Sticker Shock Induced Health Care

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    Been to a hospital lately?  Did you have to leave a limb or two behind to foot the bill?  Yeah, I know – seriously bad pun.  When it comes to health care expenses, no one is laughing…or are they?  As a brand spanking new nurse, I have seen people swear off treatment and preventative medications and screenings due to the all mighty dollar.  It can be so frustrating for the patient, their families, and even for your nurse.  There’s a million different ways I could go from here (obviously), but I am going to try to leave out the politics, the fantasy world of everyone getting adequate care and treatment, and the total misconception that the U.S. health system is anything like it really should be.  I mean, instead of promoting health and teaching avoiding McDonald’s, the 12 pack on Saturday nights, and the carton of Marlboro’s and opting for a fruit cup and some water – we end up getting our patients after the damage is done and we are trying to sustain life for as long as possible.  Or worse, we are trying to make you numb to the destruction taking place so you can continue your path of self-destruction.  Obviously, you would know if that applies to you or not, so I am not getting on that soap box.

    Lots of theories are out there on how to reduce health care costs.  Obama has thrown a brand new theory into a law for us to begin implementing.  It will require a lot of tweaking and although I am not an Obama fan at all, I will say at least we have SOMETHING to build on (but in my humble opinion, we are FAR from anything sustainable financially or medically speaking).  But hey, we have to start somewhere.  First, I will say, if you want to truly reduce your personal health care expenses, start with the basics.  Exercise.  Eat right.  Practice hygiene.  Wash your hands.  Wash your hands correctly and often.  Don’t eat or drink after others (because no, you do NOT share the same germs).  Breastfeed your babies.  Stay married and raise your children in their unit family.  Do not allow yourself to be a victim of violence in the home or on the street.  Get correctly operating smoke detectors.  Reduce risks for fire and scalds in your home including using space heaters and fireplaces properly.  Get immunized!  Babies and children aren’t the only ones who need immunizations; simple flu shots every year and pneumonia shots every 5 years, and tetanus every 10 years can make huge savings down the road.  Go to the doctor annually for a check-up and go to the doctor when you are ill.  All these things can drastically cut your medical costs.  Think of it like a car.  You don’t buy a new car and then drive it until the wheels fall off and it’s completely out of all its fluids.  You get maintenance done to avoid replacing transmissions and motors, right?  Yeah, some parts and procedures are more costly, but in the end, you save a lot.

    Ah, but easier said than done, right?  Most of us can scrape $20 for a flu shot.  But, most of us can’t cough up $5,000 for a broken limb.  So why does it cost so much to go to the doctor, yet alone, the hospital?  Who the hell is making all the money?  Rest assured, I am not giggling heading out the door dreaming of the Ivy League school your bill is sending my children to when they get to college age.  I would much prefer you not be in my ER.  When I see you, it’s typically NOT your best day.  The last thing I want to do is make it worse by stressing you about money.  I hear a lot of, “How much does that cost?”  And, that’s putting it nicely.  Some people will refuse morphine, oxygen, IV fluids, and x-rays all because of the fear of the costs.

    So what about those lines that seems so simple?  “Observation” for 24 hours that costs $3,360 seems crazy high, no?  Well, even though I did not produce this bill, it’s not from my hospital, and I am not even sure if it’s a legit bill, I would like to take a stab at WHY it costs $3,360 to observe a patient for 24 hours.

    Looking at the bill in its entirety, it appears as if this patient was pretty ill (assuming it’s a real person).  Based on the medications, the patient was in a fair amount of pain.  I saw a couple of oxycodones, which is an oral opioid pain reliever that is pretty potent.  Magnesium hydroxide and docusate sodium is simply to prevent the patient from getting constipated, which frequently happens in the hospital because of lack of mobility, and frequent opioid use.  Diazepam   would probably better be known to people as “Valium,” and it’s used to treat anxiety, alcohol withdrawal, and muscle spasms.  Bacitracin is an antibiotic, so this patient also has some sort of infection on their skin (which is also evidenced by the silver sulfadiazine which is also used on the skin – typically for burns).  Based on the drugs alone, I am betting this patient was being treated for burns of some sort – which can be very expensive because of the extensive impact it can cause on the body.

