When Hospitals Can't Care for Their Own

Passing off costs is costly to everyone

Andrew Perry, MD

I knew I had seen him before. Or was it that he looked like one of the actors from "The Office"? Either way, he did not look very happy, laying there on the stretcher in the emergency department.

"I went into atrial fibrillation [Afib] again," he said.

He ran out of medication about a month ago. The medication was too expensive for him. While at work today, he felt the palpitations return accompanied by shortness of breath. He came to the ER and had Afib with rapid ventricular response. He was getting a diltiazem infusion and would need to be admitted.

"It's not that I don't have a job, doc," he told me, "It's that my job doesn't pay me enough to cover these medications."

What kind of job does this guy have? I wondered. This is a familiar story: a patient with a chronic illness shows up in the emergency department for issues that could have been prevented if he or she had access to affordable medications. This guy probably works part-time at a fast food chain or something like that, I thought.

"Where do you work?" I asked him.

"Here in the hospital [food services]," was the reply. "I'm actually a really good chef," he said, "but nobody needs that skill anymore."

Unwillingness to provide my patient's medications resulted in an escalation of care, from stable outpatient management to emergency services and hospital admission.

This story highlights how employers and insurers attempt to "pass the buck" of healthcare costs to someone else, resulting in an overall increased cost of care. Since we, as a country, have decided we are morally obligated to provide emergency care, eventually these costs will come back to us -- the buck stops here.

Is it financially advantageous for the hospital (acting as both employer and healthcare provider) to behave this way? If we assume that the hospital charged him what it charges the Centers for Medicare & Medicaid Services, he was charged between $14,057 and $23,509 for the admission (For DRGs with "cardiac arrhythmia." Information available here). If the patient had Medicare, the hospital would receive between $3,360 and $8,133. Compare that to the estimated monthly cost of his medications: $430 a month (for diltiazem ER and apixaban, from GoodRx). If he had been prescribed warfarin instead of apixaban, his monthly cost would be $13 a month.

How much will the hospital recoup for this admission? Probably not much. This will become part of the hospital's sunk costs, and the hospital will receive some small reimbursement for being a safety-net hospital. By not providing the medications he needed a month ago, the hospital will spend more money on a hospital admission that could have been avoided.

This is not a unique story, but one that plays out every day in hospitals across the country. Have you noticed ironic disparities like this in your daily practice, too?

Andrew Perry, MD, is a resident physician at Barnes-Jewish Hospital and Washington University School of Medicine in St. Louis.




Having been retired on disability for 12 years, I can speak to this subject. I struggle every month to pay for multiple rx, even though I have Part D. SS Disability payments are our only income. And, before anyone judges me on not being financially responsible or prepared, I was 49 when struck with the sudden diagnosis, subsequent surgery, and crippling outcome. Long career ended, followed by financial ruin. I was unceremoniously shoved out of the hospital door, and have not heard a single word from any former colleagues since. Discarded like yesterday's paper. Early in my career, hospitals took care of their own. Doctors, nurses, and other healthcare workers cared about one another. Then came corporatization...

Some of this is bogus. I have a high deductible as I pay for my health insurance and can't afford a more inclusive kind. I pay for my medications. The cost of diltiazem is not prohibitive.
I don't know but does he smoke or drink?? I have patients that "can't" afford their medications but smoke, drink, and have a cell phone.
People have to accept responsibility for themselves and not expect someone else to pay for them.

The some in your title should be changed to minuscule. The majority of people in this country earn between 40 and 70 thousand dollars a year gross. After income taxes and the cost of living, rent or property taxes, car maintenance, insurances and food are deducted, what's left is not enough to pay for a monthly trip to the movies. Wake up, very few people in this "land of opportunity" are in your situation. I might also add, that part of this man's gross income goes to paying for medications for other people or have you forgotten about where the money comes from that medicare and medicaid receive?

Cell phone? You didn't really say "cell phone" did you?

Not being able to pay for medication is not always an answer. Diltiazem is not that expensive. I am not saying he is rich but too many patients want someone else to pay. Does he smoke, drink or have the latest cell phone? Does he make it to his appointments with his cardiologist or primary care. They might be able to give him samples.
There are "drug" cards that give discounts, so that medications are affordable.
I know because I have helped patients in similar predicaments.

Glad to see you clarified, I.e., “the latest” cell phone. No wonder you think this fellow needs to further explain his expenses to you. You’re an M.D. You have no earthly clue how little money other people must subsist on. It was stated up front. His Rx bill was $430. Often the “assistance” you refer to is hard to come by or nonexistent in some states. People really do have very little money to live on, especially if they are a “cook” at a HOSPITAL. That was the point of the original piece, was it not? Stop trying to paint others into a corner with “your” expectations, doctor. My guess is, you may not smoke but you likely drink, and most certainly have a better phone than the hospitalized individual who was the subject of this piece.

I work as a Registered Nurse Case Manager in a community hospital and as a discharge planner, visit with many patients prior to discharge to ensure ability to comply with the physicians discharge plan of care. Part of the problem is lack of shared decision making and patients are not aware they have treatment options. Cardiology loves the novel anticoagulants but they are often cost prohibitive. Free 30 day coupons and copay discount cards are provided when appropriate. I stress to the patient that other options (warfarin) are always available and they must have the discussion with their physician because non-compliance can be deadly.

If the patient in question looked like Stanley in The Office, I suggest that resident author let the patient know about the LEGACY trial. Exercise and diet, weight loss of 10% sustained over 1 year resulted in 6-fold reduction of continued atrial fibrillation. No medication, no chronic anticoagulation required for many of those patients. Instead, people would rather continue to eat what they like to eat, resist efforts to get them exercising, and refuse to manage their health by any method other than popping pills.

As a working RN who has been uninsured for the past 30 years, this story hits close to home.

Part of the issue is the astronomical price that hospitals charge for product. For an example, let's say that a patient received an IV of normal saline. Pt receives an itemized bill, on there the IV bag which is simply a failry durable plastic bag with basic parts on it filled with sterile H20+.9% NACL is $784.56 and the patient received 2 bags. So just shy of 1600 dollars for 2 plastic bags with saline in them? Along with $266.44 for the start kit which we all know costs probably less than 2 or 3 dollars when bought in the type of bulk hospitals buy in. So what cost the hospital maybe 10 or 12 dollars is now damn near 2 grand charged to the patient. To quote the Blue Collar Comedy troup, "there's your sign"

I am no a hospital employee but I am a home health aide and my health insurance through my employer doesn't want to pay for maintenance inhaler for my asthma. The inhaler costs $359.00 but if I end up in the emergency room or the hospital it will costs most likely ten times or more than the inhaler. It makes absolutely no sense whatsoever to not pay for the medication when it will end costing more if I end up in the ER of the hospital to be treated for something that could have been prevented by taking the maintenance inhaler.

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