aka American ER Doc Gone Walkabout… 010
I had hoped to do some comparisons, between Tassie and the US, of the prices attached to ER care – from what the patient sees.
Unfortunately, I can’t seem to be able to find anything about the payments requested of patients for emergency care in Australia – and I didn’t manage to hurt myself while in Tassie, to test the system myself. Google: nothing. Pamphlets from the various state health boards: nothing. I was never asked to generate a charge code while working in Tassie. What’s up? Don’t you guys ask the unfortunate to pay for their misfortune? How could that be? Maybe I’m missing something.
In the US, the patient might start facing billings very early on in his ER visit, and then receive a bill for charges that have no bearing on what he will be expected to pay, and never actually figure out what the medical care actually “cost.”
A maze of federal laws and regulations start the process: we must perform a “Medical Screening Exam” – an MSE to decide if there is an emergency medical condition. However, we can’t try to discourage a patient from coming to the ER by telling him how much it will cost. So, at some hospitals (most others never tried this, or have given up) the patient gets a brief exam. If no emergency condition is present, he’ll be told that to continue further evaluation, he’ll need to pay first for the MSE.
(If an emergency is likely, skip the next step and go on to ordering the CT scan – everyone in the US gets one, I believe. If you’re not sure whether his vomiting is from something in his head or something in his belly, get 2 CT scans – even if he’s vomiting from something that was in the sushi – remember, I can’t charge extra for merely making a brilliant clinical diagnosis.)
Back to the non-emergency MSE… Now, he gets the first shocker: typically $400-$500 combined physician and hospital bills. Depending on his insurance (remember in the US there are about 467 gazillion different insurance plans) – he may be required to pay anywhere from $3 to the full $400 to continue evaluation and treatment of his non-emergency condition (plus the charges for the rest of the ER visit). If he decides not to pay, and goes home, he just gets the bill for the MSE itself. $400 or so to be told there is no emergency. (I can’t for the life of me understand why more hospitals don’t do this: isn’t this a reasonable and easily administered system? Maybe it’s made less desirable by the fact that every third patient threatens a slow and painful death to the physician.)
So, the emergency patient continues on through his evaluation and treatment and then tries to figure out: how much did this actually cost, and how much do I have to pay?
Now, our hypothetical patient eventually receives a bill (in the US, a separate bill for the hospital charges and for the physician fees).
A basic but quite ill patient, but eventually discharged home, but with pathology and imaging might get a charge of $850 from the ER Doc, and something in the $2000 to $5000 range for hospital charges including pathology and imaging. But, only if you’re uninsured (and usually poor), would you actually be expected to pay that much. Various governmental and private insurance covers would pay roughly half of the physician charge and about 30% plus or minus a bit, of the hospital charges. Even if you have a very high deductible (I have a $6000 deductible – bet you can’t get that in Oz), the charges first get “adjusted” to the insurance’s contracted charge, and I pay only that much. Only the poor with no insurance have the opportunity to pay the full bill – which appears to have no relationship to the actual cost of providing their care. Isn’t America a great place! (Sorta fits in with people like Mitt Romney – sadly, I expect that many from Oz actually know who he is – making $60,000 per day but paying 15% in taxes, while people making about that much per year pay a bit more, and people making 2 days worth of his income per year pay 30% in taxes. America, the land of opportunity.)
Oops, sorry, I’m supposed to talk about medicine.
So, here’s some real life examples from my personal experience:
A mammogram. A bill is generated and sent to the patient ( my wife) for $455. If she had no insurance, like 15% of Americans, the hospital would try to get her to pay that bill (actually, the imaging department would never do the test unless she paid prior to the non-emergency test. We have insurance with a high deductible, so we’ll pay the bill – but first it goes to our insurance company for “adjustment”, and the new adjusted bill comes to us $77. We pay $77. What did the test cost? Certainly not the $455 that an uninsured person would be asked to pay? $77 that an insured person pays? Something less?
More dramatically: a little bike crash. Final diagnosis list: LeForte 2 and other facial fractures, mandibular degloving, multiple crushed facial lacerations, C5 lamina fracture, moderately bad traumatic brain injury (took a couple months to think clearly enough to return to work, but ER Doc’s have low cognitive needs, so it was pretty quick – the residents did the maths for me when needed), and a host of others. 5 days ICU, week in hospital, 6 hours theatre time plus 3 more hours by plastic surgeon debridement and initial closure in ER, multiple CTs and MRIs.
