    Reblogged this on Chasing Rabbit Holes and commented:
    This is a MUST read – Sheri de Grom covers the economics of Emergency Room care with sharp clarity.

  10. Patty B says:

    Our hospital just started this, thanks for the information on the cost. Can we refuse the care?

    • Patty – You may always refuse the care. As the patient, you have the right to refuse any care, any time. In this situation, you entered the emergency room for a true emergency. If the ER thought you were well enough to go home, they would dismiss you. If you are not well enough to go home, the hospital is legally obligated to verify your medical status with your insurance company and admit you as an inpatient. This new way of doing business is to save the hospital money by getting you out of the ER environment plus it saves your insurance company. However, because the care is coded differently, you the patient become responsible for the bill and that’s the wrong way to do business in our country. This is part of Obamacare and I for one will fight it until it goes away!

  11. atempleton says:

    Thanks so much for providing this information. I had no idea.

  12. This is good to know. I have to share with my lupus friends.

  13. FlaHam says:

    Sheri, This is extremely timely and very strong advice. Having spent more than my share of time in ER’s, and usually admitted, I know the impact. This is a great heads up to many unsuspecting folks. Thanks, Bill

    • Bill, It’s taking me a long time in responding and I do appreciate your stopping by. Once again, the administration behind medicine and insurance administrators have cooked up a way to abuse the very clients they are to serve. This could be turned around if everyone knew they had the right to refuse observation status. The reason for going to the ER is that you have an emergency that won’t wait for office hours and your regular doctor. Once the ER doc takes care of you he/she may dismiss you to home or admit you. If you are to sick to go home and they want to put you in observation status, then you are sick enough to be admitted and by law, you must be admitted. This is an ugly scam in what is supposed to be the land of the free!

  14. I just read a post about this same subject earlier today. The way Colleen put is (she’s in health care) how does an insurance company know better what you need than your doctor? Am I understanding this correctly? Isn’t the doctor doing what he or she feels is in your best interests and the insurance company is always worried about $$ ?

    • Tess – What we have in this situation is the insurance companies are in bed with the medical providers and administrators. It’s the doctor that makes the decision to send a patient to ‘Observation Status.’ Doctors are afraid they will no longer be a preferred provider by certain insurance companies (the ones that pay the most) if they don’t play along with the guidelines. A perfect example that hit far too close to home is the emergency heart surgery Tom had last month. As the surgeon who performed the surgery said, “Tom was a ticking bomb and it’s a wonder he’s lasted this long.” Going back in Tom’s records and studying labs and x-rays, Tom’s previous doctors (the four I fired in 2 days) knew for 4 1/2 years that Tom needed the surgery and his life was at risk. However, they didn’t perform a specific test on him because he didn’t complain of chest pains and ‘chest pains’ were the magic words for Medicare to approve the surgery. And, you know how I feel about Medicare. The new heart surgeon and cardiologist Tom has now told me they didn’t care about Obama’s socialized medicine. They were the doctors and they were going to take care of their patients. Think of all the patients not getting the surgery that Tom did or whatever other life threatening situation just because the patient doesn’t say the correct words. Obamacare has walked the United States into socialized medicine!

      • This is all so wrong but I like your husband’s feisty heart surgeon. Doctors should not be afraid to do their job. That’s not right. ❤

        • Tess – You are so right. Only the month before Tom’s heart surgery, I’d fired 2 other doctors on Tom’s medical team for it’s Tom’s body and not his bipolar disorder that’s causing his symptoms. We thought we were over all that and then along comes Medicare (which the government require we not only have but pay for at the same time). Tom would have had the procedure at a minimum of 3 years earlier if the doctors we trusted at that time were doing their job. Then, along came Tom turning age 65 and we entered the world of socialized medicine with Medicare. The insurance companies (all powerful with the way Obamacare has structured the rich getting richer) and medical administrators (not the doctors) are all in bed together and denying medical care where indeed it’s critical for the patient. Before Tom turned 65, our insurance would have paid the surgery at 100% and never questioned the procedure. This is a scam against those that are ill and I don’t see another way to look at it. So many loopholes are built into the 2000+ pages of Obamacare. Many of my peers said it made them fall asleep so I started underlying the outrageous aspects of the proposed law to them, and then they became as angry as I was.
          The good news is that Tom is on the path to recovery and we’ve had a few really good days together as a result of his new energy level. Thank you for listening to me rant. You are indeed a true friend.

          • I agree. This is outrageous and scary.

          • Why does life become so complicated when you are at your lowest, weakest or need the most care. It’s always about the money. 😦

            • Tess – Yes, you are so right. Everyone wants the money, the money, and more money. I clearly remember the days of patients entering the ER and never a question was asked unless it was about something to clarify the patients medical history, etc. I’ve been hearing more personal horror stories than I thought possible. It’s past time to start a campaign. We have a presidential election coming up and the candidates need to be forced to account for the issues every citizen is being faced with on a daily basis. Bottom line, our recession is not over and every individual is being squeezed from all sides.

