1. AMA (American Medical Association) artificially controlling the number of medical graduates based on a quota. Every doctor starts of a huge debt, and many don't get to practice. No experienced doctors from other countries can practice here.
2. Hospitals (many owned by Private Equity) - Maximize profit / patient. Don't show prices, lots of outrageous billing for basic care like Ibuprofen and bandages. The bills keep on coming for months after care.
3. Doctors - Gotta pay those debts. No prices advertised, Inflated costs for basic care. Specialists are booked for months.
5. Insurance companies - Can only make max 20% on administration costs. Love the high prices and denying claims for whatever reason they can find.
3. The politicians - Make $$ from lobbying insurance companies and big providers. Employers sponsored health insurance means individual workers don't have same bargaining power.
Essentially we are paying a fortune. ~5 trillion for healthcare. If we pooled all that money into a govt funded insurance pool, and removed artificial license quotas, market advertised prices, we'd have a much more efficient healthcare.
The corporations know the individuals can't coordinate between themselves to take them out. They have captured the market.
Instead we have a huge administrative bloat, gofundme pages, lowest mortality amongst the rich countries and a shit show.
That's completely ridiculous. The bar is pretty high for me to go to an ER, I'm pretty sure anything on that list would need treatment faster than 6-10 hours.
Hell, its not recommended to keep a tourniquet applied for more than two hours and even then there's a specific protocol to follow as there's risk of what will be released back into your system.
What are people even going to the ER for when they can wait for 10 hours?
I'm an ER doc. I work 3 nights a week and see probably 5--10 patients a week who have waited over 3 hours.
The basic answer: most people don't go to the ER for emergencies. That is, they go for something like a rash, cough, or fatigue that they know is not an emergency. Many of them just want work notes, although some are convinced they have a legit emergency.
We scoop up the real emergencies from the waiting room ASAP. Eg, no one in the waiting room is wearing a tourniquet; if they are, it's my job to either fix the bleed or get them to a vascular surgeon ASAP if I can't.
The majority of people who spend hours in the ER waiting room have vastly higher time preference than your or I, and often lower socioeconomic status and higher anxiety as well. Often they can't afford phone service or even a car, so it's hard for them to get places quickly. Others are homeless and want a place to sleep or very anxious and just want to be somewhere with other people in the middle of the night.
In the past year I've gone to the ER with my late 70s dad almost once a month including multiple waits in the 6-12 hour range.
* Any time a senior (I guess anyone, really) falls and hits their head doctors want a head CT. Only place to do that is the ER, but if you aren't showing any symptoms of a brain bleed or similar problems, you're low on the priority list.
* Dad had IBS and problems with severe constipation. Twice he was having significant abdominal pain and we were told by his GI doc to go to the ER for a CT to make sure there wasn't a serious problem going on. But again, pain with a history of constipation and no other immediate symptoms lands you low on the triage list. And indeed both times he was just constipated.
* The worst time - the 12 hour wait - he was experiencing severe altered mental state. His neurologist, who normally has a 2-3 month wait for an appointment, thought it was serious enough to see him the next day. After examining asked if we could go down to the ER (their office is attached to a hospital) for a lumbar puncture and other tests to rule out a brain infection. Again, apparently the ER docs disagreed, so in the waiting room we sat.
In general though my observation from all of those hours sitting in ER waiting rooms was that a significant portion of the people there were really just sick and probably should've been at urgent care or their PCP.
My wife is a pediatric ER doctor. The majority of the patients she sees shouldn’t be there from a strictly medical perspective.
But parents can’t get off of work while anything else is open, first time mom doesn’t realize that a slight temperature and a cough isn’t an emergency, dad is finally fed up that his teenage daughter has been complaining of a tummy ache off and on for 6 months and Sunday at 2am is when he finally decided he had to have answers.
> Hell, its not recommended to keep a tourniquet applied for more than two hours
Minor note: this is somewhat outdated. They've determined now it's more like 4-6 hours before it causes any damage at all.
Per Stop the bleed, Mayo Clinic, etc.
