Crash Cart: Out-of-network bills, Thanksgiving injuries, and an app for stroke image sharing

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This week: 1 in 5 ED patients may still receive a bill from a doctor out of network. Plus, Thanksgiving’s most common injuries. Join in as our editors discuss the week’s headlines.


Surprise! Here is another medical bill.


A new study shows 1 in 5 patients who visit the ER may still receive a bill from a doctor outside the hospital’s insurance network. Original Article by The New York Times.

Jaime Hope, MD: The article uses a lot of sensationalized words – patients are “caught in the crossfire”, it is the equivalent of “carjacking”, “financial roulette” and patients getting a “bait and switch” – it seems like they are vilifying doctors who want to get paid for doing their job! I like the parody video. Patients deserve transparency in billing from their insurance companies and doctors deserve fair compensation from insurance companies. Let’s evaluate the insurance companies rather than call doctors “carjackers”!

Seth Trueger, MD, MPH: There’s a lot going on here, and we’re not entirely blameless here. Loren Adler makes a great point that the main carrot insurers have in good-faith negotiating with physicians in general is to provide patients: “cut us a deal and we’ll bring you patients” — which doesn’t really apply to us because we don’t rely on insurers to bring us patients. (And remember that the average ER income has increased from around $230k IIRC to $320k over the past decade). The main issue: when it comes to negotiating networks, insurers know we have an EMTALA obligation to see patients regardless of whether or not we get paid, so they are free to walk. And because of the structural divide between many hospitals and physicians, insurers still get to list our ERs as “in network.” Insurers have done a great job of labeling this a “surprise bill” problem rather than a “surprise lack of coverage.” I just don’t think there’s a market mechanism to fix this, and unfortunately the truly unfortunate stories of patients being hit with huge bills, particularly in other settings (the secret out of network anesthesiologist or second surgeon) might lead to a heavy-handed legislative ban on balance billing. There’s some reasonable fixes to Medicare’s “greatest of three” rule, e.g. setting a floor for rates that insurers have to pay for out of network ED visits (e.g. 250% the Medicare rate).


Nicholas Genes, MD, PhD: Still trying to figure out how “financial roulette” is different from regular roulette.

Ryan McKennon, DO: It’s like carjacking. Except you are giving the keys to a carjacker you sought out.  Then you and the carjacker to take a look at the car, do some tests and find out whats wrong. Then the carjacker does an expert job of fixing your car. Then the carjacker gives you back your car. Then you’re pissed when your insurance does not cover the cost of the repairs to your car even though they told you the shop where the carjacker worked was “in network.” Otherwise it’s exactly like carjacking.


Thanksgiving: The first cut is the deepest.


Knives, not deep fryers, are the most common Thanksgiving-related injury. Wild turkey attacks made the list as well… Original Article by Vox.

Jaime Hope, MD: I admit that I’m surprised that there aren’t more deep-fryer related incidents – usually combining alcohol and dropping a heavy cold object into boiling oil leads to some level of shenanigans.  I’m wondering how many burnt floors occur with this cooking method. The statistical graphics were entertaining. And it left me wondering what kind of “refrigerator or freezer mishaps” are occurring.  Tipping? Hands getting too cold? I did learn (although probably could have figured it out on my own) not to chase a wild turkey; the turkey itself doesn’t kill you but the barbed wire fence or ground might!  Of note, having worked the Monday after the Thanksgiving holiday weekend, I can say in a completely non-scientifically way that this Thanksgiving holiday caused increased CHF, COPD, chest pain, abdominal pain, depression, need for med refills, and vaginal bleeding – at least according to the stats of my shift.

Nicholas Genes, MD, PhD: In a way it’s comforting – with so much disturbing news this month, the media still loves to publish holiday-related harm pieces. Maybe readers like the schadenfreude, or are simply thankful they don’t have it worse. And the data is out there, waiting to be queried, no matter how limited it is (how do 100 hospitals combined only add up to 358,000 visits?). At least the writer isn’t trying to influence policy.

Ryan McKennon, DO: I was a bit disappointed to see that both injuries from “wild turkey attacks” were from people who were hurt running away from turkeys. It would be a much cooler story to be mauled by a wild turkey then tripping and breaking your wrist while running away from one. If you are going to get hurt, might as well have a cool story to go with it 🙂



App for strokes extends across hospitals.

Acute stroke images now can be sent without a neurologist present. Original Article by Medscape.

Jaime Hope, MD: It’s a brave new world. You can fear the technology or embrace it, it is coming either way. Issues like security, reimbursements, and malpractice protection will arise. Overall, it sounds like this App and other Telemedicine technologies are improving patient access to quality care. Beam me up, Scotty!

Nicholas Genes, MD, PhD: Jaime is right – it’s a brave new world – and people are asking, appropriately, why consumer tech is so far ahead of health IT. Smartphones have facilitated image sharing and videoconferencing for years, while hospitals have hid behind HIPAA and the bureaucracy of mandated business agreements and pricey vendors. Now that the rest of the world is shooting ahead, too, I hope American patients won’t tolerate delays, much longer.

Ryan McKennon, DO: I don’t think hospitals are “hiding” behind HIPAA and the dense regulatory requirements. I’m sure most would love to implement something like this that is cheap and easily to use but do not due so because of the fear of penalties, fines, and lawsuits that would inevitably flow from using an app like this. Trim down the regulation and make it more reasonable and I think you will see this type of service being implemented much more rapidly.



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