    Now, this patient has several oxycodone uses, which is a strong pain killer, and it’s likely this patient was probably getting opioid medication via IV prior to it being changed to oral opioids.  These meds are great for killing pain, but they also reduce breathing rate (can be drastic if given IV), and cause constipation as well.  They also cause dizziness and confusion – especially in the elderly.  So to sum it up, this patient has a skin infection, is on some potent opioid medications, and is constipated.  The very common effects of these things are likely to result in dizziness, which increases their risk for falling down.  They have a risk to have that infection become systemic.  If this patient is an alcoholic, you don’t have the patience to read what all that would entail – but very simply, they are at risk for seizures, stroke, falls, cross tolerance for opioid use (thus creating a need for higher doses), which increases their risk for reduced breathing, and a host of electrical imbalances that can lead to cardiac dysrhythmias.

    Yes, this isn’t CSI, and I am not doctor.  But my point is, this is a very simple snap shot of a complex medical issue (or at least it can be assumed it was complicated).  And likely, this is page 90 of the bill.  The point is, there was a lot more going on with this patient than meets the eye.  But still, why so much for observation?  Well, when the bill says observation, it’s likely an all-encompassing figure.  It’s not just some guy employed by the hospital to sit and watch the patient (of course, who knows).  “Observation” is vague.  It could mean putting the patient in a private room for 23 hours with telemetry monitoring, regular EKGs, vitals being taken frequently, and a sitter put in the room.  It could also mean they let the guy sleep off his drunkenness and just made sure he was breathing and not choking on his own vomit.  It could mean that the patient had a sitter for 23 hours.  It could be whatever the doctor and nurse feels will ensure the safety of the patient and keep them stable.  Some patients are on oxygen, or ventilation, or are on very serious medications that cause breathing muscles to slow down or stop all together.  So still, why would observation be so much?

    Well, first, you have the little pads that stick in various places on your chest.  Assuming you don’t want used ones, you get new ones (and they don’t cost that much), but the hospital has to pay for them, and they aren’t going to take a loss.  Then, they have to pay someone who knows what they are doing to stick them on you.  The hospital has to pay that person’s salary, and they have to bill enough to cover the salary of their employees.  Then, the actual heart monitor has to be attached to those electrodes (again, hopefully by someone who knows what they are doing).  The monitor wasn’t donated to the hospital – they had to pay for it – and they aren’t going to take a loss when it comes to billing.  Then, if it is a telemetry monitor, that monitor transmits those signals to this room (about the size of your master bedroom’s closet) where your heart’s electrical flow is monitored on a computer screen – one of like 25 to 50 screens in this room.  That monitor is watched 24/7 by a nurse specially trained to read those squiggly lines to determine if you are having dysrhythmias, a heart attack, or arrhythmia (that means your heart stopped).  Most of those screens have alarms – but the alarms are pretty sensitive, so it’s important to have someone there who knows what it all means.  Then, if you do have an issue, that telemetry nurse calls your nurse, who has to drop everything to go check to see if you are showing symptoms of a heart issue or if you just accidentally pulled a lead off your chest.  And the patient who was in the middle of getting their medicine or treatment is usually irritated that we had to leave for a minute to see if the telemetry patient is still alive (of course, no one’s problems are ever as big as our own, right?)  So, this patient needs more than a heart monitor – they need vital signs typically every 2 to 4 hours depending on the situation.  So, that means (for some hospitals) a person has to go in there and wake the patient to get those vitals so they can be reported if there’s a problem.  I failed to mention, but the telemetry nurse and the tech all want to get paid, too – and the hospital has to bill the patient to pay the employees.  Then of course, all hospital staff is trained in CPR and other life-saving certifications in case something should be bad for the patient – and usually, staff pays for their own certifications – so at least that doesn’t get passed on to the patient (although in a round-about way, I am sure it does).  Then of course, some patients that are on suicide watch, have mental confusion, or are dangerous to themselves, require either someone to physically sit in the room with them (a sitter – which they also have to be paid), or they require restraints.  Restraints seem like an easy way out –but we are encouraged to rarely use them.  Using them requires documentation every 15 minutes, orders to be in place for only limited time frames, and far more work than you could imagine.  So if restraints are used, it is a lot more in resources.  And yes, everyone wants to get their hourly pay.