But yea faster than 6-10 hours that's for sure. I bet if you went into that ER with an average time of 9 hrs and a tq stamped hour ago on your arm, they'd get you in pretty fast though. Triage is still a thing
Most people go to the ER for non-emergencies. The good news: if they have you sitting around for hours then it means it was not an emergency and you (probably) won't die.
Be worried if you check in and they hurriedly shuttle you into an exam room. That means they think you have an actual immediate life threatening emergency.
We have private healthcare so you need medical insurance for treatment - if you don't then they stabilize you and send you to the nearest state hospital if it is warranted.
State hospital - lots of folks who got stabbed or shot due to alcohol or crime related violence - apparently overseas medical students love to come here to learn all about trauma surgery and getting to stitching people up.
Private hospital - people with babies who have fever or crying and folks with chest pains and in my case a kid who just had seizure - she got first dibs to ER because they triage cases.
I'm not sure why at that point it's even considered an ER visit.
Clearly if you can wait 10 hours for something, it wasn't an actual emergency. Are hospitals just gambling that these people won't die in the waiting room? What's actually going on?
Is there a perverse financial incentive to drag it out?
ERs prioritize on severity, not first-come-first-serve. If you go for stomach pains and while you're waiting, someone else comes in with a severed limb, they will get seen right away and your wait just got longer.
More notably, more serious problems may require more staff. If the nurses are busy cleaning up bio material, you get to wait a little longer too before you get triaged.
The incentive is not to drag your wait out, so much as to have the minimum staff needed to keep patients stable. Stabilizing people in critical condition is literally the one job of the emergency room.
On the other hand, people go to the ER for all kinds of reasons that are more urgent than urgent care, but less than true emergencies. Sometimes, they even go because they can't be denied admittance for lack of ability to pay, when a general practitioner at regular practice would have been a more appropriate physician to see.
All of that said, a 10 hour wait either means there's an absurdly high number of non-emergencies, or they're facing severe shortages (self inflicted or otherwise).
Yes, a large fraction of ER visits aren't emergencies. Typically they triage new patients, take the actually critical ones immediately and everyone else waits.
I'm not sure wait time is an informative metric, vs something like survival rate for different kinds of conditions.
As someone who has far more reason to interact with ERs than the normal person, if you have a problem that needs to be seen within the next week by a specialist and not just a GP, you have to go to the ER to actually get it addressed. Otherwise you won't be seen for months.
The fact that this is even a point of investigation is very frustrating. Wait times at local restaurants in my area are basically constant and will remain so, because if there is an observable queue, someone opens a new restaurant or an existing one puts on more staff and finds space for more tables.
If people were permitted pay directly for emergency visits, and new hospitals allowed to open then it would be ridiculous for there to be a general problem with trending wait times. Someone would add more emergency capacity somehow. That isn't even in conflict with keeping a public system either, there can still be a public system. Just let people who can afford their own emergency care fund their won care.
The problem here is precisely that deliberative bodies trying to work out how much emergency care is required instead of creating an easily-joinable class of people who benefit financially from providing care and leaving decisions up to them. That works well for almost literally every service out there and there is no reason to think it would fail for emergency healthcare. These people attending clearly have hours to shop around.
The article is hazy on this point, but the monopoly agreement set an slo of 220 minutes (3 hours 40 minutes), and it was fairly stable, but worsening by tens of minutes per year.
Since then, the hospital in question increased to 10 hours 45 minutes.
Worse, the federal government stopped tracking this metric, and now, among hospitals that elected to share the number, the median is over 5 hours.
So, if you live in the US, you’re probably screwed, regardless of whether you live in appalachia.
In addition, depending on how you model ER admissions using queueing theory - the wait times very quickly goes exponential with even relatively small changes.
I imagine all the signs about don’t abuse the staff and incidents of abuse against hospital workers went up at the same rate as the wait times. Abusing the staff is wrong but you have people that have come there because they think they are about to die without attention, they really don’t have a choice
I was thinking it might be interesting to show a map of regions to the closest hospital, and color code it by the operator, like ballad health = red, banner health = green, etc. I'll see if OpenStreetMap has this data available
The roughest thing that Ballad has done is take the brand new NICU from Holston Valley in Kingsport that was opened in 2016 [1], shut it down and move it 30-45 minutes further away to Johnson City in 2019 [2]. Granted we know drive times are further up here, and helicopters are faster, but that could be precious minutes for a NICU baby.