- Hospital bill: $74,348. Adjusted bill: $18,876. I paid deductible, insurance paid the rest.
- Plastic surgeon bill: $9,192, Adjusted bill: $2,013. Insurance paid that.
- Emergency physician charge: $805. Adjusted charge: $450
- Total Radiologist charges: $1083 Adjusted: $437
(As I was rounding those numbers to the nearest dollar, I was reminded: Have you Aussies ever noticed, that you have no Pennies? Where did they go? What happened? Are there no frugal penny-pinchers in Australia? If you do have frugal people, what do they pinch? Just asking. No criticism implied.)
If this had been my son, self employed without insurance, he would not get those adjustments, and, unable to pay the bills, would have filed for bankruptcy – as do many other Americans with major illnesses, each year.
Estimates suggest that about 60% of bankruptcies in the US are related to medical bills.
My insurance contract is considered by hospitals and doctors to pay reasonably well – so, I would conclude that collecting about 25% of the hospital bill, and between a third and half of the doctor bills, provides adequate compensation for the time and costs involved. Howzat?
So, it seems that the true cost is something less than the $18,876 of the adjusted bill. And, that the plastic surgeon was satisfied with the roughly $225 per hour of his time that he was paid – and didn’t really need, nor expect, to be paid the roughly $1,000 per hour that he charged. I trust that you get the point.
(Just noticed: He also charged separately for an open nasal fracture. I always thought that the nasal fracture was part of the LeForte – be pretty hard to do the LeForte and skip the nose. Maybe I’ll ask for a refund. One might conclude that scamming to increase the revenues is part of the American game. You might be right.)
Now we have a system that generates a charge that is not expected to be paid, but which can bankrupt many people. An adjusted charge, which appears to be a revenue that will pay adequately for the costs of providing care. And no ready way of understanding what care really costs. A CT scan is charged at $2000, but the expected revenue from a good insurance contract may be only $500, and the average cost of doing the CT scan may be $400, and “marginal cost” of doing one additional scan may be only $20 for a non-contrasted scan.
So, if I’m trying to make rational decisions, what number do I use? I don’t know.
It helps to explain the common “gripe” among US ER Docs that their collection rate is less than 50% of billings (about 22% in the ER at University Hospital) – the charges are inflated beyond any expectation of payment. Our expected, optimized expected payment should probably be about 50% or less of what’s actually written down. It also helps explain why some cost/benefit analysis in American medical journals is hard to fathom – the articles often just pull charge data which doesn’t relate to reality. But a federal legislative proposal to have an American version of the UK’s NICE (National Institute for Health and Clinical Excellence) is a political football with charges of “socialism” for trying to figure out the cost and benefit of various clinical care strategies.
So, I guess we might never know: It cost what?
Don’t forget to read previous installments of ‘American ER Doc Gone Walkabout‘.
About Rick Abbott
What. A. Mess.
Please explain to a non-American: Why on earth can insurance companies single-handedly adjust charges, and why are the hospitals content with the adjusted amount? Is this some sort of rebate programme?
I’m not Australian, but I would like to tell you how things are here, in Germany. More than 90% are in the government-mandated but not government-run health insurances. They currently charge 14.7%. Of that, 7.7% go off your gross income, the other 7 are paid by the employer.
Your two incidents in Germany would have cost you this: Mammogram: Normally €5, but is waived for preventative measures. Otherwise payable upon entry to the physician’s office. Don’t know what the physician bills to the insurance but it is in some catalogue somewhere, I can look it up if you want.
Bike accident: €5 for Ambulance, €10/day of hospital stay. Would have maxed out at 28 days/€280. €5/annual quarter for follow-up visits. Total of medical copays must not exceed more than 1% of annual income.
Going way back into the 70′s, hospitals and doctors sent a bill for a charge that approximated the income that they needed to make a reasonable profit (including enough so that they collected enough extra from paying patients, to make up for those who didn’t pay). Changes in insurance plans resulted in an inflationary race between falling insurance payments -- as a percentage of the billed amount -- and the increase in billed charges: if inflation is, say, 2% -- but the insurance payment falls from 90% of the bill to 88%, then the medical care provider needs to increase his billed charge by 4% to keep up with falling payments and inflation. 40 years later, the billed charge no longer reflects the cost of providing the care nor the required payment to cover the cost of the care.