    The cost of the medications (at least the common ones) is not that much.  Of course, I have seen crazy rates for things as simple as Tylenol due to the fact that hospital meds are done differently than you buying them over the counter and even different from getting something from the pharmacy on your way home from your doctor’s office.  A Tylenol is ordered and it goes to the pharmacy at the hospital.  The pharmacy has to pull the med, get it to the floor, and ensure that it will be accounted for that particular patient.  They also have to make sure they have delivered the right dose, the right route, the right drug, the right patient, the right time, etc.  Then, the nurse has to retrieve it.  That involves a machine that requires our fingerprint, then we select our patient from our list of patients, verify how many we are pulling, and again all the “rights” to drug delivery.  Then, we deliver it to the patient.  But of course, we can’t just say, “Here’s your Tylenol.”  We have to verify the patient’s ID to the medication record, ensure they are not allergic to Tylenol, that they aren’t on another medication that would cause any problems when adding it to their system, and that the medication fits the patient’s needs.  For example, if the patient is an alcoholic with a damaged liver, the nurse might call the doctor to make sure Tylenol is appropriate since Tylenol can have adverse effects on the liver.  If the doctor realizes that giving that medication would not be best and another drug might be better, he calls in a different medication – and the process starts all over with a different medication.

    Keep this in mind also – most of the time, on your bill, you will not see an item that reads, “nursing care” followed by a dollar amount.  Why?  Because we are around the clock providing medications, education, a sympathetic ear, arranging discharge, arranging transportation for patients who will be going to rehab centers, coordinating communications with the doctor, giving education about medications and drug processes, arranging and reading labs, confirming and questioning orders, and so, so much more.  Some hospitals are considering going to electronic badges that read when a nurse enters the room and when they leave – in hopes of getting more accurate billing.  But then the argument is; what was done in that time?  Obviously, nurses do a lot.  They hold hair for someone throwing up, help change sheets, and change diapers.  But, they also provide instruction to the new mom about how to care for her first baby and assess patients for in-home violence.  They teach people how to care for their new stump after an amputation, and teach how to do self-insulin.  They deliver meds (sometimes, it can be 20 medications at once)- and if the patient has difficulty swallowing or is old or young, that can take a lot of time.  It’s not practical to bill for nursing time because what we do with our time varies so greatly!  So if a patient required a nurse at the bedside for a lot of in-depth care, that dollar figure might not be out of the realm of normal.  It boils down to about $140/hour.  So, is that unreasonable for 1-5 people tending to “monitoring” the patient at the bedside plus all the monitoring done electronically, charting, drug administration, etc.?  In reality, it’s not.  An average nurse makes about $60,000/year – and they carry patient loads of anywhere from 1:1 to 1:5+.  I worked on a telemetry/step-down unit and we would average 5 to 6 patients per one nurse.  It’s a lot of not getting to take a bathroom break, a lunch break, or working 12 hours – most of which is spent on your feet.  We work behind the scenes advocating for our patients which can easily result in a doctor getting their feathers ruffled.  And that is just one nurse – that’s not including the cost of the equipment, assistive staff, documenting, documenting, documenting.