Hospital costs are rising which is putting them out of business, which causes mergers and takeovers by organizations that specialize in extracting profit out of hospital services. These organizations do this by reducing costs by lowering nursing staff numbers to like 20% of what they were before, which pretty directly leads to lower quality service. The cost increases in the medical industry are quickly making the whole system nearly untenable. We could see a system collapse in the near future. One way of mitigating this is providing the same services outside of a hospital- for example the cardiologists leaving the hospital and starting a private practice. This leads to reduced overhead and maintains tenability of the whole system.
> One way of mitigating this is providing the same services outside of a hospital- for example the cardiologists leaving the hospital and starting a private practice
Bad idea. If anything, what you need in a hospital is short paths to transfer people from one specialist department to another (or, should the patient be too unstable to transport, to call up the specialists to get down to ER), and you need integrated IT systems to not waste time with data transfer.
There's a combination of causes... and probably they're also applicable for the US:
- rising costs of energy (electricity, gas)
- decades of underfunding of building construction and maintenance, leading to a massive backlog of issues
- same for IT
- modern machinery (ultrasounds, MRTs, CTs) costs immense amounts of money
- general staff shortages that need to be filled via expensive temp-staffing agencies on one side and cause wage rises for those employees that remain
- as a result of that, beds have to be marked as "inoperative" and they don't generate income, whereas the expenses keep piling up (there finally are reform plans to pay hospitals for providing beds, but it's a ... let's say toxic minefield)
- rising costs of administrative bullshit and legal compliance
- insurances being utterly ridiculous regarding payments, both
In the US, I'd add "more and more people unable to pay", which leads to the cost of care for these people being redistributed to everyone else.
Barbara Kingsolver's book "Demon Copperhead" is a gut punch of a look at the degree to which Appalachia has gotten fucked over over the years, and is also just an absolutely fantastic novel with some of the most beautiful writing I've read in years:
Seems ironic that Kaiser is banging on about the horrors of healthcare monopolies. Are they not themselves a giant healthcare monopoly that just happens to operate in a wealthier geographic area?
Sutter Health is my local hospital monopoly. They're the only reason that Sacramento is the most expensive place in the country to have a baby. And the quality isn't exactly high. I know someone who just had knee replacement surgery and they were sent home a few hours after their surgery. When my grandpa had the same surgery in the 90s, they had him stay for a few days to recover. Now they just want to churn and burn their 'customers'. In addition, my wife after giving birth was only allowed to stay the bare minimum. It's shockingly gross how we've commoditized access to healthcare into this assembly line style racket. Contrast to Europe, when I hit my head on a train and needed stitched, I got a free ambulance to their ER where two nurses and a doctor immediately stitched me up for less than 40 EUR and was given world class care. We're doing something wrong in America when we pay the most extreme prices for the most basic care. We're getting gouged so executives can line their pockets. We should be rioting but we all just accept it. And it's not like Obamacare or Biden have done a single thing to change things. Obamacare just forced everyone to buy insurance... it didn't really change the fact that when you go to use it you get crappy care. And even when you go to a place like UCSF, the quality of care isn't that great. They put my wife's IUD in wrong and we ended up with a second kid. Healthcare in America is shit quality.
Sutter is not a monopoly, especially in the Sacramento area. In Sacramento there's Kaiser, Dignity, Sutter and UCD, plus numerous smaller office chains such as Hill Physicians, etc.
What you likely meant is your employer's health plan is only Sutter... which is entirely a different thing.
> I got a free ambulance to their ER where two nurses and a doctor immediately stitched me up for less than 40 EUR and was given world class care
With most health insurance plans, everything you described would cost you only a co-pay as well (usually $20-40). Uninsured people are the ones stuck with $10k ambulance ride bills... after all, someone has to pay for the services.
Even with the government funded healthcare here in Spain people don't spend thousands a month in taxes. In fact very few people pay that much anyway.
I'm genuinely shocked how much health insurance costs in the US. I'm glad we just cover this through the state here. It works fine and I never have to pull out my wallet.
