
Emergency rooms are monopolies - jseliger
https://www.vox.com/health-care/2017/12/4/16679686/emergency-room-facility-fee-monopolies
======
mbroshi
In order to open a new hospital in most jurisdictions, by law you need the
permission of other local hospitals [0]. That's like being required to get the
permission from Google to start a new search engine.

0\.
[https://en.wikipedia.org/wiki/Certificate_of_need](https://en.wikipedia.org/wiki/Certificate_of_need)

~~~
limeblack
My father is an executive at a major hospital and this is only part of it.
There is also issues of brands forming monopolies when appearing in
communities. Mergers are also incredibly complex. Also lots (but not all
hospitals) are nonprofits which complicates it further. ERs are required to
treat patients if they come in which means some are making tons of money while
some not at all. One person can significantly alter ERs profits[0].

[0]
[https://www.beckershospitalreview.com/finance/the-12m-patien...](https://www.beckershospitalreview.com/finance/the-12m-patient-
that-drove-insurance-rates-higher-in-iowa.html)

~~~
FireBeyond
Is very insightful to read those comments. So many people who, faced with
socialized medicine, screamed "DEATH PANELS!"...

See premiums rising and all of a sudden, "We need to consider letting this
person die a noble death."

It's like a paradigm shifting, without a clutch.

~~~
Shivetya
however this issue like the costs of health care are exaggerated by local and
federal government rules. when you prevent competition, when you force
coverage regardless of need, and you lock out more options, costs only go one
direction.

just like tax laws, medical laws and implementation are done to favor specific
groups to the detriment of others unfortunately

~~~
raquo
> force coverage regardless of need

This is like, the main way to make insurance affordable.

[https://www.investopedia.com/terms/a/adverseselection.asp](https://www.investopedia.com/terms/a/adverseselection.asp)

------
scythe
EMTALA is also a _huge_ welfare cliff. Let's say Antius and Grasshoppedon both
work at McDonald's. In accordance with the wisdom of the prophets, Antius
saves 20% of his paycheck every month (somehow) eventually accruing... oh,
say, $9001 in savings, or way more than the average US household.
Grasshoppedon spends all his money, because that's how the fable goes. One day
they're both injured in a workplace accident and rack up a $25000 medical
bill. Antius's savings are wiped out, he goes bankrupt, no credit for seven
years, etc; Grasshoppedon meets _exactly the same fate as Antius_ , i.e.,
Antius's fiscal prudence amounts to diddly-squat.

And then economists wonder why the savings rate is so low.

------
athenot
At night the ED is the only place open. I believe there should be 24/7 Urgent
Care centers, where people like the person in the opening of this article
could go and receive care that (1) is not life-threatening but (2) can't wait
till dawn.

However, in the mean time there are ways to help.

1\. If you don't already have one, get a Primary Care Physician. Go for a
wellness visit, get their practice to know you. Then if something like that
happens at 1am, you can call the office, leave a message and get a callback
from a nurse within 15-30m who can help you through your options and help with
over-the-counter options to make it through the night until the office opens
(or until urgent care opens). Or of course they can counsel you to go to the
ED if they think there's a risk. But the point is, you can already weed out
some unnecessary ED visits that way.

 _Note: not all providers have that service, so it 's best to enquire when
selecting a physician._

2\. Many insurers have a nurses hotline but few people know about it. Check
your policy. In the same way, they can help triage your situation, though it's
less ideal since they don't know your medical record so they will tend to play
it safer (ie. higher likelihood to send you to the ED). But it's better than
nothing.

3\. If the issue is pain management, you can also try your neighborhood 24/7
pharmacist. They can't diagnose you but again they might have tips to help you
through the night until you can get proper care.

~~~
maxerickson
The only way to get widespread 24 hour urgent care in the US is to make it a
billing code in the emergency room. There's often already 24 hour urgent care
available in major urban centers.

Of course, this raises the question. Why isn't urgent care a billing code in
small emergency departments?

~~~
chimeracoder
> Of course, this raises the question. Why isn't urgent care a billing code in
> small emergency departments?

Because it's still emergency physicians performing the work, for the same cost
(both marginal and overhead).

The answer is to open up actual urgent care practices, which are cheaper to
run, not to change the billing codes used in emergency room settings.

~~~
maxerickson
I remain unconvinced that running an entire separate practice is obviously
cheaper than adding primary care doctors to ERs. I'm sure it makes more
financial sense given the current regulatory and reimbursement regimes.

I mean, when I've been in the local ER it hasn't exactly been a hive of urgent
activity, you chat with the intake nurse and then watch her sit there and do
things other than interact with patients for half an hour.

