100% agreed with this. This is an insightful comment. people have no idea how much practice patterns would change if less defensive medicine could be practiced. So much of the inconvenience of medicine exists because the standard of care is extremely conservative to ensure minimal risk of litigation. The few states that have malpractice caps really doesnt change anything--those states just provide a good practice environment in rare situations, but doesn't change the way that standard medicine is practiced because that is developed out of state as a national consensus.
Its not about frivolous lawsuits as much as defensive medicine which is the standard of care. For example if you come in to the Emergency department with a traumatic brain bleed (even a tiny spec on your scan), then you end up getting another scan at 6 hours, likely platelets since you took a baby aspirin that day, a very expensive neurosurgery evaluation, keppra for 2 weeks, and continuous monitoring, even though by all metrics you have a very benign pathology. Why? Because this is the standard of practice. Not because it makes any sense.
also, keep in mind that the factor that matters the most for practice patterns (especially defensive ones which drive up cost) is not where a doctor practices, its where a doctor trains. Since most doctors train in high risk litigation environments, and most standard of care procedures are developed with defensive practices in mind, the standard of care is high cost high utilization medicine.
I think there is an important point for people to remember: The cost of a procedure, like a CT scan, is not the cost of the procedure. The amount you are getting charged is the Chargemaster rate.
The Chargemaster rate is the same no matter who you are, the different is what people pay from the chargemaster bill. Let's say you are given tylenol and the charge master is $50. The reason why this is so high is because medicare will then say that they pay , say, 20% the chargemaster rate, and thus elderly patients pay $10. This is why elderly patients are seen as great patients for revenue: They all actually can pay something, even if its only a fraction of the chargemaster. A gold plated insurance patient will pay Medicare+30%, and thus the gold plate insurance pays $20. The patient with no insurance then is also billed $50 because they don't have an agreement with the hospital. Thus, what likely happens is that they pay $0 and goes bankrupt, or more likely, these patients don't have any net worth at all. This creates a weird situation where the homeless, destute, and people with no net worth essentially get infinitely free healthcare. These patients tend to be very high volume healthcare users (homeless patients that take $5000 ambulance rides as taxis because they know they will never actually pay a penny, despite having millions of dollars of charges.). This is what the Affordable Care act tried to prevent: by making people pay something, you were actually decreasing costs for all because you remove free riders who present the majority of sunk costs in the healthcare system. Very few people if ever pay for the full cost of a procedure or chargemaster. The chargemaster is a negotiation tactic. Not a final bill.
That is why a CT Scan costs thousands of dollars. Because everyone knows you'll only end up paying a fraction of that if you have insurance. And if you pay cash, its only a few hundred bucks, because thats how much people get paid anyways.
Source: I'm an ER Doc.I do research in healthcare and billing
I'm an ER Doc. The focus on illegal immigrants is way off base.
There's a law called EMTALA which is basically an unfunded mandate that says, in part, we can't just turn away patients because they can't pay. This was because slot of hospitals (university of Chicago in particular) were dumping or transferring patients to other hospitals who couldn't pay and making huge news stories. As you mention, this means people who can’t pay get free health care.
Who does this end up being? Almost 100% alcoholics and homeless patients, often with severe mental illnesses. When there are no resources for them, they end up taking ambulance rides to the ED, say they have Chest pain, and then we give them thousand dollar workups that you end up paying for. Illegal immigrants at large county hospitals are often grateful for any care and usually actually do end up paying at least some portion of their bill, and often are not super high utilizers.
For example, do you know who the number #1 utilizer of NY state medicare dollars is?
Trust me, if hospitals could sort out paying from non paying patients they'd do that in a heartbeat (if they have one). There's lots of programs that try to draw those sorts of patients in, like international elective procedure patients and elderly patients who are universally paid for by Medicare.