Let’s say that a physician wishes to make $150 an hour and provides a service that usually takes an hour (ignoring overhead, billing, etc. costs) and provides that service to 5 different people: one with no insurance who will pay 20% of the bill and then skip the rest of the bill, one on Medicaid (insurance for low income Americans -- but generally only those pregnant or with children, though that is scheduled to improve with the new healthcare legislation) which might pay 30%, one on Medicare (for Americans over age 65) paying 40%, and one with “good” private insurance (generally only available and affordable through an employer provided insurance cover)paying 50%, and finally a self-employed guy who has lots of money, but can’t get insurance because of a “pre-existing” condition -- toenail fungus or something (this is also scheduled to be revised in the new healthcare plan -- no more rejections because of pre-existing conditions) who will be expected to pay the full amount. So, to collect $750 for the 5 procedures, with these (fictional, but not too far off) payment contracts, the doctor will have to charge $312.50. In fact, the discrepancy is much worse because nobody has 20% of their patients paying 100%, and is likely to have more contracts paying closer to 40%.
Similar maths hold true for hospitals which need to cover their costs.
In a rational world, the hospitals and doctors would stop the madness, and list, as their billed charge, the payment that they would expect to receive from their best insurance contract. And, they would accept that from their uninsured patients. My best guess is that the inflated charges are kept as a public relations ploy -- allowing them to whine in public about their poor reimbursement: “Can you believe, I took out that gallbladder, and insurance paid only $2000 of my $5000 bill? I’ll only be able to afford a single shot Latte at Starbucks this week.”
The picture is further muddied because until the 1980′s, hospitals would itemize bills: $1.00 for a bandaid, $50 for an hour of nursing, $100 for some ertapenem, etc. Since the 1980′s hospitals have been forced to transition to a bundled payment scheme: $10,000 for pneumonia, $12,000 for CHF, $15,000 for a STEMI -- again fictional amounts. The hospitals try to cut costs -- home a day quicker, once a day antibiotic administration if possible, whatever. The insurance plans (primarily led by Medicare -- the federal plan for oldsters) try to restrict that by penalties -- such as no payment if someone is readmitted within a short time -- presuming that the readmission might have been prevented by longer or better treatment the first time. The initial ER care gets bundled into the payment, so for admitted patients, the true costs of ER care are buried deep within the hospital accounting system.
Of all this, the patient sees only the initial -- very large -- bill, the EOB (Explanation of Benefits) showing the “adjusted” (i.e. what the insurance has a contract to pay) bill, and how much of that bill will be paid by insurance and how much is left for the patient to pay. The patient might be tempted to believe that the insurance company is his friend: “Look what a savings the insurance company negotiated on your behalf.”
You might be tempted to believe that all this paperwork generates overhead costs that far exceed overhead costs of any other medical system in the known universe. You might be right.
(BTW, the new American healthcare plan does require insurance coverage of a defined table of preventive health benefits, so this year that mammogram would indeed be free. If the wackos (I include here the supreme court as a potential wacko nominee) don’t succeed in derailing the healthcare plan, I consider that the plan, even with all its blemishes, may potentially bring the US into a semblance of a humane society. Just so you know a bit where I come from.
Finally, next time I crash my bike, I’ll ride to Germany first.
Thank you, Rick, for the heads-up.
So it is the insurance companies who use their clout to contractually cut prices and extend that cloud to their customers as a service, even if the company itself doesn’t pay a dime. Which wouldn’t be too terrible if that didn’t make the hospitals to overcharge everybody without an insurance, i.e. the poor.
Did I get that right?
Reading your answer to Minh Le Cong, I realized that I had forgotten another group of co-pays in the German system AND got some numbers wrong, which I’d like to hand in belatedly for fairness’ sake.
When you hand in a prescription in at a pharmacy here, most medicines cost €5. Some medicines, usually ones where your insurer got a good deal with a pharma company, especially generics, are free from co-pay. Others cost €10 or more, but honestly I don’t know which ones or how much.
Now correction 1: Seeing a physician in his office is €10 per quarter, not €5.
Correction 2: The 1% of income co-pay ceiling is valid for patients with chronic diseases only (defined as any illness where the treatment exceeds two years), while everybody else has the ceiling at 2%. There are more limits in place, but going into them would go too far.
Oh and another point: Children until their 18th birthday do not have co-pays. At least that part is simple.
When you’d like to ride your bike here, you are cordially invited to our beautiful rural bike paths, which are even nicer without crashing. If you must, however, crash your bike, doing so in the UK, France, Italy or anywhere else in the EU should be a similarly non-bankrupting experience. Or Oz. Or NZ, or Japan, or… well you get the picture.