~~~
chimeracoder
> I remain unconvinced that running an entire separate practice is obviously
> cheaper than adding primary care doctors to ERs. I'm sure it makes more
> financial sense given the current regulatory and reimbursement regimes.

Emergency medicine and primary care are completely different settings. "Adding
primary car doctors to ERs" doesn't really make any sense. The structure of
care delivery is completely different.

~~~
maxerickson
Is the structure of care delivery different for good reasons or is it
different because ERs don't make accommodations in their care delivery for the
many non-emergency cases that walk into ERs?

(and of course they don't because they aren't going to bill insurance
companies any less than they can consistently get them to pay)

~~~
chimeracoder
> Is the structure of care delivery different for good reasons or is it
> different because ERs don't make accommodations in their care delivery for
> the many non-emergency cases that walk into ERs?

Yes, the actual structure of care that is delivered is entirely different. You
can't just stick primary care inside an ER and expect it to work. The two
aren't similar.

------
dv_dt
For costs: medical service + profit + profit accounting overhead + cost
shifting overhead > medical services

There was a period in time where there were very high losses in emergency
rooms because there are legal obligations for conferring care in that setting.
Many emergency rooms were getting closed down and that's also a big problem
for communities. So it's in a way understandable (not necessarily excusable),
because some of this I would infer is cost shifting to meet those obligations.
Maybe it's shifted to too much profit now.

Both sides of the problem, IMHO come from completely disconnected cost/profit
transaction loops in America's healthcare. It's one big reason why single
payer systems cost so much less. There is a much more straightforward relation
between costs, care, and budgets in those systems so you can actually manage
the direct problems instead of managing multiple red-tape layers each trying
to competitively maximize, minimize different areas.

~~~
bluGill
We are talking about ER rooms here: people who need ER services are not in a
position to do any sort of shopping around. When seconds count you cannot
afford the minutes needed to get to the next ER. In theory it is possible that
one is significantly better and so it would be worth the time, but in practice
all the ERs in any given area are going to be not very different in ability to
provide care. Even if the closer ER transfers you to the other getting to the
first in time started care sooner.

~~~
Waterluvian
It's a perfect candidate for a socialized program. We all pay a tax to
guarantee that ERs are available and equipped for everyone at a moment's
notice.

~~~
__sha3d2
Not to mentioned it's already a socialized program... who foots the bill when
nobody pays? Me & you.

~~~
dv_dt
I would say the current rules are not socialized in any sort of good faith
method. Certainly not in a way that provides transparency of costs and
effectiveness. Nor in any way how a socialized universal healthcare system
would approach it.

~~~
__sha3d2
I 100% agree with you. Our capitalist overlords are resisting the intelligent
socialization of an already poorly socialized program.

------
tlb
It's a mystery why hospitals are still considered worthy recipients of large
gifts. People donate tens of millions of dollars for a hospital building,
inside which the hospital proceeds to rapaciously overcharge its patients.

It's true that most hospitals themselves are non-profits, but the service
providers in the hospital range from moderate capitalists to very predatory
ones. Donating to the hospital just means they charge less overhead, and the
medical corporations operating within them keep more. Doctors are great and
all, but I don't feel like they need my charity.

------
ohazi
It's not a monopoly, it's a cartel. There are a dozen hospital networks near
me, but they all have opaque pricing and billing, so they all charge like
this.

You can try to regulate these facility fees, or force them to be made public,
but as it stands there's no reason for them to go anywhere but up,
indefinitely.

------
trgv
Something I've noticed are advertisements for ERs. Really. I was a little
shocked when I saw one on the way to work.

It says:

"Trouble breathing? Nausea and fever? Stomach pain? Our ER can help."

"What's your body telling you? Any one of these symptoms could be a warning
sign of something serious. Our emergency room offers fast, expert care 24/7 to
keep you healthy."

I had never really thought of hospitals, especially ERs, as a business before
I saw that. I guess that was naive.

~~~
selimthegrim
I saw a lot of these in Houston for some reason.

------
panic
If you live in California, consider writing or calling your State
Assemblymember in support of the Healthy California Act
([http://www.healthycaliforniaact.org](http://www.healthycaliforniaact.org)),
which is stuck in the State Assembly right now. It would establish a single
payer system for the state and let people get emergency care without these
outrageous bills.

~~~
refurb
Wasn't that tried before and the estimated cost was more than the entire State
of California budget?

The chance of that bill ever going anywhere is effectively zero.

