Under Obamacare Er Costs Actually Increased

Based on 2011 data by the Health Cost Institute (PDF), the average cost of er visits increased by 5%, to about $1,381 per emergency room visit.

That is about a month of rent for some Americans. It remains above $1,000 per visit (average) nationally. This is much more than an average Primary Care visit to the doctor.

However, in the Obamacare health care paradigm, the frequency of er visits is increasing.

Why? PCP’s may be turning down patients because the Obamacare health plans don’t give a high enough reimbursement to physicians and clinics.

ER Costs
The above table by CareFirst.com compares Urgent Care costs versus Er costs, based on presenting symptoms.

A 2015-typical emergency room visit for a cough shouldn’t cost $1000, but the resources needed to run an emergency room department often require these charges: ER’s are equipped with modern technology, 24/7 nurse and physician staff that is specially trained for acute emergent situations, not to mention security staff for protection of patients, visitors and staff.

But there are even more startling developments regarding er costs that would shock most people:

There is a huge variation in the cost of each er visit: “Bills sent out for sprained ankles ranged from $4 to $24,110,” according to a report by the Washington Post.

Reasons to Go to the ER: Part 1

Why do we go to the ER? For a cold? A cough?

No: The ER is where true medical emergencies are presented by a patient and treated by a skillful emergency medical “pit crew”. Their job is not to be your primary care doctor, it is to save a limb, to treat people who have been in an accident, to save the life of a friend, brother, sister, father and mother. When we misuse the ER for coughs, to get a general health check up, we are using up the resources in our local area that could be used to treat a truly sick person faster. Even with the current process of triaging patients (prioritizing the severity of symptoms in patients and ordering who will get treated in which order), having nurses and other medical personnel tied up with registering non-emergencies makes little sense.

What if, while the ER fills up with non-emergencies, the nurses have to turn someone away who has a deadly and sudden condition? It’s time to pause and call the primary care physician, or locate another option like Urgent Care if it is available; most emergency room visits in the United States are NOT emergencies and a waste of this emergency resource.

The below conditions are considered true emergencies and if you exhibit these conditions, you SHOULD go to the ER.

Severe Headache. On a pain scale, it’s 10/10 – Headaches like this may come with vomiting, hematemesis and other conditions. If you feel it is the worst headache in your life, then you SHOULD go to the ER.
Exacerbation of a Chronic Condition: when a previously diagnosed condition becomes worse, or new symptoms arise. A person with chronic fibromyalgia who develops severe spasms and excruciating pain should go to the ER. A person with increasing numbness in their extremities while undergoing chemotherapy should go the ER. A person who had a mild allergic reaction to a food they ingested now develops increased swelling of the face and arms SHOULD go to the ER.
Severe Medication Side Effects such as shortness of breath, chest pain, loss of vision, hearing and any other side effect that results in bodily dysfunction or damage. A person takes a medication prescribed by their doctor and as their doctor indicated, they experienced one of the side effects which is very severe: chest pain. They SHOULD go to the ER for a side effect that suddenly develops and is severe.
Asthma Attack, Difficulty of Breathing, Shortness of breath. A person unable to breath is in grave danger of losing consciousness – if they are on the road, this can be doubly dangerous. This person SHOULD go to the ER.
Chest pain, pain in left arm or jaw, sudden weakness or dizziness lasting longer than two minutes. May indicate a heart attack or loss of consciousness.

Go to Part 2 of the Series: Reasons to Go to the ER

Photo by Tony Webber (CC)

What is an Urgent Care Center? Are they Okay to Go to?

What is an Urgent Care center?
UC careAn urgent care center is a business that provides non urgent health care services. Many urgent cares have differing operating hours – some may be open 24/7 and others only until 6PM on some days of the week. It is a good idea to call before you go to any nearby UC, as they may have limited operating hours – unlike the ER.

Urgent care offices may refer patients to the ER if the severity of the condition is beyond the available experience of the personnel, or the services provided by the particular urgent care office. Bill Fay of Debt.org writes, “Care at urgent care centers is paid for on a fee-for-service basis. They usually accept most private health insurance plans, with co-pays averaging between $25-$50.”

The Cons of urgent care offices:
– Urgent cares may close as early as 6PM (see above example), so may not be a reasonable option for medical care, late into the evening.
– Close times and opening times vary greatly as well as schedules. You should call or visit their website to make sure they’re open before you go to an Urgent Care.
– Still may be too expensive for low income patients. Cost per procedure varies by business.

– Cannot treat complex conditions or serious injuries, so they may refer you to the ER if you have a more serious condition than they are able to treat.

