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Bias in the ER

nautil.us

71–80 of 84 posts

Re: Bias in the ER

#71
post #66

Earlier quoted context omitted.

It's a new finding a quite striking if true Estimates are ~250k/yr for medical error, ~30k road deaths for the US https://news.ycombinator.com/item?id=11627213 You can hear the researcher talking about it here: http://www.bmj.com/content/353/bmj.i2139

The number of people killed by medical errors thing is a little controversial. People who are about to die anyway get a lot of medical interventions (which is more opportunity for errors, big small). If a patient accidentally gets an extra dose of their antacid 48 hours before they die, is it really likely that error led to their death? Because it would be counted in that 250k/yr number...

> Because it would be counted in that 250k/yr number.

Do you have a citation that these kinds of trivial, harmless, errors are being counted as medical error deaths?

Re: Bias in the ER

#72
post #71

Earlier quoted context omitted.

The number of people killed by medical errors thing is a little controversial. People who are about to die anyway get a lot of medical interventions (which is more opportunity for errors, big small). If a patient accidentally gets an extra dose of their antacid 48 hours before they die, is it really likely that error led to their death? Because it would be counted in that 250k/yr number...

> Because it would be counted in that 250k/yr number. Do you have a citation that these kinds of trivial, harmless, errors are being counted as medical error deaths?

Sure, here's a good overview of some of the controversy with this issue.

https://www.nytimes.com/2016/08/16/upshot/death-by-medical-e...

Re: Bias in the ER

#73
post #33

Earlier quoted context omitted.

Cost inflation in the US is huge due to a combination of red tape, CYA, customers with good insurance subsidizing people with bad/no insurance, and many other factors. There's no simple answer, unfortunately. No one is entirely sure why medical costs are so high in the US. It doesn't appear to be any one factor that people commonly blame. Fundamentally, they don't need to be expensive; via private medical tourism, yo…

The problem is everyone gets paid too much. Our doctors salaries are far out of line with most countries , we have the strictest drug pricing laws in the world, and people love to sue. We also have a significant portion of the population paying no medical bills while the rest is overcharged to compensate. On top of that our health insurance is full of middle men like "PBM's" that do nothing but raise costs. The combo…

I'm an ER Doc. The focus on illegal immigrants is way off base.

There's a law called EMTALA which is basically an unfunded mandate that says, in part, we can't just turn away patients because they can't pay. This was because slot of hospitals (university of Chicago in particular) were dumping or transferring patients to other hospitals who couldn't pay and making huge news stories. As you mention, this means people who can’t pay get free health care.

Who does this end up being? Almost 100% alcoholics and homeless patients, often with severe mental illnesses. When there are no resources for them, they end up taking ambulance rides to the ED, say they have Chest pain, and then we give them thousand dollar workups that you end up paying for. Illegal immigrants at large county hospitals are often grateful for any care and usually actually do end up paying at least some portion of their bill, and often are not super high utilizers.

For example, do you know who the number #1 utilizer of NY state medicare dollars is?

http://nypost.com/2009/07/12/hosp-itality-abue/

Trust me, if hospitals could sort out paying from non paying patients they'd do that in a heartbeat (if they have one). There's lots of programs that try to draw those sorts of patients in, like international elective procedure patients and elderly patients who are universally paid for by Medicare.

Re: Bias in the ER

#74
post #70

Earlier quoted context omitted.

The number of people killed by medical errors thing is a little controversial. People who are about to die anyway get a lot of medical interventions (which is more opportunity for errors, big small). If a patient accidentally gets an extra dose of their antacid 48 hours before they die, is it really likely that error led to their death? Because it would be counted in that 250k/yr number...

Yeah there are question marks about the methodology etc. though it still seems there are a lot of errors https://www.pamedsoc.org/tools-you-can-use/topics/quality-an...

Preventable medical errors are certainly something we should continue to work to reduce (significant progress has been made over the past few decades in that regard).

I'm not advocating complacency, just pointing out that many people think the 250k/yr number is substantially inflated.

Re: Bias in the ER

#75
post #25

Earlier quoted context omitted.

I had a professor in undergrad who worked on order entry research. He talked about one of the problems facing Vanderbilt as far as scanning costs. CT scans and MRI are crazy expensive. Trauma patient comes in, doc orders a CT scan, it comes back and he says, "shit, this doesn't tell me what I need to. I knew I should have ordered an MRI instead." They used a decision tree learning algorithm and trained it using attri…

Just curious why are MRI and CT machines so expensive? They are the ultimate tool for debugging the human body. Shouldn't they be very affordable?

I think there is an important point for people to remember: The cost of a procedure, like a CT scan, is not the cost of the procedure. The amount you are getting charged is the Chargemaster rate.

The Chargemaster rate is the same no matter who you are, the different is what people pay from the chargemaster bill. Let's say you are given tylenol and the charge master is $50. The reason why this is so high is because medicare will then say that they pay , say, 20% the chargemaster rate, and thus elderly patients pay $10. This is why elderly patients are seen as great patients for revenue: They all actually can pay something, even if its only a fraction of the chargemaster. A gold plated insurance patient will pay Medicare+30%, and thus the gold plate insurance pays $20. The patient with no insurance then is also billed $50 because they don't have an agreement with the hospital. Thus, what likely happens is that they pay $0 and goes bankrupt, or more likely, these patients don't have any net worth at all. This creates a weird situation where the homeless, destute, and people with no net worth essentially get infinitely free healthcare. These patients tend to be very high volume healthcare users (homeless patients that take $5000 ambulance rides as taxis because they know they will never actually pay a penny, despite having millions of dollars of charges.). This is what the Affordable Care act tried to prevent: by making people pay something, you were actually decreasing costs for all because you remove free riders who present the majority of sunk costs in the healthcare system. Very few people if ever pay for the full cost of a procedure or chargemaster. The chargemaster is a negotiation tactic. Not a final bill.