Cheers!
P.S. Those who have opted out of the usual scheme have more U.S.-style private insurance. Biils are WAY lower but then the insurers don’t “adjust” them.
P.P.S. I believe “medical bankruptcy” is a non-term outside the U.S.
Rick, once again , great piece of medical journalism! can I ask if in the US, you have to pay full price for medicines as a patient. here in Australia, we have a great scheme called the PBS or pharmaceutical benefits scheme, where the government heavily subsidises the costs of medicine, in particular for pensioners. Also, when you go work at the Indian Health Service , do the patients still get charged or is it free?
If I sound breathless, it is because I just shoveled a meter of snow off my deck. And picked up the pieces of a bird feeder that a bear had torn down. I presume that this is as foreign to Ozzies as the American non-system of care is.
The answer to the pharmaceutical question is: it depends. With no insurance, medicines can be quite expensive. Even with governmental Medicaid and Medicare, some medicines may be quite expensive or unavailable. With private insurance, medicine costs depend on the plan and whether the medicine is available as a generic, or only as a brand name (typical might be $8 for a generic, $25 for a brand name without an acceptable alternative, and $50 or $75 for a brand name with an alternative available). Occasionally, you get a really good deal. A patient once showed me his receipt for linezolid: “Your copay is $9. You have saved $2001 dollars on this prescription. Medication non-compliance is a big issue here: even with insurance, many patients cannot afford the co-pay. A couple years ago, one of our large chain stores -- Walmart -- started a $4 program. They generated a list of perhaps 50 medicines available as generics, and charged $4 for a 30 day supply for chronic drugs, or for a typical course for acute care meds like antibiotics. However, the list is pretty limited. It forced many of the other pharmacies (chemists) to match their price -- that’s one of the good things about the competitive market. As another example, i use a steroid nasal spray -- cost $58 without insurance, $38 with my insurance “adjustment”, $24 if I mail order it from Canada, and $12 in Oz. I bought a whole batch and brought home with me (sorry, Australia, I took advantage of your good nature. I didn’t really need to do that, I suspect it was illegal and if the US homeland security folks monitor this I’ll spend time in jail, but it just felt so good to save a couple bucks.)
It’s not uncommon for us to admit a patient with something like heart failure, who is sever failure because he couldn’t afford his medications. So we spend thousands on his monthly “tuneup” admission because he can’t afford, or his insurance doesn’t cover the full cost of, a couple hundred dollars of meds. Same with asthma, when the patient can’t afford those $80 HFA puffers. Or far more expensive combo steroid/long acting beta inhalers.
Indian Health Service: it’s a mix. If I understand correctly, the individual never pays. But, the IHS always tries to collect what it can from any insurance the person has: Medicare, Medicaid, private. It’s one of the dumb things about the system: ultimately, the payments all come from the federal government coffers (except for a small proportion of our patients with private insurance). But, one part of the Federal Government (the IHS) sends a bill to another part (Medicaid), and the bill gets “adjusted” and paid. Extrapolating from our costs when I worked at a private hospital, the billing cost is about $15 -- $20 per visit just to get money moved from one government account to another. A first year accounting student would flunk his exams if he designed the system. The final bit -- a bill to the patient for the remaining co-payment is skipped by the IHS, and paid directly from the IHS accounts.
I’ve seen estimates that we’d have perhaps 18% more to spend on patient care if the only accounting required was internal accounting controls rather than all of the billing and adjusting (sorry, don’t recall the reference -- it was a few years back -- comparing US and Canada.)
Thanks RICK . I understand why you Yanks are so good at emergency medicine now. You get lots of practice on really sick patients who can’t afford their primary care and chronic medicines
Here in FNQ we get a lot of patients who are not eligable for medicare so frequent play a part in compiling bills for their ED visits. Once the triage staff are aware of their status many will round down their triage if possible to decrease the bill with Cat 5 costing around $200 and Cat 1 costing just over $800 from memory. This does not include any pathology (one off cost of around $19 for all bloods regardless of the number of tests requested) and imaging (around $50 for a plain CXR and $600 for a non contrast CT chest & abdo). Most of the bills I have compiled have been for GP worthy presentations which is crazy seeing as they charge $70 or so for a similar service to a Cat 5 presentation, but I guess thats where we make the money!
Those prices don’t sound too far off (if you’ll accept within 150% ad not too far) from what they would cost in the US if we billed for something that we actually expected to collect from insurance.