The Pros urgent care offices:
– Faster-than-ER wait times and some are open 24/7.

– Treat minor injuries and illnesses.

– Faster-than-PCP wait times(you are seen the same day as opposed to being seen 1-3 weeks later at a PCP).
– Less expensive than ER*.
– Some insurers cover certain Urgent Cares and encourage you to use them for non urgent reasons.

Suggestions on selecting an Urgent Care office for non-urgent health care needs:
To ensure you have the best experience do review the Yelp reviews available online to help make a determination; take into consideration that one bad review does not necessarily make an office unworthy of a visit – but three or twelve do make a difference when there are no positive reviews.
– One bad review does not make a bad Urgent care.
– Many bad reviews and no positive reviews may indicate a poor office for health care needs.
– Overly positive reviews may not all be genuine, if the office is particularly new.
– Exercise a bit of careful scrutiny and ask family and friends for suggestions on options.

*ER visits MAY be covered by your insurer so may not cost you anything. Please speak to your insurance provider regarding going to the ER and if it will cost you anything. On the other hand, Urgent Cares NOT covered by your insurer will cost you out of pocket or some other amount. Please speak to your insurance provider.

Image credits: Tom Woodward, CC

Nearly 70% of Americans are on at least one prescription drug

An article worth noticing — 10 Big Pharma Statistics That Will Make You Cringe, by Emedcert.com:

“It’s been called America’s New Mafia; it’s been blamed for killing thousands of people. In the 2015 Harris corporate reputation poll that measures the quality of an industry’s reputation, the pharmaceutical industry ranked 9th out of 14 industries, with only 37% of public mentions being positive.”

Further, the article shares these figures and citations:

“- Nearly 70% of Americans are on at least one prescription drug, over half of Americans take two prescription drugs, and 20% of Americans are on at least five prescription drugs – Mayo Clinic

– For every $1 pharmaceutical companies spend on R&D for a new drug, they spend $19 on advertising that drug – BMJ

– 51% of drugs prescribed to Americans are generics, but they only make up 8% of the country’s total amount spent on drugs. The other 49% are the drugs with exclusive marketing rights, which makes up 92% of the total drug spending – IVN

– The percent markup of the prescription drug Xanax is approximately 570,000%. That means that the consumer cost per 100 tablets is roughly $137.79, while the cost of the active ingredients is $0.024 – LiveStrong

– In 2013, the total amount spent on drugs topped $329.2 billion. That’s roughly $1,000 per person – Last Week Tonight”

Reasons to Go to the ER: Part 2

Do you visit the ER for primary care needs, like mild coughs, prescription refills and general health checkups?

If you are one of the millions of Americans using the ER because you have no other option, please read this article.

A spotlight on the tremendous cost of ER overutilization and misuse:

The Huge Cost of Misuse of the ER: “Misuse of EDs accounts for $4.4 billion in waste annually and contributes to the high cost of American health care.” Georgia Health News
ER Over-utilization & repeat usage: Of 53 Million ER visits between 2006 and 2010, about 8 percent of patients returned within three days, and 1 in 5 made a repeat visit over the next month; a third of revisits occurred within three days, and 28 percent over a month, occurred at a different ER. Press Herald
Post-Obamacare ER usage: “Doctors say emergency room visits have increased since the advent of Obamacare”. Washington Times
ER Prescription requests & abuse: “More than two million people went to the emergency department in 2010 because of misuse or abuse of drugs – that is well over 6,000 ER visits a day.” Drug Abuse Warning Network’s (DAWN) 2010 report
Emergency Room Staff: Their Job and The Cost of Misuse
The ER is where true medical emergencies are presented to be treated by a skillful emergency medical team of doctors, nurses and medical assistants, specially prepared to treat life or death health emergencies.

Ideally, people who truly need emergency care would go to the ER – but today’s Emergency Departments are frequently misused for relatively tame conditions, such as coughs and moderate fevers.

Sometimes people go to the ER for second opinions, a place to stay, prescription refills and — very inappropriately — for nothing at all!

It shouldn’t surprise the reader to hear that this type of misuse of the ED is a tremendous waste of state and local resources, and a burden on this much-needed emergency resource.

According to Georgia Health News, “Misuse of EDs accounts for $4.4 billion in waste annually and contributes to the high cost of American health care. Patients with insurance are often unaware of the actual costs of the medical care they receive at an ED, because they pay little or nothing out of pocket. ”

The following reasons are appropriate uses of the ER. After this list we will give you three options for health care that you should consider as good ways to get the non urgent care you need.