              • Indeed. Squeezed and squeezed ever more.
                In Canada you go to the hospital and it is heaven. My mother had been in and out of hospitals most of her life with this or that. You get looked at, fill out forms, get a bed and get taken care or but I am afraid the beginning of private care has started here.

  15. Very insightful….that explains a bill our middle daughter just got from an emergency room visit in May. Thanks for the information.

    • Kirt – Your daughter has the right to ask the hospital for an itemized statement. That way she will know for sure if she went into ‘Observation Status’ or not. Each patient and/or caregiver is supposed to understand they are going in to observation status from the ER. The bottom line, if you are sick enough to go into observation instead of going home, then you are sick enough to be admitted overnight and your insurance will pay at a higher rate. This new ruling is not in favor of the patient and only has big insurance and big medicine as the winners.

      • Can’t thank you enough for the information. I shared your info with my daughter and my wife…they are researching my daughter’s billing. Thank you very much!!

        • Kirt – The billing office will more than likely be rude but they almost always are. I would never have straightened out Medicare’s policy on Mental Health if a fellow blogger hadn’t spoken up and told me the magic words to use. She has her own billing practice and I often think she may be the last responsible billing practice on earth. You’ll find Denise @ http://inspired2ignite.com. She doesn’t normally blog about her work but has a delightful way of engaging the community. Please ask your daughter and wife to hold firm with their demands. A federal law as well as consumer law backs up the requirement of a medical institution to produce an itemized billing upon demand by the patient or their representative. In reality, I recommend having the itemized statement in your hand before you pay for any service. Medical facilities are notorious for billing incorrectly. If we as consumers don’t fight this new ruling on the ‘observation’ status, it will become the standard for practice and then only the wealthy will have access to medical care.
          I outlined, in my response to Patty B above, the choice she may make when she’s at the ER faced with this decision. Sheri

  16. Wow, what an eye-opener and thank you so much for this fact. Many of us will be in this situation some day and I would never have known about this additional shift in cost coverage without your post.
    Patti

  17. inesephoto says:

    Sheri, thank you for the explanation. Does the patient or family have any say in this? I have had a very bad experience with refusing to stay over night… They had punished me hard…

    • Inese – Hello and nice to see you here. YES, you and whoever holds your medical proxies has the right to refuse any and all medical decisions. I haven’t blogged about the need for medical proxies but am going to do so soon. Every situation is different but my stand is that the only reason for a patient going to observation status is to save the insurance company money and save the hospital ER resources. If a patient is too ill to go home, the patient is ill enough to be admitted per their insurance requirements.
      It sounds as though you had a different experience when you refused to stay over night. Did you leave the hospital AMA (against medical advise). BTW, medical professionals will tell you that your insurance company won’t cover your charges but I’ve taken Tom out of the hospital AMA so many times I’ve lost count and the insurance company has always covered the charges.
      I’m concerned when you say they punished you hard. Is that because you refused to stay over night? Did the medical professionals say you would be at risk if you didn’t stay the night?

      • inesephoto says:

        Sheri, thank you for your concern. It was too long a story. To make it short: I signed the papers to let me go as I was promised by the day shift doctor. This one was the evening shift doctor, and she warned me that I would regret it – well, she rather threatened. She was really mad at me. Then she performed a lumbar puncture that kept me in the hospital another 3 days. She got her way. I couldn’t prove that it was intentional but I could read her face. My spine is no good, and that puncture made it worse, not mention that the puncture was unnecessary in my situation. It wasn’t the first time when I got to deal with aggressive and ambitious doctors, but luckily I had many great experiences and my life was saved at least two times.
        Inese

        • Inese – I’m so sorry that particular doctor got her way and you are now living with her mismanagement of your medical needs. I’ve had situations where a surgeon or other doctor will tell me it’s okay to go home if I feel strong enough and the nursing supervisor will try to get me to stay. If the doctor tells me it’s okay to go, trust me, I’m gone. Our hospitals are the worst places to pick up life treating diseases.
          I faced somewhat of a similar situation when I allowed myself to be talked into a surgery I should never have had. It was one of those cases where I was heavy into researching Tom’s care and I didn’t look after myself. As a result, what was to be a 1 1/2 hour surgery for me lasted 6 hours and I lost 1/2 the blood in my body and acquired a hospital infection. I still haven’t regained all of my blood. Medicare said I had to go home at the end of 2 1/2 days but I was so sick, the nursing staff at the hospital couldn’t find a nursing facility that would accept me within a 200 mile radius. Tom was in no shape to take care of me at the time. I came home to sit in my recliner because during the surgery I wasn’t moved for those 6 hours and it caused serious nerve damage to my right side and like you with your damaged spleen, I now have limited use of my right side due to nerve pain. It’s difficult to know exactly what we are supposed to do but in this case, you and I both received bad medicine!

  18. Lignum Draco says:

    A very sad state of affairs. They say Australia is much like the US but 10 years behind. I hope we never catch up to this, but it may be inevitable, given cost blow-outs here.