My "premium" healthcare plan, whose premiums are in the four digit a month tier (to your sister comment's point, although to my good fortune, my employer covers 100%)...
the ER copay is $250. Then you will be paying for labs, DI, and medications beyond that.
In fact, as someone who has worked as a paramedic for 12 years, and worked in health insurance software for a similar period, I have -never- seen an ER stay that you'll get only a co-pay of $20 for.
No, they’re effectively a monopoly for most of the services people actually need. It’s well researched and documented. Google it. They even settled an anti-trust lawsuit with the state a few years back.
It’s a racket. They’re just ripping people off. Sutter is the sole reason healthcare in Sacramento costs more than in LA-and for worse quality care. They’re a grift.
> With most health insurance plans, everything you described would cost you only a co-pay as well (usually $20-40). Uninsured people are the ones stuck with $10k ambulance ride bills... after all, someone has to pay for the services.
You’re either uninformed, lying, or both. Have you ever called an ambulance in California? It’s $2000 minimum even with insurance. This is with an Anthem Blue Cross PPO from a tech company. I’ve had to use an ambulance twice in the last decade and it was considerably more than $20-$40… you were only off by a factor of 50x or 100x.
On top of the highway robbery of private health insurance we have a defacto single payer public healthcare system for retirees and those on public assistance that is the government's largest expense, currently sitting in the #2 spot (a major issue that keeps getting kicked down the road), after that you have interest on the debt that is borrowed to fund everything, and then defense (and no, defense can't be cut, don't even go there). We are heading for a surprise failed bond auction (where private investors cause a government shutdown because they refuse to purchase bonds).
Biden is going after a major elephant in the room: the sprawling UnitedHealth monopoly. And Trump took the first stab at the other sprawling healthcare monopoly: regional hospitals.
If the people do not start voting in moderate statesman and serious legislators then all their petty dumb ass concerns are going to get crushed out of existence in one fell swoop of mandatory fascist-socialism...if they are lucky. Honestly, I can't venture to guess the fallout of a bond auction hiccup. All I know is that it will involve pain for everyone in the world.
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1. AMA (American Medical Association) artificially controlling the number of medical graduates based on a quota. Every doctor starts of a huge debt, and many don't get to practice. No experienced doctors from other countries can practice here.
2. Hospitals (many owned by Private Equity) - Maximize profit / patient. Don't show prices, lots of outrageous billing for basic care like Ibuprofen and bandages. The bills keep on coming for months after care.
3. Doctors - Gotta pay those debts. No prices advertised, Inflated costs for basic care. Specialists are booked for months.
5. Insurance companies - Can only make max 20% on administration costs. Love the high prices and denying claims for whatever reason they can find.
3. The politicians - Make $$ from lobbying insurance companies and big providers. Employers sponsored health insurance means individual workers don't have same bargaining power.
Essentially we are paying a fortune. ~5 trillion for healthcare. If we pooled all that money into a govt funded insurance pool, and removed artificial license quotas, market advertised prices, we'd have a much more efficient healthcare.
The corporations know the individuals can't coordinate between themselves to take them out. They have captured the market.
Instead we have a huge administrative bloat, gofundme pages, lowest mortality amongst the rich countries and a shit show.
In 2023, it reported the same statistic at seven hours and 40 minutes.
In the latest report, ER time for admitted patients had reached 10 hours and 45 minutes.
Hell, its not recommended to keep a tourniquet applied for more than two hours and even then there's a specific protocol to follow as there's risk of what will be released back into your system.
What are people even going to the ER for when they can wait for 10 hours?
The basic answer: most people don't go to the ER for emergencies. That is, they go for something like a rash, cough, or fatigue that they know is not an emergency. Many of them just want work notes, although some are convinced they have a legit emergency.
We scoop up the real emergencies from the waiting room ASAP. Eg, no one in the waiting room is wearing a tourniquet; if they are, it's my job to either fix the bleed or get them to a vascular surgeon ASAP if I can't.