~~~
epmaybe
I think I'd be in favor of introducing a public option and seeing how it
competes with other commercial insurance options. Going completely single
payer seems very risky, and could upset a large percentage of californians due
to the subsequently necessary rise in taxes.

~~~
redblacktree
I wonder just how big those increases would be though. I've seen several
informal surveys of my Facebook friends with respect to the cost of their
health insurance, and numbers range from $400-$1200/mo. And keep in mind that
many of these are subsidized by their employer. That seems like a lot of money
that could be taxed. (i.e. you'd pay the tax instead of a health insurance
premium)

~~~
epmaybe
The rational thought process is that yes, tax what would have been spent on
health insurance premiums. However, in practice I'm not so certain that it
would interpreted as such by taxpayers.

------
HappyKasper
The insured pay the price. Hospitals will never turn away a patient with a
medical emergency - the inability of certain patients to pay is factored into
hospital finances, raising the price for those who do pay.

~~~
analog31
The health care system has arbitrarily chosen the "hospital" as the place
where nobody can be turned away.

If your kid has a possible ear infection or broken arm, and you have
insurance, you go to an urgent care clinic. If you don't have insurance, you
go to a hospital. In all other respects, the care is the same.

~~~
bluGill
If you go to urgent care you are seen in order of arrival. In the ER you are
seen based on need. This results in very different care experiences. Also you
should expect that urgent care is more familiar with the types of things
people should go to urgent care for - while the ER can deal with them they may
take longer.

The kid with the simple ear infection will wait longer in the ER. (Note that I
added simple: if the ear infection is complex the ER may see the kid sooner,
but those are cases where when Urgent care finally gets to the kid they
transfer to the nearest ER)

~~~
FireBeyond
> If you go to urgent care you are seen in order of arrival.

Most "decent" urgent care facilities will triage. That's one of the reason why
you're asked why you're there on check-in (and also to ensure you're not
complaining of something acutely emergent).

------
DoodleBuggy
Putting aside the often absurd costs for a moment...

Many ERs are also severely overburdened, understaffed, and overcrowded often
with very high ratios of non-emergency patients to emergency patients. This
creates huge wait times for patients and puts significant stress on medical
staff.

Talk to your friends, family, coworkers, almost everyone has a bad story to
share, whether about absurd wait times, wild costs, billing screw-ups,
insurance debacles...

And talk to your doctors and nurses too, they are just as frustrated.

~~~
dsr_
They're overcrowded because they are the only health care available for a
large number of people.

There's only one way forward which will work, although there are lots of
different ways to do it: universal healthcare.

~~~
gbacon
Invigorating the malady is not the cure.

------
pimmen
We pay a far lesser portion of our GDP in Europe for health care and we have a
longer life expectancy, higher chance of survival for the majority of cancer
and cardiovascular diseases.

It’s not that hard to understand; you try to control market forces when you’re
talking about inelastic demand because that kind of demand is an opportunity
for serious abuse. Isn’t that the reason the US has its war on drugs? Yet it
can’t see this more expensive and deadlier problem?

~~~
rukittenme
Gasoline is an inelastic good but its price is relatively low and affordable
because of the abundance of suppliers. In the US, local monopolies provide
health care.

~~~
eesmith
How is that relevant?

In many European countries, gasoline taxes are quite high. Wikipedia's "Fuel
tax" page says that in 2014 Germans paid US$6.14 per US gallon of gasoline.

Yet there is also an abundance of suppliers in Germany.

The hospitals in many European countries are publicly owned and operated.
Quoting Wikipedia's "Healthcare in Denmark" page, "The central government
plays a relatively limited role in health care in Denmark ... Hospital care is
mainly provided by hospitals owned and run by the regions."

There are five such regions. Aren't there, using your argument, also five
local monopolies in Denmark? But the situation in Denmark is nothing like the
US.

~~~
rukittenme
I think you need to reread what I wrote and understand what I'm arguing.

The OP argued inelastic demand drives price gouging which isn't true in the
case of gasoline. Price gouging in medicine isn't driven by inelasticity, its
driven by a dearth of suppliers.