Examples of Appropriate Use of the ER
Although these are examples, they will serve to clearly separate in your mind what a life or death health care need is, versus a low urgency health care need.

Conditions that qualify as an emergency and are appropriate use of the ER:

In children:

If your child is turning blue or pale, has slow or labored breathing, is lethargic or hard to wake.

Why: Turning blue or pale is an abnormal state for a child, indicating suffocation and/or organ dysfunction. This child SHOULD go to the ER.

A fever of 101 or higher for babies under 3 months.

Why: In this early stage, babies can be vulnerable to all kinds of health conditions that may require medical attention immediately. This child SHOULD go to the ER.

Severe abdominal pain or possible appendicitis *
Why: Appendicitis can be deadly. Severe and sudden pain in the abdominal area can be/can become a very serious condition.

Ingested toxic chemical or medications – poisoning and drug overdose
Why: The faster a chemical or poison can be cleared out, the better. Organs may begin shutting down if an accidental overdose has occurred.

Head trauma with loss of consciousness
Why: A loss of consciousness is an uncertain condition which requires further study; and head trauma can result in further harm to you that may manifest much later.

Severe difficulty breathing or asthma attack
Why: shortness of breath, work of breathing and asthma attack are a dysfunction of the body which may lead to suffocation and death.

Broken bones
Why: broken bones along with bleeding or loss of consciousness and severe pain should be treated at an ER where the staff is specially prepared to treat this type of injury.

Pressure or tightness in the chest
Why: Pressure or tightness in the chest may indicate a more serious condition.

Why: Bleeding that doesn’t stop may lead to loss of consciousness and needs immediate attention for evaluation of severity and treatment.

Severe Burns
Why: Severe burns are significant injuries that require immediate attention, much like prolonged bleeding.

Severe falls, even without injuries
Why: A fall, whether very severe or minor, may not show symptomatically immediately after the fall. It is good to get checked out, even if it has been a day or two after the fall. Like car wreck injuries that aren’t visible on the patient, fall injuries can manifest a little bit after the accidental fall and may be severe.

Car or motorcycle wreck / bicycle accident / work accident
Why: Some injuries are internal and may go undetected by hospital staff during the initial evaluation immediately after a collision or workplace injury. Sometimes a patient will come in days after complaining of severe pain, though at their initial presentation in the ER they were able to leave ‘without injury’.

Assault / Domestic Abuse / Rape / Suspected Child Abuse
Why: If you have been assaulted, the police department or the emergency room are the proper places to go. Any assault warrants a visit to the ER and local police should be called on to investigate. Suspected child abuse should be reported to police for investigation.

Why: A stroke can be deadly and manifests in different ways. Some of the ways to identify a stroke is by looking for one of the below conditions or all three:
– Drooping on one side
– Weakness on one side
– Slurred or strange speech
Call 911 if you see any of these signs.

Three options for medical care that is effective and can be faster than the ER:

1. Go to Urgent Care!
Call a local urgent care, find out if they’re open, and ask them if they take your insurance.

Ask them if the symptoms you or your child/friend has are worth going to the ER for.

Then go and get your condition treated.

Urgent cares have varying operating hours so calling the office you are considering is best before heading out. If you regularly have moderate conditions that need care, you could jot down your favorite local urgent cares that you can go to. Since some insurers will cover urgent care visits (please call your insurer to confirm), it will be less expensive for you and less expensive for the state, alleviating the burden on the local ER(s).

2. Call your insurer to locate your PCP and schedule an appointment.
Doctors shouldn’t be hard to reach, but if you have trouble getting an appointment, face lots of delays in your care – then it’s time to speak to your health insurer and ask them to give you another PCP (primary care physician). Not all doctors do a good job of spending an appropriate amount of time with each patient – some are hurried, some don’t express the attention and care needed to treat a person and send them home with assurance and hope. It’s good to find one that listens to you, provides you more than 10 minutes of their time to answer your pressing needs, and will be happy to speak to you over the phone. A doctor shouldn’t avoid his patients, nor should he hold them in suspicion.

3. Learn to treat common illnesses such as coughs, colds and fevers at home. Some conditions simply require that you wait them out, like a cold. A child with a fever can seem like a disaster to parents that have never been instructed by grandparents or parents to treat it; it’s important that you be educated, so spend some time in the library, or on webMD studying how to treat common illnesses that don’t require a PCP or an ER visit. Some parents go to the ER today simply because no one taught them how babies behave in their first 12 months. This lack of education leads to worried, frightened parents; if you are a grandparent or an older generation of parent, instruct your children in the treatment of common health problems.