The majority of people who spend hours in the ER waiting room have vastly higher time preference than your or I, and often lower socioeconomic status and higher anxiety as well. Often they can't afford phone service or even a car, so it's hard for them to get places quickly. Others are homeless and want a place to sleep or very anxious and just want to be somewhere with other people in the middle of the night.
* Any time a senior (I guess anyone, really) falls and hits their head doctors want a head CT. Only place to do that is the ER, but if you aren't showing any symptoms of a brain bleed or similar problems, you're low on the priority list.
* Dad had IBS and problems with severe constipation. Twice he was having significant abdominal pain and we were told by his GI doc to go to the ER for a CT to make sure there wasn't a serious problem going on. But again, pain with a history of constipation and no other immediate symptoms lands you low on the triage list. And indeed both times he was just constipated.
* The worst time - the 12 hour wait - he was experiencing severe altered mental state. His neurologist, who normally has a 2-3 month wait for an appointment, thought it was serious enough to see him the next day. After examining asked if we could go down to the ER (their office is attached to a hospital) for a lumbar puncture and other tests to rule out a brain infection. Again, apparently the ER docs disagreed, so in the waiting room we sat.
In general though my observation from all of those hours sitting in ER waiting rooms was that a significant portion of the people there were really just sick and probably should've been at urgent care or their PCP.
But parents can’t get off of work while anything else is open, first time mom doesn’t realize that a slight temperature and a cough isn’t an emergency, dad is finally fed up that his teenage daughter has been complaining of a tummy ache off and on for 6 months and Sunday at 2am is when he finally decided he had to have answers.
Minor note: this is somewhat outdated. They've determined now it's more like 4-6 hours before it causes any damage at all.
Per Stop the bleed, Mayo Clinic, etc.
But yea faster than 6-10 hours that's for sure. I bet if you went into that ER with an average time of 9 hrs and a tq stamped hour ago on your arm, they'd get you in pretty fast though. Triage is still a thing
Be worried if you check in and they hurriedly shuttle you into an exam room. That means they think you have an actual immediate life threatening emergency.
State hospital - lots of folks who got stabbed or shot due to alcohol or crime related violence - apparently overseas medical students love to come here to learn all about trauma surgery and getting to stitching people up.
Private hospital - people with babies who have fever or crying and folks with chest pains and in my case a kid who just had seizure - she got first dibs to ER because they triage cases.
Deleted Comment
Clearly if you can wait 10 hours for something, it wasn't an actual emergency. Are hospitals just gambling that these people won't die in the waiting room? What's actually going on?
Is there a perverse financial incentive to drag it out?
More notably, more serious problems may require more staff. If the nurses are busy cleaning up bio material, you get to wait a little longer too before you get triaged.
The incentive is not to drag your wait out, so much as to have the minimum staff needed to keep patients stable. Stabilizing people in critical condition is literally the one job of the emergency room.
On the other hand, people go to the ER for all kinds of reasons that are more urgent than urgent care, but less than true emergencies. Sometimes, they even go because they can't be denied admittance for lack of ability to pay, when a general practitioner at regular practice would have been a more appropriate physician to see.
All of that said, a 10 hour wait either means there's an absurdly high number of non-emergencies, or they're facing severe shortages (self inflicted or otherwise).
I'm not sure wait time is an informative metric, vs something like survival rate for different kinds of conditions.
How did the rate of increase change?
If people were permitted pay directly for emergency visits, and new hospitals allowed to open then it would be ridiculous for there to be a general problem with trending wait times. Someone would add more emergency capacity somehow. That isn't even in conflict with keeping a public system either, there can still be a public system. Just let people who can afford their own emergency care fund their won care.
The problem here is precisely that deliberative bodies trying to work out how much emergency care is required instead of creating an easily-joinable class of people who benefit financially from providing care and leaving decisions up to them. That works well for almost literally every service out there and there is no reason to think it would fail for emergency healthcare. These people attending clearly have hours to shop around.
Since then, the hospital in question increased to 10 hours 45 minutes.
Worse, the federal government stopped tracking this metric, and now, among hospitals that elected to share the number, the median is over 5 hours.
So, if you live in the US, you’re probably screwed, regardless of whether you live in appalachia.
[1] https://www.timesnews.net/living/wellness/holston-valley-unv...