That is why a CT Scan costs thousands of dollars. Because everyone knows you'll only end up paying a fraction of that if you have insurance. And if you pay cash, its only a few hundred bucks, because thats how much people get paid anyways.

Source: I'm an ER Doc.I do research in healthcare and billing

Re: Bias in the ER

#76

Earlier quoted context omitted.

I was quoted prices that varied by almost ten times when I was looking for a CT scan. An independent lab, owned by the head of radiology at a hospital in another County, was $268 USD if paid at time of service, cash or credit card. He used to have several locations, but the other hospital bought out all the locations near them. And closed them almost immediately.

And this is just one of the many problems with the US medical system, even if it went to a single payer system taking the individual off the hook, the cost of delivery is completely out of control due to (in my opinion) a lack of "proper" capitalism. Perhaps any acquisitions in the field of medicine should be subject to antitrust laws?

They are the subject of antitrust laws. Hospital mergers are often blocked due to this very issue

Re: Bias in the ER

#77

Earlier quoted context omitted.

The problem is everyone gets paid too much. Our doctors salaries are far out of line with most countries , we have the strictest drug pricing laws in the world, and people love to sue. We also have a significant portion of the population paying no medical bills while the rest is overcharged to compensate. On top of that our health insurance is full of middle men like "PBM's" that do nothing but raise costs. The combo…

pass laws to protect physicians from frivolous lawsuits or at least limit damages Several US states have harsh caps on medical malpractice damages. They still see massively-rising medical costs. And in uncapped states the rate of growth in malpractice damage awards hovers very close to the rate of inflation of the US dollar. Which sort of destroys the argument that "frivolous lawsuits" and massive damage awards drive…

Its not about frivolous lawsuits as much as defensive medicine which is the standard of care. For example if you come in to the Emergency department with a traumatic brain bleed (even a tiny spec on your scan), then you end up getting another scan at 6 hours, likely platelets since you took a baby aspirin that day, a very expensive neurosurgery evaluation, keppra for 2 weeks, and continuous monitoring, even though by all metrics you have a very benign pathology. Why? Because this is the standard of practice. Not because it makes any sense.

also, keep in mind that the factor that matters the most for practice patterns (especially defensive ones which drive up cost) is not where a doctor practices, its where a doctor trains. Since most doctors train in high risk litigation environments, and most standard of care procedures are developed with defensive practices in mind, the standard of care is high cost high utilization medicine.

Source: ER doctor

Re: Bias in the ER

#78

Earlier quoted context omitted.

pass laws to protect physicians from frivolous lawsuits or at least limit damages Several US states have harsh caps on medical malpractice damages. They still see massively-rising medical costs. And in uncapped states the rate of growth in malpractice damage awards hovers very close to the rate of inflation of the US dollar. Which sort of destroys the argument that "frivolous lawsuits" and massive damage awards drive…

It's less the actual damages as much as it the defensive medicine that occurs because of the constant risk. If you show up with the flu, but it could be some weird disease that shows up in an MRI, the incentive for the doctor is to get you an MRI. I used to believe in caps, but I think we could do better than that. Create a no-fault insurance market that pays people without the hassle of civil trials. That has the po…

100% agreed with this. This is an insightful comment. people have no idea how much practice patterns would change if less defensive medicine could be practiced. So much of the inconvenience of medicine exists because the standard of care is extremely conservative to ensure minimal risk of litigation. The few states that have malpractice caps really doesnt change anything--those states just provide a good practice environment in rare situations, but doesn't change the way that standard medicine is practiced because that is developed out of state as a national consensus.

Re: Bias in the ER

#79
post #25

Earlier quoted context omitted.

Just curious why are MRI and CT machines so expensive? They are the ultimate tool for debugging the human body. Shouldn't they be very affordable?

I think there is an important point for people to remember: The cost of a procedure, like a CT scan, is not the cost of the procedure. The amount you are getting charged is the Chargemaster rate. The Chargemaster rate is the same no matter who you are, the different is what people pay from the chargemaster bill. Let's say you are given tylenol and the charge master is $50. The reason why this is so high is because me…

What do, for example, tourists pay? When I buy a plane ticket to the US, there is travel insurance, but I have never needed to use it and do not know how it would work.

Re: Bias in the ER

#80
post #61

Earlier quoted context omitted.

I don't need to make an argument. Call your doctor and ask him how much he pays for his malpractice insurance. I used to know some people in healthcare tangentially and the answer is $50,000 to $250,000 A YEAR depending on specialty etc. Sometimes the practice will pay these costs for you, so the doctor might not be paying it directly but the money is coming from somewhere. My friends told me malpractice insurance wa…

Consumers need protection from doctor's mistakes, plain and simple. I don't need to make an argument either. Call someone who has lost their child to a doctor's mistake.

Consumers pay for this so-called protection through higher costs, but what good does it do?

Call a person who has lost their child to a doctors mistake and see how the 'protection' has worked out for them.

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