In Denmark, you have few suppliers but the suppliers you do have are owned and
regulated by the government. It's not a relevant comparison. They are not a
market-based supplier.

~~~
bonzini
It's not driven by the dearth of suppliers, it's driven by the impossibility
of choosing the cheapest provider due to a combination of 1) the lack of
transparency in hospital pricing; 2) not being able to anticipate your
expenses; 3) the insurers being able to "cheat" by agreeing on lower prices
with the providers; 4) insurers forming a cartel.

When there are so many forces pushing against the creation of a free market
and a healthy balance between supply and demand, there is only one thing that
the government can do: either socialize it (that's what happens with roads,
for example), or regulate it like there's no tomorrow (that's what happens
with utilities). However, in the US it is blasphemy to even suggest doing
either thing to healthcare.

~~~
rukittenme
You're absolutely write to go after my "dearth of suppliers" point. It
certainly is not the only reason for healthcare costs or even a large
percentage. I even say so in a different comment.

1 and 2 are absolutely valid points and share responsibility for healthcare
costs.

> However, in the US it is blasphemy to even suggest doing either thing to
> healthcare.

I wholeheartedly disagree with this. Healthcare is the most regulated industry
in America.

------
mywittyname
ERs are one of the few places where hospitals actually earn a profit. My
partner fights on behalf of hospitals when insurance companies deny a claim.
And over the past years, insurance companies have taken to denying valid
claims just to get out of paying. An egregious example being a patient that
needed heart surgery and the insurance company deemed it medically unnecessary
because they claim he should have been observation only.

Claims denial departments are exploding, they used to be 4-8 person teams for
a major hospital five years ago. Today my partner has 32 direct employees at a
much smaller, regional hospital.

Hospitals have come to the realization that it's basically impossible for
insurance companies to deny ER claims. After all, the patient came in with an
"emergency."

~~~
FireBeyond
> An egregious example being a patient that needed heart surgery and the
> insurance company deemed it medically unnecessary because they claim he
> should have been observation only.

United Healthcare got in hot water for denying coverage for airlift EMS for
MVA victims saying that the "trip wasn't preauthorized with the insurer"...

------
oftenwrong
If you are interested in the various failures of the American health care
system, I recommend reading _Catastrophic Care_ by David Goldhill. It's a bit
depressing, but eye-opening.

------
peterwwillis
One of the ways consumers can push back on this is by becoming educated on
health care practice. I would never have let a hospital give me a CT scan for
a simple throat problem.

Then there are other issues that (supposedly) you have no control over. When I
was hit on my bike, I refused the trip in the ambulance to a hospital. But
when I got worse just an hour later, I ordered a taxi to go to an urgent care
clinic. The clinic said I needed to be treated at a hospital, and then
insisted that they would not let me leave except in an ambulance - which I
then had to pay for.

Another thing that's stupid: apparently you have to pay for your ambulance
ride in Pinellas County, Florida, but you _never_ have to pay for your ride in
Montgomery County, Maryland.

The reason you don't have to pay in Montgomery County? The state forced the
county to shoulder tens of millions of dollars in teaching funds, and they had
to come up with the money - so they made a law that county EMS could directly
bill insurers, and this money goes directly to the county.

~~~
FireBeyond
> and then insisted that they would not let me leave except in an ambulance -
> which I then had to pay for.

As an EMS provider, that is against the law. As long as you can show
competence and comprehension, you are entitled (as you did with the ambulance
in the first place) to refuse care, or any part of it ("You can dress my
wounds, but not transport me"). They may wish to document your refusal AMA
("Against Medical Advice") for their liability / stave off abandonment claims,
but "refusing to let you leave" is akin to kidnapping, no different to if
anyone else had done it.

(Psych holds and such in my area require Law Enforcement involvement, even on
scene, as they are the only people authorized to actually 'enforce' the
involuntary transport/hold laws, though it's with our recommendation).

------
spott
Anyone have any good data on the profitability of hospitals? I've always
gotten the feeling that they are generally not making a whole lot of money,
but I don't have much data to back it up. Is this kind of data even public?

You can construct a narrative for a bunch of different situations for
Hospitals:

* High ER costs in order to offset the large number of people who just can't pay, but need to be treated anyways. * High costs in order to deal with all the regulatory requirements on Hospitals (it seems everything is regulated in a hospital, down to the kind of TP in the bathrooms). * High costs because hospitals have local monopolies and _can_ screw patients. * etc.

I don't have enough data to figure out which one of these is the "right"
version of the facts. Does anyone else?

------
firefoxd
Idea: yelp for hospitals. With list all prices and fees.