At one time, we rationalized charging more than the office based doctors because of the time inefficiency of ER’s -- we would sometimes sit around for hours waiting for a real emergency to happen. But, that was when mostly emergencies came to ER’s. Now that we see so many non-emergencies, the patients wait for us, rather than us waiting for the patients. But the charges stay the same -- we just don’t collect what we charge. I’m losing track of the logic here. Or, perhaps, there is no logic to keep track of.
Absolutely brilliant Rick, thanks for this.
I recently met a guy from the USA whose son died in his mid-twenties of DKA -- didn’t know he had DM and was sick for a week or so but didn’t want to go to hospital as he had no insurance and huge bills from a previous illness. DKA patients don’t die that frequently -- they get sick as hell but to die because you couldn’t afford the potential bill is a bit shocking
Isn’t it a remarkable mix: large numbers of folks with non-emergent conditions, but no place else to go, that clog our ER’s and hamper our ability to care for the emergencies. Contrasted with cases like yours who avoid the ER because of costs that they can’t afford, and have a moral sense that they should not use a service that they can’t pay for, -- and instead pay with their life. Sad.
I wonder if charging patients a small co-payment, as in Germany, might decrease our ED overcrowding? It might encourage patients with minor conditions to go to their GP instead of clogging up the ED. I feel that in Oz there are too many people wjust are advantage of the fact that ED care is free, and don’t realize how much it is actually costing the government (and taxpayers).
In the US, the copays are pretty large ($250 wouldn’t be to uncommon -- waived if you are sick enough to be admitted) for private insurance, very low for some of the public insurance ($3 low). But are not usually collected at the time of the visit -- so the deterrence to inappropriate usage is limited. Back in the late 80′s, there was a large push to collect the copayments up front. It became an administrative nightmare and was abandoned fairly promptly.
I agree with Rick.In GP land in Oz, we have been charging copayments for years and it does not deter anyone.Most EDs in OZ are part of the public hospital system, that we all fund as taxpayers…so to ask for extra copayment for a public service is like raising the taxes for all.
And remember that 13%of Australians live in rural and remote Australia, pay taxes like everyone else, yet see none of the tertiary ED facilities down the street where they live.
solutions to ED overcrowding are more involved than charging punters a fee.
Sorry about the typo in my original comment -- should say ‘too many people who just take advantage of the fact that ED care is free’.
Minh, I don’t quite see how asking for a co-payment is like raising taxes -- after all, it will only be patients using the service who will pay it, not everybody. (Of course, everybody still pays for the bulk of the services, via funding of the hospital.) Rural and remote Australians who never attend a tertiary ED will not pay it either. Perhaps I am not quite understanding your point, if that’s the case, please clarify.
Co-payments in GP-land are different and weren’t set up to deter people, but to improve remuneration for GPs. (Actually I’m not sure they don’t deter people -- I’m pretty sure I’ve met people who presented to my ED for minor conditions because they didn’t want to pay to go to their GP.)
I agree that the overall solutions to ED overcrowding are going to be complex, and trying to deter ‘GP-patients’ from ED isn’t the most acute issue at the moment in terms of affecting patient outcomes. But they are an inefficient use of the health dollar, and also has adverse impacts on quality of training and trainee satisfaction (as an advanced ED trainee, I definitely see this among my peers).
Sally, I appreciate the viewpoint you are taking. In the ED there are lots of presentations that could and should be handled elsewhere. By asking people to make a copayment , I dont see how this is going to change things in the ED. And where does the money go from this copayment..back to the politicians and bureaucrats..so hence my analogy that it is like raising taxes. If a hospital were to try to keep the money their overall budget from the feds would be cut. As for rural Australians, well some come into town to do shopping and other things and might even take a holiday in cities so will turn up to ED in the big smoke! To make them pay for that visit to a big smoke ED when they pay the same regular taxes as anyone else, yet have none of the benefits of a tertiary ED in their rural town..to my mind thats asking a lot of good will. When I work in the ED in Cairns, I agree that there are lots of presentations that are due to the fact a GP was either not available or the patient just did not bother going to see a GP in the first place. The ED here recently increased there bed space and guess what , it is always still full or short of acute beds. I totally agree with your view that it is an inefficient use of the health dollar which should be invested in keeping as many people out of hospital as possible. But asking citizens to pay extra when they do go to ED already exists in OZ, namely the private health system .