    • Thanks for checking in. Yes, it is indeed a sad state of affairs. The US government is becoming more and more socialized in all aspects. Medical care is taking a direct hit. Eventually every other aspect of our government will be socialized if we don’t turn our country around.
      Our food chain started becoming threatened as far back as the 50s when government (Dept of Agriculture) started setting limits to what could be raised and how many acres, etc. Gov went on to tell farmers and ranchers what fertilizers and pesticides could be used and then gov jumped into bed with the manufacturers of certain big ag and now if farmers want to grow products which we consume here in the US and export liberally to a large population base, and now to further the problem if farmers want to continue producing those crops they most buy the seeds from the fertilizer, etc. companies.
      If course the run-off of the ag production goes into our rivers and streams and the rest is history. The world’s most valuable resource, known as clean drinking water, will be unavailable to all.
      Sorry about the rant.

  19. ksbeth says:

    thank you so much for your insight into this. i had absolutely no idea.

    • Beth, If we are to overturn this practice, we must question every medical decision. If a patient is sick enough to remain in observation then they are sick enough to be admitted. This is a scam by big medicine and even bigger insurance trying to cut their expense and dump it on the individual with medical issues. If you must go to the ER, ask questions. You do not have to do what the ER physician recommends. I cannot give medical or legal advise. I simply don’t want anyone to fall into the trap of being in ‘observation’ when they have adequate insurance for admission as an inpatient. Sheri

  20. gpcox says:

    Of course, the older I get the more difficult the problems – isn’t progress wonderful! Thanks for the info and advice, Sheri – you know I’m at the age of needing it!
    All my best to Tom and the vets and the volunteers!!

    • G.P. – I don’t call this progress. I call it scamming the patients the medical industry is to protect and serve. Big medicine and big insurance climbed into bed together and cooked this idea up. The ruling they came up with is good for no one but themselves. As I commented to Patty B above, you never have to accept ‘Observation Status.’ Be aware or have someone you trust be aware of where you are, at all times, in the ER environment. The bottom line is that if you are sick enough not to go home, as per your treating physician, then you are sick enough to be admitted to the hospital for at least one night and your insurance will pick up a higher percentage of your care.

  21. chris13jkt says:

    It’s good to have you remind us about the matter Sheri, as not every people know the consequences of being transported from ER to Observational Unit

  22. Gallivanta says:

    It must be so hard to think of all these things when an emergency is happening. Almost need patient/consumer advocates on standby in a hospital to help people with these paper/insurance issues.

    • Gallivanta: Hello and thanks for stopping in. To the best of my knowledge, all patient advocates are employees of the hospital. Although you’d think they would advise, they can’t anymore than I can. If someone ask about the regulation, the advocate can alert the patient’s family to the consequences the same as I can. I’ve admitted Tom far too many times to ever expect to meet anyone in admissions that did more than want to see our insurance cards and how to reach us for billing.
      In these days of tight money, we no longer see frills and the extras that were automatic givens back in the 70s. I think that was the last time I saw anyone helped with their food tray. Now, if the inpatient is unable to remove the cover of their meal, sit up enough to see the plate and reach the eating utensils then the meal goes back to the dining facility without being touched. It was probably in the 60s that nursing assistants came into the hospital room and gave patients back rubs with lotion and rubbed their feet to help them relax into a good night’s sleep. Those days are long gone and I don’t believe we’ll see their return.

      • Gallivanta says:

        Oh, that is really sad that there isn’t even anyone to help with feeding. I know when my mother was in hospital recently, it was hard to get anyone to remember to put her hearing aid in for her. Apparently it was easier to shout at her and receive incomprehensible answers. 😦

        • Gallivanta – It’s the simplest things isn’t it that improves the quality of life for the patient. I also faced the issue of having my father’s hearing aid put in while he was in the hospital. He was a kind and simple man and never asked for anything and would rather be uncomfortable than have anyone have to go out of their way to do something for him. I explained over and over that it was ‘their responsibility’ to take care of him and that included all aspects of his care including his hearing aids. Thankfully the few times he was hospitalized, it was for short periods of time.
          I’m truly concerned about the problem of patients not being helped with their food. A volunteer isn’t allowed to help (as in a member of a volunteer group). That leaves it to a family member or friend. We both know that it’s often impossible for a family member to be present and friends have other commitments or live in other parts of the country. I faced this situation myself in 2010 when I was in the hospital and had 2 surgeries back to back. Of course I couldn’t have anything after the first surgery as they were going to have to do surgery again the next day but in the middle of the night after the 2nd surgery I wanted some jello or something cold. The dining room brought the jello to my room but I couldn’t reach it and there was no one available to help me. Tom was exhausted and I’d sent him home and I’d also told friends they didn’t need to come in that day as I thought I’d probably need their help later. It is a sad situation and tells me to be prepared the next time Tom or I end up in the hospital. Hopefully that will be far in the future. Sheri

  23. Sheri, cogent, highly relevant writing of the most serious and valuable nature. It’s great you are making people aware of these issues.
    My best to you always
    john

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