The Emergency Room, we’re not just for emergencies anymore…

Dr. J. got sleepy when he was typing his last post, so he forgot about getting to his point which was that medicine evolved to the point where the regulations and billing processes are so complicated, that the free-market exchange of goods and services no longer exists. In fact it’s difficult to figure out how much anything costs so it’s tricky to figure out what a reasonable price to do this in the clinic would be.

After digging, Dr. J. ran the list of items of how much it cost if he did a thorough return to clinic visit for an established medicare/medicaid patient in Mrs. Dr. J.’s shoes and how much it would cost Dr. J. to provide her with 2 litres of iv fluids over four hours in his office. This is all theoretical.

Total material cost

IV Start Kit – $2.27
IV Catheter – $1.23
Clave Connector – $2.69
IV Tubing – $1.55
10 cc Saline Flush x2 – $3.84
Normal Saline – 2 Litres – $10.50
10 cc Syringe x 2 – $0.28
20 gauge needle – $0.11
Red Top blood collection tube – $ 0.24
Purple Top blood collection tube – $0.36

Diagnostic Testing

Complete Metabolic Panel – $38 + $28
Complete Blood Count – $24

Total COSTS – $113.07 for materials.

CMS Reimbursement for Hydration (4 hours)
Clinic ‘Level Four’ Evaluation – $76.55
First Hour – $57.08
Second – Fourth Hours – $45.87 (total)

Total Medicare Reimbursement $179.50

Overage to cover the cost of the doctor’s time, nurses time, and general office overhead: $66.43.

That overage would be greater with private insurance, to be sure.

That is definitely not enough to cover the cost of doing business, especially if you assume that you’re taking up a clinic room for four hours to run the IV fluids in. Then there is the opportunity cost of not being able to see other patients efficiently. Perhaps if the physician had an extra room for these sorts of things, but then that would also be contributing to his overhead in square footage, liablity insurance for a broader scope of practice, etc…and you can clearly see why folks are routinely shunted to the emergency department for these sorts of specialty maneuvers where the cost breakdowns are different.

The emergency room can bill $114.66 for the facility and if Dr. J. understands correctly $217.75 for the physician fee. This brings reimbursement up from $179.50 to $435.36 for the services rendered (plus the additional $76.55 to the PCP IF she saw the patient in clinic rather than sent the patient to the ED after talking by phone.

What this does is it transforms the Emergency Room to a mission that goes beyond emergent care to acute specialty therapies that primary care providers are no longer equipped to perform themselves. Dr. J. saw a patient in his office who reaccumulated  fluid in his belly due to liver disease. Dr. J. is neither his hepatologist, nor is his office equipped for him to tap the fluid, not that he couldn’t it’s easy peasy apple squeezy to do. So he called his GI buddy and said, hey, can you do this. The GI guy said it’s kinda a clusterfuck, but he could and would rather do that than send him to the ER for them to do or to admit to the hospital for him to do. He got it worked out, but he’s still trying to figure out a better system to do paracenteses for patients in the outpatient setting.

Dr. J. expects a $1000 estimation of benefits from his insurer. Given he paid a $115 copay, he will probably be on the hook for a little bit more. God only knows how much BC/BS paid NAITMC for services rendered, probably $400. None of which makes sense beyond that Dr. J. agreed to the terms he signed up for with his insurer.

In a more transparent, less regulated market based model, the doctor in his office would probably charge between $250-300 depending on what the market would bear. Dr. J. thinks mosts would find this reasonable.

Dr. J.