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If you think you're having a heart attack...

...make sure it's not heartburn. Time magazine has a special issue on the costs of medical care. One of the examples looks at the $21,000 a woman, who thought she was having a heart attack, was charged for three hours in a Connecticut emergency room. She was told she had indigestion. Maybe that's worth $21,000, but she had to pay it herself since she had no insurance.The very long article by Steve Brill is currently available here (though I just bought a print copy at the newsstand). The bottom line is that we Americans are spending ourselves to death through over-priced hospitals, over-priced tests, over-priced technology and drugs, and over-priced hospital administrators and doctors. If the Affordable Health Care Act is to be effective, it will have to take on these gougers.AND...non-profit hospitals are among the biggest offenders. Read it and get indigestion!

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Well, I will take the opposite point of view. I had three episodes of heartburn over a five day period. The last one was severe enough that I decided to see my doctor--whose assistant told me to go instead to the ER and not stop at his office. The cardiac stents inserted the very next day cleared up that heartburn (and the three blocked arteries causing the so-called hearburn).It's too bad that it's so difficult to distinguish beteen certain relatively benign conditions and heart attacks. I'm all in favor of developing protocols for ERs to inexpensively diagnose patients who present with ambiguous symptoms, but when in doubt, go to the ER immdiately. My experience is an object lesson in the dangers of self-diagnosis.

Glad the stents worked. Just for the sake of the discussion, if you don't mind. Did you ignore the first two "heartburns" or did you go to the doctor? Hospital? for them? Do you have any idea how much the stent insertion and related tests and care cost (insurance, etc.)? Don't feel obliged to answer my nosy questions. Thanks.

I've had EKGs a number of times because upper-gastric distress presents too much like a possible heart incident for doctors and nurses to ignore. Pleased to report that my ticker is in good shape but I do take medication to control GERD.

Jim P: The Time article is about the cost of doctor/hospital/tech, etc. Do you have a clue about the EKG charges? Very glad your heart's just fine!

I thought there were laws that prohibited charging people for visits to emergency? If she was really having a heart attack would she have been charged? Or is she being charged because there was not acute condition? I can understand the hospital potentially billing the insurance company if she is coming in for primary care, but if she is having an emergency, they should have to cover the cost of the initial test. $21,OOO.OO for an EKG.....give me a break. As soon as they discovered that there was no acute emergency, she should have been discharged.In Ontario, there is a huge emphasis on diverting people away from emergency but I would like to see some reliable studies on who is accessing emergency and for what. Yes, you have people drug seeking. Yes, you have a certain subset of pscyhosomatic/mental health. But I am sure that you have people coming because they have no access to a doctor.Take me for example. Last year I had a cyst on my back. I have no family doctor so went to walk in clinic. He prescribed antibiotics and said if they do not work go to emerg. I went to emerg two weeks later and had cyst removed. While I was there, I heard of at least three other people who were there for the same procedure. I had to come back for packing and so on.But this was a very, very simple procedure and could have been done by a nurse practioner or some other cheaper form of care. No question! I bet it cost the taxpayers 10 times more money for that non-emergency procedure that I had to go to emerg to receive rather than go to an alternative form of care.But that requires investment in alternative models of health care.SECOND: Social determinants of health Social status and income is one of the greatest social determinants of health. From the public health agency of Canada: http://www.phac-aspc.gc.ca/ph-sp/determinants/determinants-eng.php#income

Health status improves at each step up the income and social hierarchy. High income determines living conditions such as safe housing and ability to buy sufficient good food. The healthiest populations are those in societies which are prosperous and have an equitable distribution of wealth.Why are higher income and social status associated with better health? If it were just a matter of the poorest and lowest status groups having poor health, the explanation could be things like poor living conditions. But the effect occurs all across the socio-economic spectrum. Considerable research indicates that the degree of control people have over life circumstances, especially stressful situations, and their discretion to act are the key influences. Higher income and status generally results in more control and discretion. And the biological pathways for how this could happen are becoming better understood. A number of recent studies show that limited options and poor coping skills for dealing with stress increase vulnerability to a range of diseases through pathways that involve the immune and hormonal systems.

Studies suggest that the distribution of income in a given society may be a more important determinant of health than the total amount of income earned by society members. Large gaps in income distribution lead to increases in social problems and poorer health among the population as a whole.

A major issue in addressing the current health care crisis is to address social determinants of health. And one of the best ways to do this is to address income disparity and not building more health systems.The solution is not to overmedicalize or system (and I speak as someone who works in the community health care system)I like this vidoe from Ivan Oransky titled Are We over-medicalizedhttp://www.youtube.com/watch?v=GIbz9ms9Z9k

Hi Margaret,I "ignored" the hearburn incidents and did not seek treatment. It mildy passed my mind that it was not heartburn, but my wife was out of town dealing with a family emergency and I didn't want to wake up my son. The symptoms subsided when I had a cold popsicle.The second incident was the night my wife returned home. Same thought process, I didn't want to bother her with my own problems and I knew what to do--have a popsicle take an aspirin just in case and relax--things will go away in about 15 minutes. I wouldn't have even called my doctor on the third incident but I made the mistake of tellgin my wife who made me call. As soon as I got to the ER I explained to them it was probably heartburn and I was really fine. By then I felt fine and was completely pain free. They did not lsiten to me and refused my popsicle request.Yes, the hosptital visit cost well in excess of $21,000. 1 day inthe ER and two days in the Cardiac Intensive Care Unit. Two visits to the cath lab, one angiogram and one angiopalsty. 24 week post surgery physical rehab MD-prescribed and approved by insurer. Everything covered by insurance. Moral of the story--single payor health insurance and don't self diagnose.