    Another less examined cost is LAW SUITS.  It’s truly sad how bad law suit abuse can be, and it’s costing us a LOT of money in health care.  Nurses (and most all staff) spend a huge portion of their time documenting.  I mean DOCUMENTING.  We have to document what you say, our interventions we do, if they worked or not, and if you tolerated it well or not.  We have to document when we call a doctor, when we gave report, when our patient goes for labs, when you came back, when you pee, how much you peed, what time you peed – I mean, we DOCUMENT the hell out of everything.  In school, we were told, “If it’s not documented, it didn’t happen.”  Case in point, I have to ask when your last bowel movement was, because if I don’t, and you get so constipated that you develop a blockage, guess who gets the blame.  No, not the obese patient who takes Dilaudid every 2 hours and refuses to get out of the bed while using the call bell as a concierge service.  That’d be nuts, why would it be the patient’s fault?  Nope – it’s the nurse’s fault for not knowing when you had a bowel movement.  These problems have led to pretty much all patients getting stool softeners and laxatives when they enter the hospital (and the same goes for treating stomach acid with Pepcid).  We have to document that you understood when you were told not to get out of the bed without assistance.  Inevitably, a patient will do it, and fall – and suffer bad injury.  But they didn’t call anyone to help.  If we don’t document that you “verbalized understanding,” guess who pays?  The nurse.  So the nurse carries personal liability insurance to protect against being sued, as does the hospital.  These losses are passed on to the next patient in the form of inflated costs for things like medications, observations, tests, etc.  Why?  Because no hospital is in business to lose money.  For every nickel that goes unpaid, the fees steadily go up.

    Oh, and my favorite.  “I am not going to pay my co-pay.  I mean, my insurance pays everything else.  The hospital isn’t going to lose money on me.”  Guess what?  You’re wrong.  Insurance companies take your money – and they want to keep it.  That’s how they make money.   And we know business owners do not go into business to lose money.  Right?  So, simply put – a doctor might think you need a particular procedure.  For example, we’ll say you have chest pain, and the EKG and other easy tests are “inconclusive.”  So your doctor wants you to get a heart cath.  But your insurance knows that is expensive, and they don’t want to spend the money unless they HAVE to.  So they refuse to pay.  Instead, they tell the doctor to do a stress test first.  So, knowing there are rarely patients that will say, “What?  My insurance doesn’t cover it?  Well, I will just pay the $10,000 in cash because I believe I need it because you said so,” the doctor will go ahead and order the stress test.  Now, you had to shoot dye in the blood, run on a treadmill, and you damn near died.  You wait a few hours to find out that it too, is inconclusive.  Now, we have to do the stress test.  Unfortunately, that stress test has to be paid for –and thus the insurance pays their portion, you pay yours, and now the insurance and you both pay again for the heart cath.  Sadly, the heart cath will tell you with conclusive evidence what the problem is when the stress test is less accurate (but cheaper).  But, it was a gamble the insurance company took with your money and your health.  Sometimes they are right, sometimes they aren’t.  But they don’t want to pay for the more invasive yet more accurate test without first ruling out every other way of finding something that is cheaper and less invasive.

    Now, you might think the insurance paid a huge amount and you shouldn’t have to make that co-payment.  Well, most insurance companies pay a greatly reduced price for a service/test as compared to the “cash” price.  For example, the heart cath might normally cost $15,000 for someone without insurance (because it covers the cost of the doctor, the nurses, the machine, the meds, the emergency equipment and staff that has to be on standby should something go south, and don’t forget the liability insurance for everyone in the room and the hospital itself, recovery in the ICU, etc.)  But if you are fortunate enough to have insurance, you would only pay a flat fee or a percentage.  Well, your insurance company has an agreement with the hospital and/or physician that says each time the procedure is done, the insurance will promise to pay $9,000 instead of the $15,000.  Well, that’s a big difference!  But, the doctor accepts that though he won’t make as much per procedure, he is guaranteed that amount to be paid, and usually it will be paid all at once instead of $50/month from a cash patient.  Plus, by accepting a particular insurance, the doctor/hospital hopes that they will get a good portion of that business.  Maybe they accept United HealthCare.  They hope that United HealthCare will tell you, “You can get that procedure done at State Hospital.”  And of course, you will call there to arrange the procedure.  Everyone benefits. Right?