[2] https://www.balladhealth.org/saving-lives/nicu-updates
Bad idea. If anything, what you need in a hospital is short paths to transfer people from one specialist department to another (or, should the patient be too unstable to transport, to call up the specialists to get down to ER), and you need integrated IT systems to not waste time with data transfer.
Why are they rising so much?
There's a combination of causes... and probably they're also applicable for the US:
- rising costs of energy (electricity, gas)
- decades of underfunding of building construction and maintenance, leading to a massive backlog of issues
- same for IT
- modern machinery (ultrasounds, MRTs, CTs) costs immense amounts of money
- general staff shortages that need to be filled via expensive temp-staffing agencies on one side and cause wage rises for those employees that remain
- as a result of that, beds have to be marked as "inoperative" and they don't generate income, whereas the expenses keep piling up (there finally are reform plans to pay hospitals for providing beds, but it's a ... let's say toxic minefield)
- rising costs of administrative bullshit and legal compliance
- insurances being utterly ridiculous regarding payments, both
In the US, I'd add "more and more people unable to pay", which leads to the cost of care for these people being redistributed to everyone else.
https://bookshop.org/p/books/demon-copperhead-barbara-kingso...
https://youtube.com/playlist?list=PLEyPgwIPkHo5If6xyrkr-s2I6...
Importantly, we are not affiliated with Kaiser Permanente, and we are not a foundation.
<https://www.kff.org/about-us/>
Find anyplace that KFF is critical of Kaiser the HMO. I can’t, but would love to be proven wrong.
What you likely meant is your employer's health plan is only Sutter... which is entirely a different thing.
> I got a free ambulance to their ER where two nurses and a doctor immediately stitched me up for less than 40 EUR and was given world class care
With most health insurance plans, everything you described would cost you only a co-pay as well (usually $20-40). Uninsured people are the ones stuck with $10k ambulance ride bills... after all, someone has to pay for the services.
I'm genuinely shocked how much health insurance costs in the US. I'm glad we just cover this through the state here. It works fine and I never have to pull out my wallet.
No, that would only be true of most HMO plans, but most plans aren’t HMOs.
My "premium" healthcare plan, whose premiums are in the four digit a month tier (to your sister comment's point, although to my good fortune, my employer covers 100%)...
the ER copay is $250. Then you will be paying for labs, DI, and medications beyond that.
In fact, as someone who has worked as a paramedic for 12 years, and worked in health insurance software for a similar period, I have -never- seen an ER stay that you'll get only a co-pay of $20 for.
https://www.capradio.org/articles/2019/12/20/sutter-health-s...
https://amp.sacbee.com/news/local/health-and-medicine/articl...
https://www.abc10.com/article/news/local/sacramento/californ...
https://www.nytimes.com/2019/10/03/health/sutter-hospitals-m...
https://www.latimes.com/business/la-fi-sutter-health-prices-...
https://www.cbsnews.com/amp/news/california-sutter-health-ho...
https://m.youtube.com/watch?v=n5FFIkdVzq4
It’s a racket. They’re just ripping people off. Sutter is the sole reason healthcare in Sacramento costs more than in LA-and for worse quality care. They’re a grift.
> With most health insurance plans, everything you described would cost you only a co-pay as well (usually $20-40). Uninsured people are the ones stuck with $10k ambulance ride bills... after all, someone has to pay for the services.
You’re either uninformed, lying, or both. Have you ever called an ambulance in California? It’s $2000 minimum even with insurance. This is with an Anthem Blue Cross PPO from a tech company. I’ve had to use an ambulance twice in the last decade and it was considerably more than $20-$40… you were only off by a factor of 50x or 100x.
Biden is going after a major elephant in the room: the sprawling UnitedHealth monopoly. And Trump took the first stab at the other sprawling healthcare monopoly: regional hospitals.
If the people do not start voting in moderate statesman and serious legislators then all their petty dumb ass concerns are going to get crushed out of existence in one fell swoop of mandatory fascist-socialism...if they are lucky. Honestly, I can't venture to guess the fallout of a bond auction hiccup. All I know is that it will involve pain for everyone in the world.