Image credits: Lee Cannon, CC

7 Ways to Avoid Going to the ER This Winter

#1 – Call to schedule a visit to your doctor.

Talk to them about your concerns.

Your PCP can speak to you about your minor and non urgent complaints, or chronic conditions.

Running out of diabetes, asthma or other medication?

Low to moderate back pain?

It’s time to follow up. If you’re elderly, speak to a family member about helping you schedule the appointment and the transportation. Did you know? Some insurers now provide free rides to see your doctor.

Primary care docs can get to know your individual medical history, how you respond to certain medications, and prescribe you a variety of treatment options, or give you their best medical advice. They cannot always see you the same day, but they can get to know you and your health concerns more thoroughly.


Schedule a doctor’s appointment for a routine check up.

Find out who your primary care physician is by calling your health plan.
No insurance or doctor? Find free clinics near you
It’s good to establish rapport and communicate by phone or email with your doctor, especially if you are frequently ill and will be needing prescriptions.

Some go to the Emergency Department for an opinion on multiple complaints of very minor urgency. Perhaps they need to find another primary care physician; their insurer may be able to assist in reassigning them.

If you don’t have a doctor yet, call your insurer. You can also find clinics that are free in some states and cities. Lastly, Urgent Care centers may be able to provide care much faster than the ER. If you call them, you can find out about their payment options, in case you aren’t covered.


#1b – Call your dentist or an emergency dentist to treat your teeth.

Many people go to the ER for dental pain, when a clinic specially made for emergency dental treatments may be open and available to help. Give them a call. If they absolutely cannot treat you, they will likely send you to the ER anyway.

Why not try them first for that toothache?

Q: What leads to dental damage?

  • Lack of daily brushing, flossing (the brushing action, not the fluoride)
  • Sugars, acidic drinks, coffee, citrus drinks, black teas, pop and smoking
  • Fluoride is harmful to dental health and humans.
  • REDUCE ACID AND SUGAR CONSUMPTION. Drinking fewer pop drinks and coffee.

REGULAR BRUSHING ACTION. Brushing once in the morning and in the evening or after meals can be helpful; brush gently for about 1-2 minutes, without pushing too hard, and slowly for a much thorough and pain free clean.

Q: What can help teeth?
Drinking water, brushing your teeth daily, eating more vegetables, and reduced pop, black tea, dark roast coffee consumption. Stop smoking cigarettes, marijuana and drug use as they harm the whole body.

Starting a little at a time may be the easiest way to develop better habits for your teeth health.

# 2 – Keep a map of urgent care centers.

Put it on the fridge, near your computer at home, or enter a few of the nearest Urgent Cares into your phone just in case.


#3 – Be prepared.

Ensure you have a supply of fever reducer, Tylenol or aspirin, cough drops, honey and chamomile tea, in case you develop illness.

Some of us frequent the ER for coughs and fevers that can simply be treated at home with a fever reducer, cough drops and patience. 1-2 days of a cold, cough or fever may resolve itself within a week, sometimes less without a visit to the ER.


#4 – Drive carefully.

Drive with caution in winter weather. Minimize driving during holidays.

Accidents happen in fog, rain, snow weather, from lack of sleep, drug use, and cell phone distracted drivers.

Exercise restraint or leave the phone behind, if it’s too difficult.
Watch for black ice.


# 5 – Moderation.

Drink in moderation during festivities. During holidays and encourage others to be responsible about recreation.


# 6 – Shop safely.

When shopping, be respectful, safe, patient in crowded malls and shops. If you wish to avoid crowded shopping areas, try online shopping.


# 7 – Watch for ice.

Dress warmly, as necessary for the weather and look below to prevent slips down icy stairs, sidewalks and walking paths.


Feature Photo Credit: Maria Michelle

Prudent Lay ER Claims Reconsiderations

What happens when a reconsideration or appeal is filed against the prudent lay reviewer’s decision?

When a reconsideration is filed by a provider, the insurance company must review the claim once more under the Prudent Lay standard.

  • The reviewer must be a different person and not the initial reviewer.
  • The review must be done if it is the first reconsideration request.

Any second, third, fourth reconsideration request must go through the appeals process which may differ from state to state.

However, this means it will no longer be the responsibility of the insurance company. It is recommended that providers send in all relevant documentation during their first reconsideration request of the insurance company. This will ensure the insurer has proper documentation and does not need to reject the reconsideration for lack of proper supporting documents.