    No.  If you have no insurance, guess who doesn’t benefit?  The cash paying guy.  The guy who is at the end of his rope, has sold his house, and sold all his textbooks on E-Bay and still doesn’t have enough.  He doesn’t benefit because no many of us have $15,000 sitting around for a heart cath.  That guy gets screwed.

    So in the end, yes, it’s far better to have insurance than not.  But, the cost of health care isn’t jacked up simply because doctors are overcharging for services and nurses and making huge bank.  A huge cost problem is the fact that the patient who weighs 400 pounds won’t go on a diet, has a heart attack, and when he dies on the OR table during a by-pass, his family sues because the nurse didn’t document that the guy had a bowel movement yesterday.  Yes, it’s an over-simplified reason, but believe me, people sue for far less.  Every time someone sues a doctor, a nurse, a hospital, etc., the costs keep going up.  And let’s face it, anyone can sue for any reason, justified or not.  And, many doctors and nurses have told me that often, settlements happen because it’s more “cost effective” than going to court because unfortunately, no matter how right you are, a jury of your peers is more likely to believe the victim due to the suspicion of the health care industry as a whole.

    Perhaps I will follow this up with studies of law suits on health care costs, but it’s doubtful.  I am not saying health care as a whole doesn’t charge inflated prices; I am simply saying the reasons might be more in-depth than you realize.  Is it right?  I don’t know.  I see it on all sides.  I do my best and give my best to every patient, and I try to keep costs contained where I can without jeopardizing the care I give.  But you’d be surprised; most doctors feel the same way.

    I think law suits and personal responsibility (or lack thereof) has caused our health care costs to be insane.  Everyone knows being obese is bad.  Smoking is freaking deadly!  It’s been proven!  They print it on the side of every damn box of cigarettes sold, and yet, people buy them and smoke a pack or two of them every day.  But, who gets blamed when they get cancer?  Oh yeah, Camel Joe did it to you.  Just like McDonald’s made you fat and your cholesterol high.  The coffee was too hot.  The bartender didn’t cut off the patron.  The cop got sued for pursing the bad guy who ran off the road into a tree and was injured.  The burglar sues because he was injured while burglarizing someone’s house.  This is the society we live in.  Everyone wants quick answers, fast action, and they want it for damn near free.  They want to (in many cases knowingly) destroy their body, but don’t want to feel it while they do.  They want the giant chicken breasts but want them freakishly huge WITHOUT chemical enhancements – oh and the chicken has to die humanely.

    Seriously, I get so frustrated sometimes with our society.  We have so much beauty and potential.  But we are progressing at a rate our bodies cannot keep up with.  We want huge athletes and demand extraordinary performances, but we drag them before congress when they are using steroids?  We want to eat a freaking hamburger for $1, but we want it to be all natural.  Then we freak out when we discover they are putting pink glue stuff in our meat patties to stretch it and keep it cheap.

    We create the supply and the demand.  We have to take responsibility for our actions and accept that if we choose to live fast, we are going to die fast.  If you want to reduce health care costs, there’s no law, no President, no one but YOU that can do it best.  Stop the indulgence and get out of the habit of living in demand.  Instant gratification is not without its negative effects.  We can’t sit by and eat chemicals by the pound for next to nothing, smoking, drink, pollute our environment and complain when we develop obesity, diabetes, heart disease, stomach ulcers, high blood pressure, COPD, and die 10 years before our time.  Granted, some people have illness – that’s been a part of mankind since our first steps on the planet, I’m sure.  But if I had to pick between having Eve’s health risks versus today’s health risks, who would I go with?  An easy, convenient, fast food, disposable life is costing us in far more ways than deteriorating health.  It’s destroying our integrity, our families, and our morals.  You can go against the grain or roll with the punches; but nothing worth having is easy.  Get on board with living right, or start picking your plot and picking out your casket.  You can’t have it both ways.