Real Life ER Visit — Some Pitfalls

One winter afternoon Mr. C was at his health club  enjoying a workout on the StairMaster. Suddenly, he began to have a nosebleed.    In the past, any nosebleed would go away with some pressure but this was different, the bleeding  just would not stop.  Driving his car was out of the question.  Fortunately, another health club member offered him a ride to the ER.  On the way they passed an urgent care clinic but did not stop.  They were concerned the urgent care clinic might not be able to stop a nosebleed.   The towel he used to catch blood was getting very red and he was a little frightened by the thought of bleeding to death.

Holding his nose with the towel he checked in to the ER and was quickly taken to an ER room.  After 20 minutes a nurse evaluated him and took his blood pressure.  His nose continued to bleed and 30 minutes later a doctor arrived.  He put drops of epinephrine in the nose followed by a nasal pack.  The bleeding stopped, he was given an antibiotic  pill (ciprofloxacin), he  rested a few minutes then his wife took him home.  A few days later his wife removed the packing as directed.  Problem solved — at least the bleeding problem.

He eventually got a statement from his Medicare (MC) supplemental insurance company.  

Item Charges MC Allowed Out-of-Pocket
Facility charges $3,569.05 $310.92 $0
Procedure (30903) $681.00 $139.85 $0
epinephrine 4 drops $204.60 $0 * $204.60
ciprofloxacin 500mg $50.82 $0 * $50.82
TOTAL $4,505.47 $450.77 $255.42

* Medicare would not cover (“allow”) the medication because the medication was categorized as an outpatient charge.  What Medicare does not allow supplemental insurance will not allow either.  So, the patient has to pay.

Wholesale prices of medications are as follows:
epinephrine 1 mg/ml (0.1%) 1 ml ampule $2.55   (charged 80 x cost)
ciprofloxacin 250 mg 2 tablets $0.45                       (charged 110 x cost)

See the reference on nosebleeds (epistaxis).

Could there have been another way?  Less waiting and less cost?  Perhaps.  Consider the following alternative scenario:

A patient had a nose bleed for 5 minutes at which point he called his on-call primary care provider (PCP).  The patient was instructed to go to an urgent care center.  Waiting was minimal since bleeding is a big deal at the urgent care center (at the ER there are bigger things going on).   The treatment at the urgent care center was the same as the ER except a prescription for ciprofloxacin was given to him which he picked up at the 24 hour pharmacy ($0.50).    The charges and out of pocket expenses for the urgent care visit were as follows:

Item Charges MC Allowed Out-of-Pocket
Procedure (30901) $275 $94.32 $0
epinephrine nasal $20 (est) $0 $20.00
ciprofloxacin 500mg $0.50 $0 $0.50
TOTAL $270.50 $94.32 $20.50

It is important to note there is no “facility” charge at the urgent care.  Only hospitals can charge for use of the facility.  Ostensibly, this is to offset the costs of maintaining higher staff levels to be ready for really big emergencies.  In effect, by going to the hospital ER the patients with minor problems subsidize the patients with major problems.

The bottom line:  At your next visit with your PCP discuss how they want you to handle minor and major emergencies.  In general, if you feel you have time, call your PCP’s office (even at night because someone is on call) before going to the emergency room.  Use urgent care centers rather than the ER if possible.  Don’t accept a facility dispensed medication to take at home if there is a nearby 24 hour pharmacy.  If your PCP is aware of an urgent problem they will likely follow up when needed.

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  1. #1 by RxforAmerica on January 5, 2013 - 4:41 PM

    In addition to the differences in fees, I think the entire way that a complaint is approached in the emergency department is different and more costly and patients are often unaware of this. If a patient goes to the ED, the physicians there are trained to treat it as an emergency situation. They will think in terms of the worst possibilities that could cause this type of complaint. A problem is approached with concern about what prompted this patient to feel a visit to an emergency department was necessary. The emergencynprovider also must consider what problems to rule out in case this patient never follows up with another health care provider. The evaluation must be done in a time efficient manner as well and tests that are more time efficient and require less follow-up are often more expensive. This leads to more expensive and more frequent imaging scans, more IV fluids and medications, and more procedures. Emergemcy providers may also feel obliged to “at least do something” and often patients after their 8-hour wait in the triage area may request or agree to more treatments and interventions than might be provided by a lower acuity care setting. Any ideas of either health care policies or things providers might do to steer people toward more cost effective options than the ED for appropriate conditions? I enjoy reading this blog as a start.

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