I read the Brill article, which is not surprising at all.Unagidon has already explained how this operates. There is a "retail" rate, an "insurance rate" and a "medicare" rate. Very few people can afford retail. Many people cannot afford the insurance that will allow them to be charged "insurance rates."

I heard some pharmacists talking on the radio about their under use as health care practitioners the other day. I couldn't find the original story, but this article from a few years ago covers many of the same points: http://articles.latimes.com/2009/nov/30/health/la-he-pharmacists30-2009n... family doctor group has several physician's assistants you can see if you need an appointment within a day or so. It doesn't cost less than seeing the doctor. But it costs a lot less than the E.R. Maybe some of the doc's are wising up.

One of my takes on the Brill article is that the medical care, which appears to be a modern, organized, rational system, is highly irrational, unpredictable and opaque. There is no reason for anyone to be paying the kind of money that's being paid--wholesale or retail, insurance or self-pay.

In this area there are many walk=in neighborhood clinics that treat apparently minor problems. Some are sponsored by hospitals, some by doctors groups. Much less expensive than ER. I used one once when a really strange rash broke out on my face one week-end. I would have felt like a fool going to ER for a rash. The doctor said it was either an infection or shingles, he couldn't say which, so be treated both, thank God. That helped avoid an even worse case of shingles than what I ended up with. As it was, it was awful. I say Yay! neighborhood clinics!

"I thought there were laws that prohibited charging people for visits to emergency? If she was really having a heart attack would she have been charged?"George, in the US, an emergency room may not turn a patient away, but they may and absolutely do charge for their services. If your life is not in immediate danger, you sign papers promising to pay for treatment before they actually administer any treatment beyond triage.

Margaret, I am fortunate enough to have insurance, so I've never paid anything substantial in out-of-pocket payments for an EKG - probably not more than $100. If the information on this site is to be believed, the prices charged for an EKG are a relatively small fraction of $21K.http://www.newchoicehealth.com/EKG-Cost

Once I was in a period before my insurance coverage became active. Five days before it took effect. I had an excruciating pain in my leg. I suffered through it for hours, determined not to go to the hospital without insurance, but by about 5 a.m. I could take it no more and went to the emergency room.I was there for two hours. They checked my blood pressure, took a blood test and two x-rays. They had no idea what was wrong, so they sent me home with a referral to an orthopedist. When I received the bill, it was for $8,000. I went to the orthopedist. Turns out I had a muscle cramp. He gave me a handout with instructions for stretching exercises. That cost $400.As for our Catholic hospitals, when I was much younger I contracted pneumonia and I asked my friend to take me to the ER of the local Catholic hospital. Once they discovered I had no health insurance they packed me into an ambulance -- with severe pneumonia -- and sent me off to the County Hospital.

Interesting: one Catholic hospital in Brill's story seemed to take a compassionate turn on one billing example, while another seems deplorable. Both are non-profits; the first has a small operating deficit; the second is rolling in dough. And yes, where's Unagidon? What does he think of Brill's article?

Margaret, this was NPR a couple of years ago: Good quality medical care has no correlation to how much they charge you for it. http://www.npr.org/templates/story/story.php?storyId=123979339

To add to Jean: ...Or how long you live... There are charts in Brill's article showing that big bucks on medical care don't produce best outcomes. Of course, social conditions, education, genes all play a role, but it would seem some of that medical-care money could be better spent.

So, I am curious to know: how do you expect the ACA to ameliorate such situation. I read it does nothing of the kind, but that was said by people who opposed it. Since the editors of Commonweal supported it, I wonder if they read the bill and can tell us what is going to change.

The editors of Commonweal will have to speak for themselves on this...But yes, Brill's article points out areas were the ACA will not do a lot to contain costs. One example, unnecessary testing to stave off malpractice suits. The bill had "safe harbor" provisions that would have set accepted testing standards for doctors in order to curb malpractice suits, or threats of suits. It got taken out at the behest of trial lawyers who support Democrats and (some) Republicans. This is not perfect legislation by any means. A lot of compromises were made in order to get most people insured and to curb insurance company practices. I suppose one could argue that the legislation could overwhelm the system sufficiently to bring on the great reform--single payer with federal authority to control costs and set standards for drugs, testing, etc.... I don't think anyone believes that the ACA is perfection, far from it. But the way we were going wasn't controlling costs either.

Rather than the ACA, we just need a law that requires one price for all patients. No Medicare price, no insurance price, no retail price: just one price. That will prevent cost shifting, eliminate the huge amounts of insurance money spent negotiating rates with providers, and price gouging walkins. There is nothing the hospital supplied the CT woman that was worth the $21,000 she was charged; it was just gouging. I recently saw a hospital bill for a procedure - no doctor charges included - where the patient was at the hospital for about 6 hours. Total charge was about $40,000 and Medicare paid about $3,000 for those services. Those 2 amounts show an unconscionable dispersion in price. Either, or most likely both, completely misrepresent the actual value/cost.

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About the Author

Margaret O'Brien Steinfels, a former editor of Commonweal, writes frequently in these pages and blogs at dotCommonweal.