Hey Sally, Minh and Rick,
The problem of GP patients clogging up EDs is a myth and blown out of proportion. It is easy to say after the fact that a presentation was not an emergency, but it may have seemed like one to the patient. There are also numerous other reasons why ‘GP-like patients’ come to the ED, not least because a GP refers them! Also, most ‘GP’ patients can be sorted out quickly and pose little burden to the ED -- and those that can’t be sorted out quickly usually need to be somewhere like an ED where there are resources available.
Finally, it is sobering to remember that if you add up all the deaths by triage category of patients presenting to ED, triage category 4 has the most deaths.
http://www.mja.com.au/public/issues/190_07_060409/ric11435_fm.html
http://lifeinthefastlane.com/2008/12/myth-conceptions-of-er-overcrowding/
http://www.mjainsight.com.au/view?post=sue-ieraci-emergency-departments-are-not-full-of-gp-patients&post_id=458&cat=comment
Chris
The non-emergent presentations in the US, exceed manyfold my experience in Tasmania -- perhaps generally for Australia. And the non-emergent presentations vary by location. When I worked in yuppie, rich Boulder, they were for convenience (I’m rich and important, so you can take care of me when I want), or for high tech (I called my GP and he said I might need an MRI for my back pain, so go to the ER), or for scheduling (Grandma has been deteriorating for months, and today can’t walk, and I can’t get an appointment with her gerontologist -- yeah, really -- for 3 weeks). At University Hospital, the non-emergent presentations tend to be social safety net: “I lost my job, and with it my insurance, so my GP won’t see me anymore.” “I moved from Florida to Colorado, so lost my Florida medicaid and it will take 3 months to get Colorado medicaid, so here I am with my chronic CHF and out of medicine.” At the Indian Health Service, we see a very poor, very rural population, with a no-show rate of over 50% for scheduled visits: “I had a clinic appointment yesterday, walked an hour from my hogan to the road, but nobody picked me up hitch hiking.”
Over the years, a variety of techniques have been tried to dissuade such non-emergent ER use: collecting copays up front, contacting GP’s to see if they’d take patient at office, etc. None have worked, and most have been a real pain in the neck.
Federal law now prevents attempting to collect a copay until after a patient has had a “medical screening exam” and a determination has been made that no emergency exists. What’s the point, then.
Copays don’t deter the rich folks. Copays don’t deter the poor since they generally don’t have another option, and might not pay anyway when they get the bill -- and if poor an uninsured and get a gigantic bill, they simply can’t/won’t pay.
My opinion is that, in the US at least, the issues are systematic: access to care (even in the rich city, access is difficult: when I went into practice, the office docs scheduled 4 patients an hour and kept open an hour a day for walk-ins. They have been pushed to be “efficient” -- now many schedule 6 an hour with no unscheduled walk-in time. So, grandma goes to the ER when she finally dwindles enough to be unable to walk.), office docs being willing to work with uninsured patients needing care, and (is it too much to hope) someday, universal insurance coverage.
BTW, for any of you Aussies who follow the depressing US political news: Would it be too much to hope that US catholic bishops consider it moral to lobby for universal health care insurance and access to even the most unfortunate in society, and stop whining about being pushed to provide insurance coverage for contraception? WWJD? Make sure that hemorrhoid care is provided for their former altar boys?
Rick, its a bit too coincidental but the Oz federal government just passed an amendment to enable means testing of the private health insurance subsidy that comes out of our taxes. its weird but we all pay taxes to fund our public ED system yet still have to pay for this subsidy so that some of us who choose to take out private health insurance, can be financially assisted to do so, so they can go to a private ED. I think this kinda helps alleviate public ED overcrowding but at least in OZ, we all have to pay for it, even if some might never use it. The means testing now should address some of the fundamental inequities of the system that existed before, Saliently, the money saved is being pumped into more public dental services. I don’t think anyone who has worked an overcrowded ED would not be in support of more dental services.
Yet another fascinating post from Rick giving insight into the US system which paints the Australian system in a very positive light.
The discussion has also been very interesting. Keep these posts coming!
Andrew
ED Registrar, South Australia
As a non-doc (and admittedly the brother in law of Rick!), I found T.R. Reid’s book “The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care” comparing funding for medical care across the developed world a must-read, and amazed that my GP and nurses in the office here in liberal Boulder were unaware of it! We subsribe in America to our “exceptionalism”; at the same time we are letting insurance companies work for the betterment of shareholders, not patients! US is the only country in the developed world that lets sick people go bankrupt, or allow their care to be determined by their financial condition.