Excessive and unrealistic

Vox investigation exposes emergency dept. billing abuses, but also its own ignorance of nursing

A Vox piece commendably highlights excessive emergency department charges. But the piece reflects the view that only physician “treatment” and expensive equipment have any value. Apparently, triage does not. And nurses don’t even seem to exist.

May 1, 2018 – Today Vox posted a piece by Sarah Kliff as part of an admirable project to highlight excessive emergency department (ED) fees. It’s worth quoting the headline and subhead in full: “She didn’t get treated at the ER. But she got a $5,751 bill anyway; Vox’s emergency room database shows that patients can face steep bills even when they decline treatment.” Wow, so some unscrupulous ED staffer must have stolen patients’ information as they were just walking by the entrance, right? Well, not exactly. It turns out that the main examples Kliff offers are patients who did receive skilled ED care, including triage and enough evaluation that they walked out with “tangible” health items like a bandage and ice pack. But Kliff seems to think the only things that might merit a real charge would be a “diagnosis” or “treatment from a doctor,” or perhaps some tangible health equipment with greater value. In fact, health care is primarily about skilled services that require many years of training, including nursing care. The piece does consult one ED physician, who agrees that the charges at issue sound excessive, while mildly suggesting that (in Kliff’s words) “physicians should get paid something for triaging patients because it’s a valuable service in its own right.” But the piece mostly suggests that triage is trivial because it’s not “treatment.” In reality, the task is a challenging one that requires advanced skills from the nurses who generally perform it in EDs. Indeed, the main case Kliff cites itself contains a hint about why triage matters: the patient in question bumped her head because she fainted. The piece treats the fainting as unremarkable and the bump as minor (although it eventually required plastic surgery). But a triage nurse would have asked why she fainted and whether that reflected a serious underlying condition that might merit close and timely attention. Health care is not mainly about ice packs, but about careful thinking, a lot of which is done by nurses. We appreciate Vox’s effort to challenge abusive billing practices, but this piece does so in part by pretending that nursing has no value—or that it doesn’t even exist. Consistent with the vast majority of health care stories to which nurses could add value, no nurse is consulted here, and the word nurse does not appear once.

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No treatment

Kliff’s piece focuses on the case of Jessica Pell, who in October 2016 “fainted and hit her head on a nearby table, cutting her ear.” Pell went to Hoboken University Medical Center, where she reportedly got an ice pack and a bandage, which she says is “the only tangible thing they could bill me for.” She got “no other treatment” and no “diagnosis,” but did later get a bill for $5,751. In an appeal letter, Pell also stated that she “was triaged, waited and taken to have myself examined;” one Vox headline referred to her visit as “a triage visit.” The plastic surgeon she would have seen at the hospital was out of her network, so she left to see an in-network provider in order to avoid costs she could not afford. Ultimately, her insurer Cigna paid $862 for the hospital visit, an amount its contractor had determined was “reasonable and appropriate,” but that left her with a $4,989 bill. When Vox contacted the hospital for the story, it would not comment directly on the bill or its rates, but it did reverse the entire balance, including Pell’s $100 co-pay.

The story also provides context for Pell’s experience under the subhead “High bills but no treatment.” Vox’s extensive “ER database project” reportedly discovered many examples of EDs charging patients hundreds or thousands of dollars “for walking through the door.” Some “never got past the waiting room”; others “were triaged, but none received treatment from a doctor.” Some patients “declined treatment because they learned it would be out of network, were frustrated with the wait time, or began to feel better.” Nonetheless, all “ended up with significant medical bills” from the hospital.

The piece provides the additional example of Carolyn Wallace, who brought her 4-year-old daughter to the ED at Houston’s Memorial Hermann Southeast Hospital after she “ran into a coffee table and cut her forehead above her left eyebrow.” The piece states: “The only medical care Elizabeth received in that time, Wallace says, was a physician assistant taking her temperature.” Then Wallace went to an urgent care clinic where the girl “received liquid stitches.” But the hospital wanted $300 and the PA wanted $669. Wallace thought that was exorbitant, seemingly because the hospital did not give them more physical objects (“They didn’t give me new gauze or a bandage or replace the paper towel we brought from home. They didn’t give me anything to clean it with.”). The hospital reversed the $300, which the piece explains “is typically called a ‘facility fee,’ the price of entering the facility regardless of what happens afterward.” Hospital executives defend such fees, the report says, arguing that they “help them keep the lights on and doors open for whatever emergency might come through their doors, anything from a stubbed toe to a stroke patient.”

Vox closes the piece with commentary from experts who question the fees, which have been rising very quickly in recent years. The piece consults Kentucky ED physician Ryan Stanton.

Generally, Stanton argues that physicians should get paid something for triaging patients because it’s a valuable service in its own right. “I think there needs to be a fee because there is work done, there is responsibility taken by the provider,” he said. He noted that in Kentucky, for example, the state Medicaid program typically pays a $50 fee for triaging its patients in the emergency room.

It’s not clear if Stanton himself said that “physicians” should be paid for triaging, as if that was something they typically do, or if Kliff just assumed that it must be. Could this mean physicians should get paid even though nurses do the work, since nurses are just physician tools? Stanton does say the charge for Pell’s care seems “excessive and unrealistic.” He also confirms that it’s difficult for patients to learn how much a facility fee or triage will cost at their local hospitals.

It certainly does seem like some of the charges Vox has identified are excessive and unexplained. And we commend the publication for highlighting this important issue. ED billing seems tailor-made for abuse, since patient information and bargaining power is obviously low.

The problem is that most of the report seems to reflect a simplistic view of what health care is, one that operates in particular to erase nursing care from the ED. At some points the piece equates the health care patients receive with the physical objects they walk out with, the ice packs and bandages. At other times it characterizes the services they get as requiring little time or skill because they are just taking a temperature or “triage.” The piece emphasizes whether a patient got “treatment” or a “diagnosis” from “a doctor,” as if that was the real measure of whether any value was conveyed. But ED patients get as much nursing as physician care, and nursing has equal value.

In particular, “triage” is a complex process that requires a great deal of expertise, which is why the nurses who typically do it should be highly experienced ones. Few patients, or journalists, are in position to know everything a nurse is considering when asking the questions and making the observations that go into skilled triage. Stanton suggests that triage is a service that has some value. But Kliff doesn’t really seem to buy it, and in any event the piece suggests that triage is a physician function, or at least one for which they should be paid.

Consider the piece’s main example, the patient Pell. Is it possible the ED staff was considering and investigating potentially more serious issues for her? Pell did not just bump her head in a common mishap. Instead, she reportedly fainted and sustained an ear injury bad enough to require plastic surgery. Why did she faint? Were there underlying issues that could present any immediate or ongoing risks? Were any tests run or at least considered? Evaluating those issues fully would require skills and many years of advanced health training.

It seems likely that patients should have better protections and clearer decision points to avoid unwanted charges. But that does not mean that nothing of value has been called into play in the ED.

And even apart from the skilled care, how does Kliff think the hospital gets the patient information needed to send a bill?  Did the lights and the doors automatically record it? We don’t think so—not yet, anyway. Typically it is a human being who gathers that information, one who must take time to perform the work, for which the person must be paid and should be paid.

We realize all of this complicates the investigative journalism narrative, but reality sometimes does that. We appreciate Vox’s effort to highlight excessive ED charges, but the effort is undermined by an apparent failure to understand basic aspects of health care, especially the central role that skilled nurses play. Consulting nurses for the story might have helped.

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