Not that this will solve the problem but it's better than finding out you owe
$3k a week later.

~~~
wyldfire
I like the concept in general but it's infeasible here in the US for a third
party to survey prices and post results. Insurance plans renegotiate
individual prices with providers, and each plan decides on coverage. The only
way it could change would be if providers (and insurers) were to do it on
their own, but they have no motivation to do so. I think only regulation or a
seriously disruptive/innovative competitive force could do this.

~~~
tedunangst
Hospitals should be required to post price sheets. If they take a dozen
insurance plans with negotiated prices, then they post a dozen price lists.
There's no way this should be secret.

~~~
hathawsh
Check this out:
[https://www.oshpd.ca.gov/chargemaster/default.aspx](https://www.oshpd.ca.gov/chargemaster/default.aspx)

You can download chargemasters for many (most?) California hospitals, over the
past 10 years, in Excel format. I downloaded one sample and it has a list of
3700 prices, some of which are as high as $84,000.

I'm really happy to discover this resource exists, but is anyone republishing
the prices in a format consumers can work with? These sheets need UX design.

------
quickben
I'm amazed at the stupidity permeating this thread ( and wiling to burn karma
to defend against it).

A random guy wakes up at 1am with a cramped muscle. Goes to facility that is
equipped to deal with _anything_. On the spot surgeries, ability to break
teeth safely to intubate and keep alive, drugs, cabinets with up to date
equipment. Staffed with non-expired drugs that are regularly recycled. Staffed
with people that can use all that round the clock, multiple backups. Staffed
with people that keep the place reasonably sterile and safe. Staffed with all
others to support an operation like that and expecting to get sued if it fails
even a bit.

And then complains, he had to pitch in for all that. An engineer, most likely
earning above 8k usd, had to give a weekly salary for something that he
considered worth dragging his butt out of bed at 1 am.

The guy is delusional.

The US health care is, on the expensive side, and can be better, but nobody
can argue it without taking into account all that goes into maintaining that,
just so one can randomly walk inside with a spasm, or after a huge carcrash
with 40 broken bones, and liters of blood lost, and probably stay alive.

I'm also amazed how most people here just ignore the reality of the scope of
the overall operation, and claim that for a limited use case, it's too
expensive.

I'm not even going to insert a car analogy here. If you can't see why health
care by nature is socialized and a utilitarian model, I'm not going to argue
with people from USA thinking that everything should be proportional to the
service and their pocket.

Man up. You are not the center of the universe. This civilization was built
for you, by people, and no matter if you like it or not, you will pay to
maintain it for the people coming after you.

Humanity, is a social concept worth defending.

~~~
peterwwillis
Did you know that in the rest of the developed world, what you described is
considered absolutely insane, and never happens?

Not the people going to hospital thing - that happens all the time. It's just
that nobody is ever charged thousands of dollars for it.

~~~
derekp7
Do the other countries have a lower cost method of maintaining service, or is
the patient charged the same, just not all at once (i.e., spread out over a
lifetime of higher taxes)?

If there are cheaper ways of providing healthcare, what would have to change
in the US to implement it?

For example, if there are three hospitals in a region, and they worked out an
agreement among each other to not have overlap in specialized equipment (where
hospital A sends all MRI patients to Hospital B just down the road), this is
currently illegal (anti-collusion laws).

Another example -- a patient comes in with a headache. Well there could be a
number of potentially fatal conditions that could be the cause, and due to
liability reasons, they have to run tests to rule these out before giving the
patient an aspirin (yes, this is an issue, in lower-income areas people go in
for non-emergency issues that most likely doesn't need a doctor).

~~~
dv_dt
US healthcare costs are completely out of control compared to other modern
nations. We pay 2-3x the cost of other nations for our care per capita.
Primarily I would attribute that to other nations applying a universal
healthcare principle, and in some form or other placing government controls on
the prices of medical procedures and drugs. We pay more, and our life
expectancy is shorter.

[https://ourworldindata.org/the-link-between-life-
expectancy-...](https://ourworldindata.org/the-link-between-life-expectancy-
and-health-spending-us-focus)

[https://www.kff.org/health-costs/issue-brief/snapshots-
healt...](https://www.kff.org/health-costs/issue-brief/snapshots-health-care-
spending-in-the-united-states-selected-oecd-countries/)

[https://www.pbs.org/newshour/health/health-costs-how-the-
us-...](https://www.pbs.org/newshour/health/health-costs-how-the-us-compares-
with-other-countries)

------
moonbug22
Today's instalment of how America's healthcare is a trainwreck.

